The Influence of Familial Social Support on Physical Health During Reentry

Abstract

Recent sociological research has turned attention to the effects social support has on one’s overall health. However, the literature lacks specificity on how social interactions may be beneficial or detrimental to reentering citizens’ physical health. In addition, much of this literature does not examine the potentially damaging effects of negative familial interactions. From both a correctional and public health standpoint, elaborating on the impact social support and negative interactions with family have on returning prisoners is crucial to understanding positive reentry outcomes. Using three waves of the Serious and Violent Offender Reentry Initiative (SVORI) data set and a repeated measures ordinary least squares (OLS) model with a lagged dependent variable, this study examines how levels of and changes in family social support and negative interactions affect post-release physical health over time (n = 2,435). The results suggest that social support has important repercussions on one’s physical health and thus success at reintegration.

Keywords

social support negative interactions physical health reentry returning citizen

Given the burgeoning rates of reentry in the United States, it is time to consider the physical health of returning citizens as a reentry outcome. Many individuals returning from prison cite health-related issues as reasons for their failure in the community (Visher & Mallik-Kane, 2007); consequently, it is crucial that scholars focus on the health of formerly incarcerated individuals, which to date has been underexplored (Vaughn, DeLisi, Beaver, Perron, & Abdon, 2012). For many incarcerated individuals, the correctional system has become their primary source of health care (Binswanger et al., 2011), though the correctional system serves a different purpose and is ill-suited to manage the health needs of those who are incarcerated. As a result, individuals returning from prison bring their health issues into society upon reentry, putting all individuals in the community in contact with them at significant risk (Wakefield & Uggen, 2010). Of particular concern are the high rates of infectious diseases (e.g., HIV/AIDS, hepatitis C, tuberculosis) in carceral settings (National Commission on Correctional Health Care, 2002; Spohr, Suzuki, Marshall, Taxman, & Walters, 2016). Prisons are often overcrowded and have shared washroom facilities, both of which invite the spread of communicable diseases (Massoglia, 2008), enabling individuals returning from prison to potentially bring these diseases to the community upon release.

Furthermore, individuals entering prison tend to have more health problems than the general population and often leave with those problems unchanged or exacerbated (Porter, 2014; Schnittker & John, 2007). Virtually all individuals returning from prison—80% of males and 90% of females—indicate having a chronic health condition requiring medical attention (Mallik-Kane & Visher, 2008). Engaging in criminal behavior, especially chronic offending, exposes individuals to adverse physical conditions, such as concussions from fighting, posttraumatic stress disorder (PTSD), and exposure to violence, which can lead to hospitalization and medical hardships over the life course (Piquero, Shepherd, Shepherd, & Farrington, 2011). Individuals returning from prison are also burdened by medical and/or emotional health problems, making reintegration into society more difficult given the complexity of their reentry needs (Vaughn et al., 2012; Visher & Travis, 2003).

Families are not exempt from the negative effects of the reintegration process; indeed, they play a pivotal role in facilitating good health and success upon reentry for their previously incarcerated loved ones (Naser & La Vigne, 2006). The quantity and quality of social relationships affect both physical and mental health, health behaviors, and mortality risk (Umberson & Montez, 2010). Social relations, particularly social support, have both short- and long-term consequences for health outcomes and behaviors. These effects can emerge in childhood, cascading throughout the life course to foster cumulative advantage or disadvantage (Piquero et al., 2011; Thoits, 2010). Correspondingly, scholars have noted that the benefits of social support may vary across sociodemographic groups, specifically, for those individuals who churn in and out of the criminal justice system (Vaughn et al., 2012; Wakefield & Uggen, 2010). Individuals exiting prison with high levels of family support likely enjoy better physical health upon release compared with those individuals without support or with family conflict. Unfortunately, the connection between health and social support as a factor in the reentry process has been mostly ignored. Moreover, the effects of health on other reentry-related outcomes, such as employment and stable housing, have not yet been examined in relation to the physical health of reentering individuals.

Although there has been a recent emphasis on formerly incarcerated individuals’ reintegration back to society in a general sense, “the relative paucity of research on the health effects of imprisonment is surprising in light of the significant health problems faced by [incarcerated persons]” (Wakefield & Uggen, 2010, p. 396). This is complicated by the United States’ current period of “mass reentry,” generated by decades of mass incarceration (Massoglia & Pridemore, 2015). Nearly 735,000 people are released from state and federal prisons annually—about 2,000 per day in the United States (Sabol, West, & Cooper, 2009). More than 95% of those serving prison sentences will eventually be released back into society (James, 2015). Moreover, a staggering 77% will be arrested within 5 years of their release, with countless challenges ranging from difficulty finding employment to obtaining education as potential impetuses for recidivism (Durose, Cooper, & Snyder, 2014). Our study aims to be one of the first to understand how social support weighs on personal health post-release. In addition, this study is of importance by the sheer examination of phyiscal health as a reentry outcome. Reentry outcomes are not limited to recidivism, but, for example, can include employment, housing, health, support networks, and education, yet most scholarship is limited to only recidivism.

Background

Reentry is a complex and dynamic social process and one which is not uniformly experienced by returning citizens (Visher & Travis, 2003). Incarceration on its own constitutes a primary stressor, but once individuals are released from prison, a host of secondary stressors arise (Graffam, Shinkfield, & Lavelle, 2004; Pearlin, 1989). Returning citizens have many obstacles post-release, such as finding a place to live, and rekindling familial, romantic, and friendly relationships. Unexpectedly, these obstacles are compounded by the social stigma attached to a prison record (Graffam et al., 2004; Porter, 2014). Given that reintegration is fraught with stressors, health issues during this time are highly likely to be related to other reentry outcomes, such as recidivism or obtaining employment. Specifically, though research to date has not explicated the exact pathway by which one’s deleterious physical health may lead to recidivism, others have focused on the direct link between substance use and future criminal behavior (Link & Hamilton, 2017). On this journey to successful community membership, crucial outcomes such as health and social support may serve as cumulative stressors that not dealt with appropriately may promote recidivism (Mowen, Stansfield, & Boman, 2019). The reentry process is multifaceted, complex, and longlasting, resulting in a more indirect path of health-related issues on reentry outcomes that, in turn, influence later criminal offending more directly. One way to mitigate the detrimental impacts of these stressors is through social support. In the next sections, we examine the relationship between social support and health and then revisit the reentry process of returning citizens and how social support may affect their physical health.

Social Support and Physical Health

Social support is defined as the actual or perceived assistance from family, friends, and significant others in the form of emotional, instrumental, or informational aid (Thoits, 1995). Social support comes in multiple forms and may include, for example, demonstrations of love and encouragement, advice, or material assistance with practical tasks (Thoits, 2011). Considerable evidence has accrued over the last few decades showing that social support and social connections are both positively and causally related to better mental and physical health, as well as longevity (Uchino, 2009). Moreover, social support can buffer the harmful physical health impacts of stress or stressors (Cohen, Gottlieb, & Underwood, 2000), with one such stressor being reentry. Finally, social support can also foster a sense of meaning and purpose in life (Umberson & Montez, 2010), which may be linked to human agency and changes in identity and thus desistance from crime.

Research on the positive and beneficent effects of social support has been widely studied in fields from psychology to health care science and is commonly recommended as an intervention to improve physical and psychological health (Smith, Fernengel, Holcroft, Gerald, & Marien, 1994). Scholars have come to the conclusion that social support is an important predictor of health (Hale, Hannum, & Espelage, 2005), suggesting that future research focusing on the etiology of disease and sickness “may well be incomplete unless social support is taken into account” (Lin, Ensel, Simeone, & Kuo, 1979, p. 116).

In the reentry process, family members are vitally important (Naser & La Vigne, 2006). They are able to provide tangible (e.g., housing) and emotional support, as well as a crucial source of financial support (Mallik-Kane & Visher, 2008). Studies that have compared the relative effects of familial social support versus other types of social support on health behaviors have found that family is the most important influence (Franks, Campbell, & Shields, 1992).

Negative Aspects of Social Support and Family Interactions

Regardless which definition or theoretical framework is used, some social support theorists argue that the effect of social support is purely beneficial for the receiver (Franks et al., 1992). However, another line of research emerged in the 1980s that began to identify the dark side of social support (Schaefer, Coyne, & Lazarus, 1981; Smith et al., 1994). This detrimental side of “support,” which looks specifically at the tense, negative, and aggravating interactions between individuals, can actually exacerbate symptoms and stressful life circumstances (Schaefer et al., 1981). In other words, there are features of the dynamics between loved ones, particularly family members, which can have deleterious effects on physical health for the person on the receiving end of this alleged support. Indeed, the same assistance and social interactions that benefit some people can have a detrimental impact or be viewed as unsupportive by others (Smith et al., 1994). For example, in one of the first studies conducted on the negative aspects of social support, Rook (1984) found an asymmetrical relationship between support and well-being: The negative interactions and experiences with others were more robust and longlasting than the positive effects of supportive social interactions (Franks et al., 1992).

The Social Support–Health Link

Two primary theoretical models dominate the literature regarding the mechanisms involved in the social support–health link (Brown & Gary, 1987). First, the main effect model suggests that if an individual is embedded in a supportive network, than he or she is generally healthier than someone who is not (Cohen & Wills, 1985). This kind of support is related to overall well-being and facilitates positive affect, stability in interpersonal relationships, and an acknowledgment of self-worth (Cohen et al., 2000). Thus, these social resources are beneficial regardless if the person is currently facing stressful circumstances (Cohen, 1988). Specifically for physical health outcomes, social support results in “suppressed neuroendocrine response and enhanced immune function” (Cohen et al., 2000, p. 11). In addition, under the main effect model, social support can predispose people to engage in health-promoting or self-care behaviors (Cohen, 1988; Cohen & Wills, 1985).

Conversely, the stress buffering model proposes that in the context of a stressful life event, someone who can mobilize strong, supportive resources from their social ties has a better chance of combating or minimizing the negative effects of stressors on health (Cohen & Wills, 1985). Under the buffering model, social support can intervene at two different points in the causal chain between an individual’s stressful experience and a harmful, pathological outcome (Brown & Gary, 1987; Cohen & Wills, 1985). At the appraisal stage, when the stressor first presents itself, social support works to influence whether someone initially interprets an event as stressful (Thoits, 1986). Having confidence that your social network will provide the necessary resources, should you need them, strengthens one’s ability to perceive a negative or stressful event as relatively benign. Individuals with this level of social support are more inclined to define a potentially stressful situation as less traumatic or difficult (Cohen et al., 2000).

At the stage that prompts a physiological response to stress, social support may intervene in three ways: (a) by facilitating a reappraisal of the event as nonstressful, (b) by inhibiting maladaptive coping strategies, or (c) by providing resources to cope with the existing stressful event (Cohen & Wills, 1985). In the second stage that prompts a physiological response to stress, family members can physically restrict their loved ones from engaging in unsuitable approaches to handling stress such as heavy alcohol or drug use. In the third stage, family members can attenuate the stress response by providing direct resources—whether emotional or instrumental—to their loved one in the form of support that is currently desired (Cohen & Wills, 1985). The main effect model and the stress buffering model can function concurrently in the pathway between social support and health. Nevertheless, we would surmise that the majority of recently incarcerated individuals are more in need of the mechanisms implied by the stress buffering model because they are already under extreme amounts of stress and are more acutely in need of social support as they reenter.

Family Context During Reintegration

When thinking about the relationship between returning citizens, social support, and health, the returning citizen’s familial context must be considered. During the process of reintegration, research has found that those with strong family support were more likely to succeed (i.e., not recidivate) than those with weak or fragmented family support (Graffam et al., 2004). Unfortunately, returning citizens have likely strained relationships with many individuals in their personal network in multiple ways (Clear, Waring, & Scully, 2005). For families, the cost of having an incarcerated loved one is often substantial, and spouses of family members are often trapped with their incarcerated partner’s legal debt and credit problems (Visher, Debus-Sherrill, & Yahner, 2011). Furthermore, families with incarcerated loved ones often withdraw from community life and participation in community organizations, such as attending church or other local social functions (Clear, Rose, & Ryder, 2001). Together, the above research shows that having an incarcerated family member affects one’s own ability to garner fiscal and social support. As such, families are often in a diminished position to provide various types of social support, such as instrumental support.

During reintegration, families continue to exert an influence on whether or not the returning individual sustains communication with their loved ones (Harvey & Bray, 1991), similar to the control of contact and communication while people are incarcerated. Extensive research demonstrates that returning citizens who retained contact with their family members while in prison are more likely to have positive reentry outcomes (Naser & La Vigne, 2006). However, if contact with family members is stressful or limited, as would be the case with negative familial interactions, then positive outcomes stemming from social support are diminished. Here, families may consider contact with a returning loved one risky or even costly, given the resource depletion they experienced prior to and during their loved one’s incarceration. Should the family retain contact, it is possible that family-returning citizen interactions are fraught with anxiety, tension, expectations, and, relatedly, disappointment (Brown & Bloom, 2009). Naser and La Vigne (2006) note that “the period of incarceration creates artificially high expectations of family and intimate partner relationships and that when these expectations are not met, relapse, antisocial behavior, and recidivism are soon to follow” (p. 95).

Individuals, including returning citizens, function at their best when they are in a supportive environment (Hale et al., 2005). In the pathway between stressful life circumstances and health outcomes, “the instrumental, informational, and social-emotional support supplied through social interaction serves to mediate the impact of stressful life events,” such as reentry (Brown & Gary, 1987, p. 165). Unfortunately, returning citizens are often not a subject in studies about social support (for recent exceptions, see Berg & Huebner, 2011; Cochran, 2014; Duwe & Clark, 2011; Mowen et al., 2019; Mowen & Visher, 2015; Pettus-Davis, Veeh, Davis, & Tripodi, 2018; Spohr et al., 2016) or health, leaving much information about the link between social support and health for incarcerated individuals underdeveloped.

Current Study

Given the previous research on social support, physical health, and the challenges of reentry, we hypothesize the following:

Hypothesis 1: Positive familial social support will have a beneficial effect on a returning citizen’s physical health after release from prison.

Hypothesis 2: Negative interactions between the returning citizen and their family members will have an adverse effect on their physical health after release.

Accordingly, the current study has two broad purposes. First, we seek to better understand how overall health is related to and affected by social support as an isolated entity. Understanding these associations can help guide future research in the improvement of public health and criminal justice, especially for reentry processes. Second, this study adds to the literature by attempting to ascertain the potentially variable effects social support may have on a family member’s reintegration. Ensuring a smooth transition from prison to society has implications for public safety and public policy, including the likelihood of being victimized by a recently released citizen who has not yet properly transitioned away from prison life.

Method

Data

The current study uses data from the Serious and Violent Offender Reentry Initiative (SVORI)—the largest post-release reintegration study to date. SVORI is a federal initiative that funded 69 separate state and local agencies to develop programs intended to improve reentry for formerly incarcerated persons (Lattimore & Visher, 2009). To achieve the initiative’s prescribed goal—increasing public safety by reducing recidivism—a multisite impact evaluation of the outcomes including education, employment, housing, and health for released citizens was conducted (Lattimore et al., 2012). The data collection efforts spanned 12 states from July 2004 to November 2005 and included more than 150 adult prisons. Participants were interviewed in person where interviewers collected detailed information on criminal and substance use histories, education, employment, and varying needs across a range of services. Overall, SVORI respondents had extensive criminal, alcohol, and drug using histories; low levels of education; low employment skills and training; and many had criminal justice–involved family members and friends. Most of the adult men in the sample had served a previous prison term and many had a history of violent or serious personal offenses, in line with the initial objective of high-risk releases (Lattimore, Steffey, & Visher, 2010).

Data were collected on adult males at four different time periods: 30 days prior to release (in prison; Wave 1) and 3 (Wave 2), 9 (Wave 3), and 15 (Wave 4) months post-release (Lattimore & Visher, 2009). Questions across waves were similar except that post-release waves also included information regarding experiences with the reentry process. The initial sample in Wave 1 was 1,697 respondents; however, as is common with many large-scale studies or studies on offenders (Western & Wildeman, 2009), there was a loss of nearly 40% of respondents due to attrition between Wave 1 and Wave 2. Research involving the SVORI data has noted that this attrition was random (Lattimore et al., 2010; Lattimore & Visher, 2009; Wallace et al., 2016) and that there were much lower rates of attrition across Waves 2 to 4. Next, our dependent variable—physical health—has little to no missing data across waves among those remaining in the sample. Accordingly, missing data were addressed using listwise deletion. Finally, other scholars have shown that in the SVORI data, individuals who attrited from the sample at Wave 2 were not significantly different from those respondents who were interviewed at later waves (Lattimore & Visher, 2009). We conducted an analysis regarding differences between respondents who did and did not attrite between Waves 1 and 2 (individuals were reinterviewed, regardless of whether they had missed an interview at prior waves). Our results show no significant differences in the dependent variable—physical health—for these groups.

Our sample comes from Waves 2 through 4, given that these waves occur post-release and capture health after incarceration. The best predictor of current health is past health; as such, to determine whether social support had any effect on physical health, we controlled for prior levels of physical health. To do this, we included a lagged physical health variable (our dependent variable) in the model. This necessitated using respondents who participated in at least two sequential waves. This also helped to alleviate the issue of the effect of attrition on sample size: Participants in our study did not need to complete all four waves to be included. For example, if a respondent participated in Wave 2, then their health score from Wave 1 was the lagged dependent variable when modeling health at Wave 2. If a respondent participates in Waves 3 and 4, then their health score from Wave 3 was the lagged dependent variable when modeling health at Wave 4. However, if the respondent only participated in Waves 1 and 3, for example, we do not include them in our sample. The total number of observations is 2,435, which is nested within 760 individuals in Wave 2, 811 individuals in Wave 3, and 864 individuals in Wave 4.

Dependent Variable

The dependent variable of interest, physical health, is a portion of the SF-12 Summary Health Scale, which is a shortened version of the SF-36 Health Survey. The SF-12 asks respondents about a few physical health domains including physical functioning, bodily pain, vitality, emotional and physical role functioning, and social functioning. These concepts form our physical health variable. Average scores of the short form closely mirror the original 36-item survey and are used in large-scale surveys as a valid and reliable measure of physical health (Ware, Kosinski, & Keller, 1996). Scores are weighted averages of item responses, so that higher scores indicate better physical health, whereas lower scores indicate worse physical health. For ease of interpretation, physical health was standardized with a mean score of 50 and a standard deviation of 10 (Utah Department of Health, 2001). Table 1 is a summary of all the SF-12 items, including physical and mental health.

Table 1:

SF-12, Version 1.0

Dimension	Number of items	Summary of content	Number of response choices	Range of response choices
Physical functioning	2	Moderate activities, climbing several flights of stairs	3	Yes limited a lot to no, not limited at all
Role limitations—physical	4	Accomplishing less than wanted, limitations in the kind of activities	2	Yes/no
Bodily pain	2	Effect of pain on normal work, both inside and outside of the home	6	Not at all to extremely
General health	1	Personal evaluation of health	5	Poor to excellent
Vitality	1	Felling full of like	6	All of the time to none of the time
Social functioning	2	Extent to which physical health or emotional problems interfere with normal social activities	5	All of the time to none of the time
Role limitations—emotional	2	Accomplishing less, not working as carefully as usual	2	Yes/no
Mental health	2	Downhearted and blue, calm and peaceful	6	All of the time to none of the time

Source: Reproduced from Brazier and Roberts (2004).

Independent Variables

There are two independent variables of interest: positive familial social support and negative familial interactions (see Wallace et al. (2016) for previous work with these scales). Positive social support is a factor scale consisting of six items: “I feel close to my family,” “I want my family involved in my life,” “I have someone in my family to talk to about problems,” “I have someone in my family to turn to for suggestions,” “I have someone in my family who understands my problems,” and “I have someone in my family who loves me.” The response set for each item was a Likert-type scale ranging from 1 for strongly agree to 4 for strongly disagree. Using principal components analysis, a single factor emerged with an eigenvalue of 3.86 and factor loadings ranging from 0.72 to 0.88. In addition, Cronbach’s alpha for the measurement of internal consistency was .89. Higher scores indicate higher levels of positive social support.

The second independent variable of interest, negative familial interactions, also a factor score, was captured using the following three items: “I fight a lot with family members,” “I often feel like I disappoint my family,” and “I am criticized a lot by my family.” Here, the response set was also a Likert-type scale ranging from 1 for strongly disagree to 4 for strongly agree. Again, using principal components analysis, all three items emerged on a single eigenvalue of 1.95 with factor loadings from 0.72 to 0.84. Cronbach’s alpha for negative familial interactions was .73. Higher scores on this scale indicate higher levels of family negativity. It is important to state that negative familial interactions should not be considered the absence of positive familial support. Rather, it encompasses the respondent’s perceptions of negative interactions and detrimental feelings associated with family members. We separate these two independent variables to better assess their distinct effects on the reentering citizen’s physical health (see Wallace et al., 2016).

Control Variables

Demographic and socioeconomic variables were used as controls in all models. Age at Wave 1 is a continuous variable and is grand mean centered. We control for age since as people grow older, their physical health and likelihood of engaging in crime typically declines. The effects of familial social support, stress, and physical health may also vary by race (Vaughn et al., 2012). Race was coded using two dummy variables indicating whether the participant self-identified as Black (“Black” = 1) or another racial/ethnic minority such as American Indian, Alaskan Native, Asian, East Indian, or Hispanic (“other race/ethnicity” = 1); White is the reference category. High school diploma is a dichotomous variable indicating whether the respondent had not completed 12 years of high school or received his general educational development (GED; 1 = yes). Given the debilitating effects prison may have on one’s overall health, it is important to control for length of time in prison (Hammett, Roberts, & Kennedy, 2001). Days incarcerated is a continuous variable indicating how long the person had been incarcerated before their Wave 1 interview. SVORI experimental group is a dummy variable indicating whether the participant used SVORI reentry programming (1 = yes).

We also control for several health characteristics of the respondents. We control for the current mental health of the respondent because previous research has found that one’s mental health can have an adverse (or beneficial) impact on physical health (see, for example, Thoits, 2010; Umberson & Montez, 2010). Mental health is a continuous variable taken from mental health items in the SF-12 Summary Health Scale, which is a shortened, reliable version of the SF-36 covering aspects of mental and emotional health (Utah Department of Health, 2001). The SF-12 Summary Mental Health Scale (MCS) consists of weighted averages of item responses, with higher scores indicating better mental and emotional health, whereas lower scores indicate worse mental health. See Table 1 for items that constitute the mental health scale. Chronic health condition is a dichotomous variable included to control for any chronic or enduring health conditions the respondent may have. They were given a 1 (yes) if they indicated ever having any of the following: asthma, diabetes, heart problems, arthritis, serious back problems, tuberculosis, HIV/AIDS, hepatitis B, or hepatitis C. Chronic health issues were controlled for to minimize the possible confounding effects lingering health issues may have on a respondent’s overall physical health. Needs health care is a dummy variable signaling that the respondent requires, but does not currently have, health care coverage.

All the following control variables were dichotomized for simplification: married, has children, currently employed, gang member, drug offender, currently in prison, and wave. Married is a dichotomous indicator if the respondent was married at the time of the interview. Has children is a dummy variable indicating whether the respondent has any children; this variable comes from Wave 1 and is time invariant. Currently employed is a measure indicating whether the respondent has found stable employment. One third of the sample is currently in a gang and self-identified as a gang member, which comes from Wave 1 and is time invariant. An indicator for whether they were convicted drug offenders was used as well; this variable also comes from Wave 1 and is time invariant. Respondents who were reincarcerated during subsequent waves of the study were still interviewed by SVORI researchers; as such, they remain in our models. The variable currently in prison (1 = yes) shows that the interview took place in prison. Wave 3 and Wave 4 are dummy variables controlling for the wave of the survey. In addition, Wave 1 interviews took place in a number of different states; to control for potential state differences in respondents’ health, we included a fixed effect for the 12 states in the sample. Finally, we use a lagged dependent variable—physical health—to control for the individual’s underlying physical health level. Note that the lagged dependent variable for Wave 2 comes from Wave 1, the in-prison interview. Like the outcome, the lagged dependent variable is standardized. Descriptive statistics, by wave, for all study variables are provided in Table 2, and a correlation matrix of all variables is shown in Table 3.

Table 2:

Descriptive Statistics for All Variables by Wave

	Wave 2		Wave 3		Wave 4
Variables	M	SD	M	SD	M	SD
Physical health—standardized	−0.024	1.049	−0.060	0.988	−0.080	0.998
Mental health—standardized	0.157	0.949	−0.021	0.991	0.012	1.009
Has chronic health condition	0.400	0.490	0.408	0.492	0.407	0.492
Positive family support—standardized	−0.012	1.015	0.021	0.986	0.043	0.964
Negative familial interactions—standardized	−0.004	0.992	−0.021	0.994	−0.068	0.966
Currently needs health care	0.545	0.498	0.526	0.500	0.519	0.500
Interview took place in prison	0.075	0.263	0.224	0.417	0.163	0.370
Black	0.547	0.498	0.514	0.500	0.543	0.498
Other race or ethnicity	0.106	0.308	0.098	0.298	0.081	0.273
Currently married	0.097	0.296	0.119	0.324	0.136	0.343
Has children	0.634	0.482	0.626	0.484	0.657	0.475
No high school diploma or equivalent	0.431	0.496	0.421	0.494	0.409	0.492
Is currently employed	0.758	0.429	0.829	0.377	0.818	0.386
Drug offender	0.299	0.458	0.306	0.461	0.302	0.459
Current gang member	0.398	0.490	0.399	0.490	0.392	0.489
Logged number of days incarcerated	6.483	0.891	6.485	0.877	6.473	0.899
SVORI treatment group	0.550	0.498	0.549	0.498	0.528	0.500
N	763		813		729

Note. SVORI = Serious and Violent Offender Reentry Initiative.

Table 3:

Correlation Matrix

Variables	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17
1. Physical health	—
2. Mental health	−.17	—
3. Chronic health condition	−.44	−.04	—
4. Positive family support	−.08	.24	−.04	—
5. Negative familial interactions	−.04	−.33	.03	−.46	—
6. Currently needs health care	−.31	−.13	.27	−.06	.15	—
7. Interview took place in prison	.07	−.35	−.06	−.21	.24	.09	—
8. Black	−.10	.06	.08	.15	−.07	.09	−.10	—
9. Other race or ethnicity	.02	.00	.04	−.03	.06	.02	.07	−.26	—
10. Currently married	.05	−.02	−.07	.03	.01	−.07	−.03	−.03	.04	—
11. Has children	−.15	−.07	.02	.04	.00	.12	−.03	.13	−.04	.17	—
12. No HS diploma	−.12	−.04	.06	−.02	.03	.11	−.04	.22	−.04	.01	.12	—
13. Currently employed	.15	.01	−.12	.08	−.15	−.12	−.18	−.10	−.04	.09	.06	−.16	—
14. Drug offender	.04	.00	−.05	.04	.01	.08	.03	.09	−.13	.02	−.02	.11	.00	—
15. Current gang member	.09	−.18	.05	−.09	.17	.07	.12	−.12	.16	−.01	.03	.02	.03	−.03	—
16. Days incarcerated	.11	.11	−.05	.15	−.13	−.09	−.06	.15	−.01	−.01	−.20	−.05	.13	−.04	.05	—
17. SVORI treatment group	.00	.10	−.03	.16	−.08	−.07	−.01	.07	.07	.05	−.04	−.10	.09	.04	−.10	.16	—

Note. HS = high school; SVORI = Serious and Violent Offender Reentry Initiative.

Analytic Strategy

To assess the impact of familial support—both positive and negative—on the physical health of returning citizens, we conduct a repeated measures ordinary least squares (OLS) regression with a lagged dependent variable. Put simply, our data are structured so that waves are nested within people, where each respondent can have multiple rows in the data for each wave they participated in. Due to this, we employ robust standard errors that are adjusted for observations clustering within respondents, making our models more conservative. Model diagnostics reveal variance inflation factors (VIFs) range from 1.04 to 3.01, with a mean VIF of 1.46, which are below the standard threshold for collinearity (Kennedy, 2003).

Results

Table 4 displays a baseline model (Model 1), without the family social support predictors, two additional models which include either positive family support (Model 2) or negative familial interactions (Model 3) and a final model that includes both support variables with all covariates (Model 4). Before discussing the independent variables, we note which control variables have a significant effect on physical health. Because all control variables in the models retained significance in the same directions and approximate effect strength, we discuss the findings for control variables for all models collectively. As expected, lagged physical health is positively associated with current physical health. For instance, in the baseline model, for every standard deviation increase in prior health, current health is 0.46 higher. Current mental health is negatively related to physical health, which is unexpected given the literature on overall health, which posits that one’s mental and physical health usually reciprocally influence each other in the same direction (see, for example, Umberson & Montez, 2010). This unexpected finding may be linked to the fact that the primary physical and mental health questions in SVORI data are self-reported health. Although research on self-rated health states that it has excellent predictive validity (Schnittker & Bacak, 2014), this conclusion may not stand with criminal justice-involved populations (Fahmy, 2018; Mallik-Kane & Visher, 2008).

Table 4:

OLS Models Predicting Physical Health With Lagged Dependent Variable and Social Support (N = 2,133)

Variables	Baseline	Positive family support	Negative familial interactions	Both support variables
Positive family support—standardized		0.047*		0.021
Positive family support—standardized		(0.018)		(0.019)
Negative familial interactions—standardized			−0.080**	−0.071**
Negative familial interactions—standardized			(0.020)	(0.021)
Lagged physical health—standardized	0.449**	0.449**	0.450**	0.450**
Lagged physical health—standardized	(0.028)	(0.028)	(0.028)	(0.028)
Mental health—standardized	−0.211**	−0.220**	−0.239**	−0.240**
Mental health—standardized	(0.021)	(0.022)	(0.023)	(0.023)
Has chronic health condition	−0.429**	−0.424**	−0.425**	−0.423**
Has chronic health condition	(0.040)	(0.040)	(0.040)	(0.040)
Currently needs health care	−0.320**	−0.318**	−0.309**	−0.310**
Currently needs health care	(0.038)	(0.037)	(0.037)	(0.037)
Interview took place in prison	0.043	0.049	0.064	0.064
Interview took place in prison	(0.055)	(0.055)	(0.055)	(0.055)
Black	0.110**	0.105*	0.105*	0.103*
Black	(0.041)	(0.041)	(0.041)	(0.041)
Other race or ethnicity	0.052	0.053	0.053	0.054
Other race or ethnicity	(0.057)	(0.056)	(0.056)	(0.056)
Currently married	0.015	0.008	0.006	0.004
Currently married	(0.046)	(0.046)	(0.047)	(0.047)
Has children	−0.089**	−0.093**	−0.093**	−0.094**
Has children	(0.035)	(0.035)	(0.034)	(0.034)
No high school diploma or equivalent	−0.038	−0.042	−0.030	−0.033
No high school diploma or equivalent	(0.038)	(0.038)	(0.037)	(0.037)
Is currently employed	0.180**	0.185**	0.176**	0.179**
Is currently employed	(0.053)	(0.053)	(0.053)	(0.053)
Drug offender	0.029	0.025	0.022	0.022
Drug offender	(0.040)	(0.039)	(0.039)	(0.039)
Current gang member	−0.083*	−0.079*	−0.070	−0.070
Current gang member	(0.037)	(0.037)	(0.037)	(0.037)
Logged number of days incarcerated	−0.020	−0.023	−0.027	−0.028
Logged number of days incarcerated	(0.021)	(0.021)	(0.021)	(0.021)
SVORI treatment group	−0.063	−0.065	−0.065	−0.066
SVORI treatment group	(0.035)	(0.035)	(0.035)	(0.035)
SVORI Wave = 3	−0.101*	−0.106*	−0.112**	−0.113**
SVORI Wave = 3	(0.042)	(0.042)	(0.042)	(0.042)
SVORI Wave = 4	−0.074	−0.079	−0.084*	−0.085*
SVORI Wave = 4	(0.040)	(0.040)	(0.040)	(0.040)
Constant	0.539**	0.553**	0.583**	0.585**
Constant	(0.161)	(0.160)	(0.160)	(0.159)
R ²	.442	.444	.447	.447

Note. Robust standard errors in parentheses. OLS = ordinary least squares; SVORI = Serious and Violent Offender Reentry Initiative.

p< .05. **p< .01.

Next, individuals with chronic conditions report lower levels of physical health. Expectedly, individuals in need of health care report having poorer physical health. Respondents who are Black reported better health than Whites. This is counterintuitive given that Black males are typically more unhealthy than their White counterparts both in the general population (Levine et al., 2001) and in incarcerated populations (Fahmy, 2018; Iguchi, Bell, Ramchand, & Fain, 2005). Interestingly, respondents who reported having children also reported poorer health; on average, respondents who are parents reported a physical health score that was 0.09 lower than their counterparts. Although this is a significant finding, a one-tenth standard deviation decrease in health is not especially large. Respondents reporting they were currently employed had better physical health than those not employed, which is consistent with past research (Berg & Huebner, 2011). This may be because these individuals now have access to health care through their jobs and have taken advantage of that as well as better care of themselves since their employment. Conversely, they might have been able to secure employment simply because they can engage in physical labor and other physically demanding occupations. Next, the dummy variables for study Wave 3 show individuals reporting worse health when compared with Wave 2, or 3 months out of prison. We suppressed the state-fixed effects in Table 4 for space, but there are some differences among statesthat are worth noting. These findings are consistent across all models. If the case originated in Indiana, Maryland, or Washington, the respondent reported poorer health. Maryland had the largest detrimental effect of about −0.30 across all waves; thus, participants from Maryland were reporting about 0.30 standard deviations lower health than the reference state of Iowa.

Moving forward to the key independent variables of interest, we first turn our attention to the positive family support model in Table 4, which shows that social support has a positive, significant effect on physical health. This finding is supportive of Hypothesis 1 and lends credibility to the argument that social support can affect not only one’s mental and emotional well-being but also physical well-being (Thoits, 2010, 2011; Wallace et al., 2016). Because positive social support is standardized, we can interpret this finding as for every one standard deviation increase in positive familial support, current physical health increases by approximately 0.05 standard deviations. Although this is a modest finding, it is an important initial step signaling to future researchers that there is more to be understood in the discussion of health and social support, especially for returning citizens.

The second focal independent variable, negative familial interactions, is presented in Table 4. We found that negative familial interactions had a negative effect on the respondent’s current physical health, thus finding support for Hypothesis 2. For every one standard deviation increase in negative familial interactions, current physical health decreases by approximately 0.09 standard deviations. Moreover, it is important to note that the coefficient size for negative familial interactions is larger than that of positive social support. Finally, in Model 4, when both positive and negative family support are placed in the model, the effect of positive family support is no longer significant. In other words, having detrimental or harsh family ties and interactions may exert a stronger impact on the released citizen’s physical health than having a positive or supportive environment, similar to the findings of past research (e.g., Franks et al., 1992).

Discussion

From both a reentry and a public health standpoint, elaborating on the impact familial support (and negative familial interactions) may have on returning citizens overall is critical to positive reentry outcomes, which inevitably affect the community at large. This study explored the role that both positive and negative family support have on an individual’s post-release physical health. We hypothesized that higher levels of family social support would result in better physical health and that higher levels of negative familial interactions would result in poorer physical health. Both hypotheses were supported in that these family dynamics do indeed have meaningful effects on returning citizens and may influence their ability to avoid reoffending. Moreover, though we cannot conclude with certainty which theoretical model of the social support–health link (i.e., main effect or stress buffering model) was reinforced in our findings as both can work in tandem, we suspect that the stress buffering model more closely follows the pathway that the SVORI sample identifies with. The stress buffering model is most often mobilized for those who are already experiencing the effects of stressors, of which the formerly incarcerated preparing for reintegration is a poignant example. Our findings warrant a few broader points of discussion, policy and theoretical implications, study limitations, and directions for future research.

Positive social support favorably affected returning citizens’ physical health. This finding is robust given that we control for the respondent’s underlying health with the inclusion of a lagged dependent variable, though the effect sizes are small, which may be partly due to the lagged variable. As the results indicate, the flipside of social support is just as, if not more, important. Negative familial interactions may exert an even stronger impact on the already stressed reentering citizens as they attempt to get their lives on track (Mowen & Boman, 2019).

Ensuring that friends and family members are aware of the influence they have on the success of their loved one might very well be an important piece to the recidivism puzzle. If returning citizens’ family members understood the significant link between health and social support, perhaps they would be more inclined to create a positive environment for their loved ones. A programmatic example of this is Family Re-Entry, Inc., a company which strives to facilitate a safe and successful transition from prison to the community by intervening with family members prior to and after the person’s release to the community. They focus on altering the family’s relationships with one another and hone in on “developing and maintaining a positive social support system” that helps promote skills used to strengthen communication and personal relationships (Thalberg, 2006, p. 17). These skills between family members are imperative to improve, given that communication between family members and their loved one(s) has been hindered by incarceration. Furthermore, the Vera Institute of Justice offers a series of coaching packets titled “Engaging Offenders’ Families in Reentry,” in which they detail how the broad definition of family (not necessarily just blood relatives) is the most frequently available and natural resource for those returning citizens who need them as critical partners to staying sober and avoiding criminal behavior (DiZerega, 2010). In particular, it would be constructive for families to recognize that to succeed, the returning citizen must take minor steps, rather than what family members’ typical expectations are, which tend to be rather large (Brown & Bloom, 2009). This may easily create a negative environment prone to uncomfortable interactions.

Theoretical and practical implications for family members aside, the research validates the obligation of correctional administration as a crucial part of policy implications as well. Although research in this area is limited, scholars have demonstrated that better health and health care post-release lower the likelihood of recidivism (Wexler, De Leon, Thomas, Kressel, & Peters, 1999). Reentering individuals tend to lean on their family members for a prolonged period of time after release (Mowen & Visher, 2015). Accordingly, keeping family members abreast of community-centered nonprofit organizations who can aid in the more instrumental resources for returning citizens when family members cannot, is of grave importance (Travis, 2005).

Utilizing costless strategies to promote health and well-being while impeding returning citizens from recidivating is especially important in an era of budget-stressed circumstances (Kyckelhahn, 2012). Indeed, the Pew Center on the States (2011) reports that state correctional spending has quadrupled in the last 20 years, totaling about US$52 billion per year, second only to Medicaid spending. Facilitating contact through video visitation (though not as a substitute for in-person contact) while citizens are still imprisoned can be a valuable tool to nurture weak and/or broken family bonds and begin conversations about reentry intentions (Meyers, Wright, Young, & Tasca, 2017). Because social support is mutable and can be increased during incarceration via longer visitation times, different modalities of visitation, and more privacy during visits, correctional administrators have the policy-oriented authority to implement these changes in their facilities. Moreover, other policy implications that can be motivated by both carceral and community leaders include ensuring the individual is housed in a facility as close to home and family as possible, a direct link with probation or parole agencies who can provide mental and family counseling services once the individual is released, and providing programming while imprisoned to assist in the attainment of strong communication and health boundary-setting skills.

Although the two primary models used to describe the etiology between support and wellness are documented in the literature, there is still a lack of specification regarding the mechanisms under which conditions wield the greatest impact on the health of returning citizens. This study was not able to account for the reciprocal nature of familial relationships (Clear et al., 2005; Wildeman, 2012). In addition, though these analyses describe the relationship of social support on physical health, it is probable that those who are in poor health—and thus invoke more stress and/or a financial burden for their family member(s)—may constitute an interdependence of social support and health. In other words, family support and negative interactions work both ways for physical health. Future research should improve this line of inquiry by using qualitative methods to examine the intricacies of family relationships and how returning citizens accept the type of support they require (Rozanova, Brown, Bhushan, Marcus, & Altice, 2015). Social support only works when the specific requirements of the recipient are being met. For instance, if a returning citizen needs emotional support post-release, but is only receiving support that is instrumental in nature, the mismatched support is no longer beneficial, and in fact may be damaging (Cohen et al., 2000; Smith et al., 1994). Future research should assess what kinds of family support are most beneficial and for whom (Mowen et al., 2019).

Another important avenue for future research, which is also a limitation of this study, is the differential impact of negative interactions or positive support on returning females. Using the SVORI data, Taylor (2015) found that emotional family support, though important for both males and females, had a stronger effect for females in the later waves of the post-release period. It is highly likely that both personal health and family social support operate differently for women (Pettus-Davis et al., 2018). Future research should attempt to address the particulars of the family members involved in this support framework.

There are a few additional limitations of note in our study. First, our study is limited to those convicted of a serious or violent offense, and as such, our results are less generalizable to all returning citizens. Future work should examine whether this is the case for all those released from prison. A large portion of respondents are lost after Wave 1, which was the in-prison interview (Lattimore & Visher, 2009). As expected, it is harder to track individuals once they are released from prison (Western, Braga, Hureau, & Sirois, 2015). That said, there is high retention among respondents who were able to be contacted and interviewed post-release. Notably, analyses on attrition and retention showed that the attrition was at random and unlikely to bias our results (Lattimore & Visher, 2009). Next, although SVORI asks about general family support questions, the study does not ask for details on who the sources of support are. Depending on the type of relationship involved (e.g., a romantic partner vs. a parent vs. a sibling), the nature of the support varies (Cobbina, Huebner, & Berg, 2010).

The continuum of care approach should be considered essential when dealing with reentering citizens, especially because approximately 40% of all those incarcerated report a current chronic medical condition and 21% report having an infectious disease (Maruschak, Berzofsky, & Unangst, 2015). This in and of itself should be forewarning that as the carceral population ages, these numbers will increase (Williams & Abraldes, 2007). Accordingly, because corrections is part of the community—not separate from it—formerly incarcerated individuals are likely bringing infectious diseases back, making it a public health issue (Massoglia & Pridemore, 2015). Given the finding in previous research that health problems are an important predictor of recidivism (Wexler et al., 1999), and that health influences reentry outcomes (Hammett et al., 2001; Massoglia, 2008), an assessment of health needs prior to release should be a standard part of the reentry planning process (Mallik-Kane & Visher, 2008). A prerelease health evaluation, for example, would screen for any potential health issues or those that need long-term management (Rozanova et al., 2015). Family members and loved ones can be made aware of this prior to release so they may provide critical support and improve overall reentry outcomes (Visher & Travis, 2011).

Footnotes

Authors’ Note:

The first author would like to thank Mike Reisig for his feedback and guidance on the earliest version of this paper. This research was supported by a National Institute of Justice Grant (No. 2014-IJ-CX-0024). All opinions expressed here are the authors and do not reflect those of the funding agency.

ORCID iD

Chantal Fahmy

Chantal Fahmy is an assistant professor in the Department of Criminal Justice at the University of Texas at San Antonio and received her PhD in criminology and criminal justice from Arizona State University. Her research interests focus on prisoner reentry and reintegration, social support and health, and institutional corrections. Her work has been published in Deviant Behavior, Environment and Behavior, and Journal of Adolescent Health.

Danielle Wallace is an associate professor in the School of Criminology and Criminal Justice at Arizona State University and received her PhD in sociology from the University of Chicago. Her research interests focus on discrimination in policing, recidivism, crime and health, as well as neighborhoods and crime.

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