The Relationship Between Emotional Support and Health-Related Self-Efficacy in Older Prisoners

Abstract

Objective: To determine whether emotional support, and proportion of emotional support provided by specific sources (e.g., family, other prisoners, clinicians), is associated with health-related self-efficacy among older prisoners. Method: Cross-sectional study of 140 older prisoners age ≥50 with chronic medical illness who completed face-to-face interviews. Logistic regression, controlling for demographic, incarceration, and clinical/behavioral factors evaluated the association between emotional support, operationalized as a score and as a proportion of total emotional support from specific sources, and health-related self-efficacy. Results: Higher emotional support scores, and greater proportion of support from clinicians, were associated with lower likelihood of poor health-related self-efficacy. Those with >50% of their emotional support coming from other prisoners had higher likelihood of poor self-efficacy. Discussion: Among older prisoners with chronic illness, higher emotional support, particularly from clinicians, is associated with lower likelihood of poor self-efficacy; relying on other prisoners for emotional support is associated with poor health-related self-efficacy.

Keywords

social support self-efficacy prisoners elderly aging

Introduction

An unintended consequence of mass incarceration in the United States has been an exponential increase in the number of aging prisoners. The number of older prisoners has grown 500% since 1990 (Carson, 2015). This tremendous growth not only is a result of mandatory minimum sentencing laws and more arrests in later age but also reflects population aging in general (Carson, 2015; Luallen & Cutler, 2015). Prisoners are considered “old” in their 50s as the ongoing stresses of incarceration and unhealthy lifestyles paired with inadequate health care outside the corrections system frequently result in accelerated aging (Ahalt, Trestman, Rich, Greifinger, & Williams, 2013; Human Rights Watch, 2012). Hence, older prisoners have higher rates of chronic medical illness as compared with their age-matched peers living in the community (Binswanger, Krueger, & Steiner, 2009; Fazel & Baillargeon, 2011; Maruschak & Beck, 2001; Williams et al., 2006; Wilper et al., 2009) and younger inmates (Fazel & Baillargeon, 2011; Maruschak, 2008), and they often have multiple conditions (Nowotny, Cepeda, James-Hawkins, & Boardman, 2016).

The Eighth Amendment of the U.S. Constitution mandates that correctional facilities provide adequate health care to prisoners, which includes access to care, professional clinical judgment, and administration of treatment as prescribed by the clinician (Estelle v. Gamble, 429 U.S. 97 (1976). No. 75-929). With the growing number of older prisoners, costs related to correctional health care for this population are especially high, with estimates indicating US$16 billion per year for U.S. taxpayers (Ahalt et al., 2013; Chettiar, Bunting, & Schotter, 2012; Human Rights Watch, 2012). Consequently, strategies are needed to optimize older prisoners’ health while minimizing health care costs.

One approach to meeting the increasing health care needs of the old-age prison population may be to encourage self-care as part of managing one’s health. Self-care refers to intentional behaviors one engages in to care for one’s health, such as adhering to medications, regularly seeing a primary care physician, and following a prescribed diet. Higher ability to perform self-care activities is associated with better quality of life and independence in activities of daily living among older persons, in general (Borg, Hallberg, & Blomqvist, 2006; Golden et al., 2009). Given the established benefits of self-care in nonincarcerated populations, implementation of programs to enhance self-care practices in prisons where chronic medical illness is overrepresented has been encouraged (Reagan, Walsh, & Shelton, 2016; Ruggiano, Lukic, Blowers, & Doerner, 2016). Some examples of promoting self-care include distributing self-monitoring blood-glucose meters to diabetic prisoners (Buskey, Mathieson, Leafman, & Feinglos, 2015) and using posttraumatic stress disorder peer support groups for veterans in prison (Kopera-Frye et al., 2013). However, the theoretical framework of social cognitive theory indicates that to engage in health-promoting self-care behaviors, it is first necessary for one to perceive that he or she is capable of performing the behaviors (Bandura, 1977). This perception regarding confidence in one’s ability to perform health-promoting self-care behaviors is known as health-related self-efficacy (Grembowski et al., 1993; M. Seeman & Seeman, 1983).

There is a large body of evidence supporting an association between health-related self-efficacy and a variety of positive self-care behaviors in middle-aged and older persons living in the community. Much of this literature, which is grounded in social cognitive theory, focuses on individuals with chronic illness as self-care is often critical for achieving and maintaining optimal health-related outcomes in the context of living with a chronic illness. For example, higher ratings of health-related self-efficacy have been associated with positive self-care behaviors including improved symptom monitoring in those with chronic obstructive pulmonary disease (Warwick, Gallagher, Chenoweth, & Stein-Parbury, 2010), as well as better glycemic control and greater engagement in self-care behaviors such as foot care and blood-glucose testing in those with type II diabetes (Gao et al., 2013; Norris, Engelgau, & Narayan, 2001).

Among older prisoners with chronic illness, emerging research indicates that greater health-related self-efficacy is associated with greater participation in self-care behaviors. In a study of 51 older male prisoners reporting between two and 13 chronic conditions, Loeb and Steffensmeier (2006) found that those reporting greater confidence in managing their health were significantly more likely to engage in health-promoting behaviors including immunization programs and exercise programs (Loeb & Steffensmeier, 2006). Yet, this same study also indicates that there is room to improve older prisoners’ ratings of health-related self-efficacy, with approximately 40% of the participants indicating only some or a little confidence to currently manage their health (Loeb & Steffensmeier, 2006). Furthermore, in a related qualitative study, the majority of older prisoners expressed significant fears about being able to manage their health once they are discharged from prison (Loeb, Steffensmeier, & Myco, 2007). As most prisoners return to the community (Rich et al., 2014), it can be expected that a large number of aging parolees and newly released prisoners will need to manage their health “on the outside.” Because the majority of older prisoners have at least one chronic illness (Maruschak, Berzofsky, & Unangst, 2016), improved understanding of factors associated with health-related self-efficacy may help correctional health care providers, administrators, and policy makers to determine which older prisoners may be more or less likely to engage in health-promoting self-care behaviors both during incarceration and upon release.

In the context of Bandura’s social cognitive theory, emotional support from others is posited to facilitate individuals’ beliefs in the types of activities in which they can successfully engage (Bandura, 1981, 1986, 1989). Emotional support is defined as support that involves the establishment of empathy, love, trust, and caring (Heaney & Israel, 2008). Accordingly, studies of community-living older persons have shown that higher levels of emotional support are associated with greater feelings of self-efficacy (McAvay, Seeman, & Rodin, 1996; T. E. Seeman, Unger, McAvay, & Mendes de Leon, 1999; Steptoe, Shankar, Demakakos, & Wardle, 2013) and health-related self-efficacy among older persons (Gallant, 2003). It has been suggested that the sense of predictability and stability provided through feelings of emotional support may positively affect self-efficacy. Other beneficial mechanisms of emotional support include increased feelings of self-esteem and increased feelings of control or sense of mastery over one’s environment (Cohen, 1988; Cohen & Wills, 1985). For those with chronic illness, emotional support may also translate to greater self-efficacy to manage one’s condition through a beneficial impact on motivation, coping, and morale (Gallant, 2003). However, in the unique prison setting, it is uncertain whether emotional support may be similarly associated with self-efficacy. The inherent stress of prison life (e.g., noise, shakedowns/searches, witnessing assaults, fear of victimization) may offset one’s sense of stability or control over the environment or one’s ability to cope with a chronic illness that otherwise may be provided by emotional support.

Furthermore, as people age, they tend to proactively reduce the size of their social networks and focus on fewer yet more emotionally meaningful relationships, a phenomenon referred to as “selective narrowing” (English & Carstensen, 2014). Selective narrowing has also been found to occur within the prison setting, with older prisoners reporting smaller yet emotionally closer social networks than their younger counterparts (Bond, Thompson, & Malloy, 2005). Whereas older persons in the community largely report that family members comprise the largest proportion of their close support networks (Fuller-Iglesias, Webster, & Antonucci, 2015), those who are “aging in place” in prison are likely to be estranged from family due to years of confinement (Bond et al., 2005). Therefore, among older prisoners, the quantity and quality of emotional support from family sources may be minimal. Even if family ties have been maintained throughout the course of incarceration, emotional support may be considerably strained; mounting evidence indicates the negative impact of incarceration on the family unit (Turney, 2015; Wildeman & Wang, 2017). Thus, older prisoners may need to rely on sources of emotional support, other than family, who are perceived as emotionally available within the confines of prison, such as other inmates, corrections officers, or prison health care providers. Yet very little is known about relationships between these types of sources of emotional support and health-related self-efficacy in the older prisoner population.

In the present study, we evaluated the association between emotional support and health-related self-efficacy in a sample of male and female older prisoners with chronic medical illness. In accordance with Bandura’s social cognitive theory, we hypothesized that older prisoners reporting lower levels of emotional support would have lower health-related self-efficacy, even after controlling for potential confounders such as disability in activities of daily living that are specific to the prison setting (e.g., walking to chow; standing in line for medications; Williams et al., 2006) and depression (Barry, Wakefield, Trestman, & Conwell, 2016b; Kim, Shim, Ford, & Baker, 2015). In addition, because little is known about sources of social support among older prisoners, we described what types of sources of emotional support (e.g., another inmate; family member/spouse) were reported by older prisoners, and determined whether the proportion of emotional support received by these various types of sources was associated with health-related self-efficacy.

Method

Participants and Procedure

The University of Connecticut Health Center Institutional Review Board and the Connecticut Department of Correction (CTDOC) Research Advisory Committee approved the study. Eligible participants were age ≥50, incarcerated in one of three CTDOC facilities, English-speaking, had one or more chronic conditions, and voluntarily consented to participate. Of these three facilities, one housed exclusively female prisoners. Per the approved study protocol, prisoners in administrative segregation and those who were currently hospitalized were ineligible due to safety concerns. Recruitment procedures have been described elsewhere (Barry, Wakefield, Trestman, & Conwell, 2016a, 2016b). In brief, recruitment letters were sent in batches to 453 eligible prisoners between September 2012 and June 2015. Prisoners interested in participating wrote their name and inmate number on page 2 of the letter and placed the completed form in the Mental Health Request Box or Medical Requisition Box, depending on the facility. After retrieving the forms (n = 185, or 40.8% of those invited to participate throughout the recruitment period), the research assistant (RA) scheduled the eligibility screenings. Potential participants were escorted by correctional officers and met privately with the RA in professional visit (e.g., attorney visit) areas. The RA reviewed the study purpose, specified that there were neither incentives for participating nor negative consequences for refusing, and asked prisoners to use their own words to describe the study purpose and procedures to ensure their understanding of the study. There were 167 older prisoners who provided written consent. Of the 18 prisoners who submitted a form but did not participate, one was non-English speaking, two had been relocated to another facility, four refused to meet, and 11 decided that they were not interested in participating. Face-to-face interviews occurred immediately thereafter and demographic data were collected in addition to additional data as will be further described. Reviews of medical charts (i.e., chronic medical illnesses) and CTDOC data (i.e., years incarcerated for the current offense, expected sentence length, repeat offender, violent or nonviolent offense) were completed within approximately 2 weeks of the interviews.

Measures

Chronic medical illness

Chronic medical illness was ascertained via medical chart review. Study participants were considered as having a chronic illness if they had at least one of the following 12 physician-diagnosed conditions: hypertension, myocardial infarction, congestive heart failure, stroke, diabetes mellitus, arthritis, hip fracture, chronic lung disease, cancer, HIV/AIDS, Hepatitis C, or a sexually transmitted disease. Participants with no chronic illness were excluded, and for those with chronic illnesses, the total number was summed to create a burden of chronic illness measure.

Dependent variable: Health-related self-efficacy

Health-related self-efficacy was assessed by asking participants to rate their level of confidence using the following two questions adopted from the Stanford Chronic Disease Self-Efficacy Scale: “How confident are you that you can manage your own health” and “How confident are you that you can ask a doctor about things about your health that concern you” (Loeb, Steffensmeier, & Kassab, 2011; Lorig et al., 1996). Responses were coded on a scale of 1 (not at all confident) to 5 (completely). Both questions had a nonnormal distribution of responses that were highly skewed to the left. Consequently, responses for each of the two questions were collapsed into two groups; “not at all,” “a little,” and “fairly” confident were combined into “suboptimal” self-efficacy, and “very” and “completely” confident were combined into “good” self-efficacy. Participants with suboptimal self-efficacy for either question were considered to have poor health-related self-efficacy, and all other participants were considered to have good health-related self-efficacy. We also operationalized health-related self-efficacy as the total score of the two questions, with possible scores ranging from 2 to 10, and then log-transformed the score to achieve a more normalized distribution.

Independent variable: Emotional support

Emotional support was assessed using seven questions from the Medical Outcomes Study Social Support Survey (Sherbourne & Stewart, 1991). Participants were asked in these seven questions how often other individuals were available to provide emotional support (e.g., “Someone you can count on to listen to you when you need to talk,” “Someone who shows you love and affection,” “Someone to help you make decisions”). Potential responses to these seven questions included “1 = none of the time,” “2 = a little of the time,” “3 = some of the time,” “4 = most of the time,” or “5 = all of the time.” Scores range from 7 to 35, with higher scores indicating greater level of emotional support. This continuous measure of global emotional support was the primary independent variable used to evaluate the relationship between emotional support and health-related self-efficacy.

Following approaches used by Litwin and Landau (2000) to build social support and social network measures for older adults, we also created measures to characterize the size and composition of emotional support networks of study participants. To characterize size of emotional support network, whenever participants reported for each of the seven emotional support questions that another individual was available to them “a little,” “some,” “most,” or “all of the time,” a follow-up question was asked about the types of people who provided the specific support indicated in that question. Because different types of people may provide different types of support, participants could list different people for each of the seven questions. Participants were asked to choose all that applied from a list of 10 types of people: another inmate, doctor, nurse, therapist/counselor, corrections officer, spouse, family member other than a spouse, clergy, lawyer, and other. Those selecting “other” were asked to specify (e.g., friend outside of prison; AA member). Then, the total number of people providing support (up to 10 for each question) for each individual participant was summed across the seven questions, yielding a total sum of emotional supports that could range from 0 to 70.

To characterize composition of emotional support network, we then created measures for each type of person reported across the seven emotional support questions. A “family/spouse” source of emotional support category was created by adding responses of spouse and family member other than a spouse, and a “clinician” category was created by adding responses of doctor, nurse, and therapist/counselor. Because “friend from the outside” was frequently mentioned by those who selected “other” for each of the seven questions, we also created a separate category for this response. Then, we quantified the percentage of each participant’s total sum of supports that was provided by each category of support, creating a total of eight continuous variables. For example, a participant with a sum of supports totaling 14 may have their support distributed as 28.6% from another inmate (another inmate listed as a source of support four times across the seven questions = 4/14), 50% from a family member/spouse (family member/spouse listed as a source of support seven times across the seven questions), 14.3% from a friend on the outside (friend listed as a source of support two times across the seven questions), and 7.1% from a clinician (clinician listed as a source of support one time across the seven questions). Using this method, two participants with a sum of supports totaling 14 may have different distributions of who was providing the support.

Finally, in addition to creating a “profile” of the distribution of support for each individual study participant, we also quantified the percentage distribution of who was providing the support to the sample of older prisoners as a whole (i.e., what proportion of the sum of support for the total sample was being provided by another inmate?, by a clinician?, etc.). To determine these percentages, we divided the sum of each category of support by 1,283―which was the total sum of supports reported by the study participants.

Visits

Each of the three correctional facilities included in the present study allows prisoners to have visitors. Consequently, study participants were asked the question, “Are there visitors who come to see you?” This variable was coded as a yes/no variable.

Clinical/behavioral variables

Having pain for most days of the month for 3 consecutive months indicated chronic pain (yes vs. no). Participants rated both their eyesight and hearing, respectively, as “excellent,” “very good,” “fair,” or “poor.” Responses were combined such that those rating either their vision or their hearing as “poor” were grouped versus all others. A modified version of the Williams prison activities of daily living (PADLs) index assessed PADL disability (Williams et al., 2006). Participants rated their level of difficulty performing six activities: dropping to the floor for alarms, climbing on/off the top bunk, hearing orders from staff, walking while wearing handcuffs, standing in line for medications, and walking to chow. Those reporting one or more PADLs as “very difficult” or “cannot do” were considered to have PADL disability. The CAGE, a four-question screening test for alcohol dependence (Bush, Shaw, Cleary, Delbanco, & Aronson, 1987), was administered to participants endorsing lifetime alcohol use. The CAGE acronym refers to the four screening questions which ask whether you have ever felt that you should “cut down” on drinking, whether others have “annoyed” you by criticizing your drinking, whether you have ever felt “guilty” about drinking, and whether you have ever had an “eye-opener” drink, that is, a drink first thing in the morning?. Two positive responses indicate alcohol dependence. Finally, the nine-item Patient Health Questionnaire (PHQ-9) assessed depression (Kroenke, Spitzer, & Williams, 2001). Participants were asked how often in the past 2 weeks they were bothered by problems including “feeling down, depressed, or hopeless” and “feeling tired or having little energy.” Symptom frequency is rated from 0 to 3 (“from not at all” to “nearly every day”) with scores ranging from 0 to 27. A cutpoint of ≥15 indicates moderate to severe depressive symptoms, often simply referred to as depression (Kroenke et al., 2001). Each of these aforementioned variables was considered as a potential confounder because they each have been associated with either health-related self-efficacy (Jackson, Wang, Wang, & Fan, 2014; Kadden & Litt, 2011; T. E. Seeman et al., 1999; Stevenson, Hart, Montgomery, McCulloch, & Chakravarthy, 2004; Tovar, Rayens, Gokun, & Clark, 2015) or emotional support (Emerson, Boggero, Ostir, & Jayawardhana, 2017; Reinhardt, Boerner, & Horowitz, 2009; Schwarzbach, Luppa, Forstmeier, Konig, & Riedel-Heller, 2014; Strawbridge, Wallhagen, Shema, & Kaplan, 2000) in prior studies of older persons.

Data Analysis

Descriptive statistics were calculated for participants’ characteristics. Chi-square or Fisher’s exact tests for categorical variables and either t tests or Wilcoxon tests for continuous variables and count variables were used to conduct bivariate analyses to determine the associations between participants’ demographic, incarceration, and clinical/behavioral factors and the dependent variable, health-related self-efficacy (good vs. poor). T tests, Wilcoxon tests, or Pearson correlation statistics were used to evaluate the association between the aforementioned characteristics and emotional support. Logistic regression was used to evaluate the unadjusted association and adjusted associations between emotional support and health-related self-efficacy. Then, to achieve parsimony, variables associated with emotional support and/or health-related self-efficacy at the p < .10 level (two-tailed) in bivariate analyses were considered for inclusion in the multivariable logistic model, with the exception of age, gender, and years in prison for the current offense that were forced into the model. The adjusted model was tested by entering blocks of covariates as described above. The variable “repeat offender” was excluded from the model given that it was highly correlated with age. As a sensitivity analysis, we substituted the log-transformed self-efficacy score for self-efficacy as a dichotomous outcome and used linear regression to determine whether increasing emotional support score was associated with increasing health-related self-efficacy. We also ran separate logistic regression models to determine whether increasing proportion of emotional support provided by specific types of support (e.g., proportion of support provided by another inmate) was associated with health-related self-efficacy. The p values for these models were adjusted for multiple comparisons assuming a false discovery rate of 5% (Benjamini & Hochberg, 1995). Data were analyzed using SAS Version 9.4.

Results

Of the 167 participants currently enrolled in the study, 140 (85.9%) reported at least one chronic medical illness and comprised the sample for this analysis. The most common chronic medical illnesses were high blood pressure (70%), chronic lung disease (30%), arthritis (30%), diabetes (26%), and Hepatitis C (24%). There were no differences in age, gender, and race between those with and without chronic medical illness. The study sample (N = 140) had an average age of 57.4(±7.2) years (range = 50-83 years), were primarily male, were racially diverse, with age and race compositions similar to prisoners’ age ≥50 in the United States (ACLU, 2012), and the majority (71.2%) graduated from high school. On average, study participants had been incarcerated for the current offense for an average of 7.6 (±8.8) years (range = 0.008-38.8 years), and the majority were incarcerated for a violent offense (58.3%) and were repeat offenders (70.5%).

There were 44 (31.7%) study participants with a chronic medical illness who reported poor health-related self-efficacy. Of these, 11 (25%) were categorized as having suboptimal self-efficacy on both questions comprising the health-related self-efficacy variable. As shown in Table 1, neither having visits nor demographic and incarceration-related factors differed significantly between older inmates who reported good versus poor health-related self-efficacy. However, those reporting poor health-related self-efficacy were more likely to be depressed (38.6% vs. 21.1%, p = .03), report chronic pain (79.6% vs. 62.1%, p = .04), have poor hearing or vision (70.5% vs. 49.5%, p = .02), and report PADL disability (72.7% vs. 50.5%, p = .01). The average emotional support score for this sample was 22.5 (±8.1, range = 7.0-35.0), and those who reported poor health-related self-efficacy had significantly lower mean emotional support scores as compared with those with good health-related self-efficacy (20.5 ± 7.8 vs. 23.5 ± 8.0, p = .04). There were four participants who reported having emotional support “none of the time” (score = 7) for all seven questions.

Table 1.

Characteristics of the Study Sample Overall and According to Health-Related Self-Efficacy.

		Health-related self-efficacy
Characteristic	Study sample (N = 140)	Poorn = 44	Goodn = 95	p value
Demographics
Age, M (SD)	57.4 (7.2)	55.7 (6.2)	58.2 (7.5)	.05
Men, n (%)	91 (65.5)	28 (63.6)	63 (66.3)	.76
Women, n (%)	48 (34.5)	16 (36.4)	32 (33.7)
Race, n (%)				.57
White	77 (55.4)	26 (59.1)	51 (53.7)
Black	43 (30.9)	11 (25.0)	32 (33.7)
Hispanic/Other^a	19 (13.4)	7 (15.9)	12 (12.6)
Did not graduate high school (yes vs. no ref.), n (%)	40 (28.8)	15 (34.1)	25 (26.3)	.35
Incarceration-related factors
Years in prison for current offense, M (SD)^b	7.6 (8.8)	10.5 (14.9)	6.9 (9.4)	.18
Violent offense (yes vs. no ref.), n (%)	81 (58.3)	27 (61.4)	54 (56.8)	.62
Repeat offender (yes vs. no ref.), n (%)	98 (70.5)	35 (79.6)	63 (66.3)	.11
Clinical and behavioral factors
Number of chronic conditions, M (SD)^c	1.9 (1.1)	2.0 (1.7)	1.9 (1.7)	.80
Chronic pain (yes vs. no ref.), n (%)	94 (67.6)	35 (79.6)	59 (62.1)	.04
PADL disability (yes vs. no ref.), n (%)	80 (57.6)	32 (72.7)	48 (50.5)	.01
Poor hearing or vision (yes vs. no ref.), n (%)	78 (56.1)	31 (70.5)	47 (49.5)	.02
History of alcohol abuse (yes vs. no ref.), n (%)	72 (51.8)	34 (77.3)	38 (40.0)	<.001
Depression (yes vs. no ref.), n (%)	37 (26.6)	17 (38.6)	20 (21.1)	.03
Visitors
Visitors come to see them (yes vs. no ref.), n (%)	64 (46.7)	20 (45.4)	44 (47.3)	.84

Note. ref. = referent group; PADL = prison activities of daily living.

There were eight participants coded as Other, American Indian (n = 7), and Mixed race (n = 2).

Range = 0.008-38.8 years.

Chronic conditions, assessed via medical chart review, included hypertension, myocardial infarction, congestive heart failure, stroke, diabetes mellitus, arthritis, hip fracture, chronic lung disease, cancer, HIV/AIDS, hepatitis C, or a sexually transmitted disease.

Table 2 presents the results from the multivariable model evaluating the association between emotional support and health-related self-efficacy. In the unadjusted analysis (Model 1), emotional support was negatively associated with poor health-related self-efficacy (odds ratio [OR] = 0.95, 95% confidence interval [CI] = [0.91, 0.99]); the higher the emotional support score, the lower the likelihood of poor health-related self-efficacy. The effect size remained similar even after controlling for whether or not participants reported having visitors who come to see them (Model 2), demographic factors (Model 3), and incarceration-related factors (Model 4), but increased slightly with the addition of clinical and behavioral factors to the model (Model 5; OR = 0.93, 95% CI = [0.87, 0.99]). Among covariates, participants endorsing PADL disability (OR = 2.81, 95% CI = [1.01, 7.86]) and lifetime alcohol abuse (OR = 6.91, 95% CI = [2.60, 18.39]) were more likely to report poor health-related self-efficacy. Rerunning the model using the log-transformed health-related self-efficacy score as a continuous outcome variable achieved similar results; higher social support score was associated with higher self-efficacy score (B = 0.008; SE = 0.003; p = .008).

Table 2.

Association Between Emotional Support and Poor Health-Related Self-Efficacy.

	Model 1		Model 2		Model 3		Model 4		Model 5
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Emotional support (continuous)	0.95	[0.91, 0.99]*	0.95	[0.91, 0.99]*	0.94	[0.90, 0.99]*	0.95	[0.90, 1.00]	0.93	[0.87, 0.99]*
Visitors (yes vs. no ref.)			1.09	[0.51, 2.29]	1.20	[0.55, 2.62]	1.20	[0.55, 2.66]	1.83	[0.73, 4.55]
Age (continuous)					0.94	[0.89, 1.00]	0.94	[0.88, 1.00]	0.96	[0.89, 1.04]
Female (male ref.)					1.28	[0.54, 3.01]	1.45	[0.57, 3.70]	0.84	[0.27, 2.53]
Years in prison (continuous)							1.00	[0.95, 1.06]	1.01	[0.94, 1.07]
Violent offense (yes vs. no ref.)							1.28	[0.52, 3.17]	0.95	[0.33, 2.75]
Chronic pain (yes vs. no ref.)									1.96	[0.64, 6.06]
Poor hearing or vision (yes vs. no ref.)									1.96	[0.76, 5.03]
PADL disability (yes vs. no ref.)									2.81	[1.01, 7.86]*
Alcohol abuse (yes vs. no ref.)									6.91	[2.60, 18.39]**
Current depression (yes vs. no ref.)									1.30	[0.46, 3.64]

Note. OR = odds ratio; CI = confidence interval; ref. = referent group; PADL = prison activities of daily living.

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

Regarding sources of social support, Figure 1 presents the distribution of who provides emotional support to the total sample of older prisoners. Of the various types of people indicated as providing support across the seven questions comprising the emotional support scale, a family member or spouse was reported most frequently at 43% followed by another inmate at nearly 26%, a clinician at 12%, and a friend on the “outside” at 9%. The rest of the categories were each reported at less than 5%.

Figure 1.

Percent distribution of the sources who provide emotional support to the sample of 140 older prisoners.

Table 3 presents the results from the logistic regression models evaluating the association between proportion of support from the four most frequently reported sources of emotional support (i.e., spouse/family, another inmate, clinician, and friend on the “outside”) and health-related self-efficacy. Neither proportion of support provided by spouse/family nor proportion of support provided by a friend was associated with health-related self-efficacy. Without adjustment for multiple comparisons, increasingly higher proportion of support provided by another inmate and from a clinician were each associated with poor health-related self-efficacy, albeit in opposite directions. Greater proportion of emotional support provided by another inmate was associated with higher odds of experiencing poor health-related self-efficacy (OR = 1.02, 95% CI = [1.01, 1.04]). In contrast, greater proportion of emotional support provided by a clinician was associated with lower odds of experiencing poor health-related self-efficacy (OR = 0.95, 95% CI = [0.91, 0.98]). However, after adjusting for multiple comparisons, only greater proportion of emotional support provided by a clinician remained statistically significantly associated with lower odds of experiencing poor health-related self-efficacy at the p < .05 level.

Table 3.

Results From Logistic Regression Models Evaluating the Association Between Increasing Proportion of Total Emotional Support Coming From Specific Sources and Poor Health-Related Self-Efficacy.

Source of support^a	OR	95% CI	Raw p value^b	Multiple-comparisons adjusted p value^c
Family/spouse	0.99	[0.98, 1.01]	.56	.83
Another inmate	1.02	[1.01, 1.04]	.01	.08
Clinician	0.95	[0.91, 0.98]	.006	.018
Friend on the “outside”	1.01	[0.99, 1.03]	.46	.83

Note. OR = odds ratio; CI = confidence interval.

Each source of support variable is continuous and operationalized as proportion of total emotional support provided by the specified source.

The four logistic regression models were adjusted for visitors (yes/no) age, gender, number of years in prison, violent offense (yes/no), chronic pain (yes/no), poor hearing or vision (yes/no), prison activity of daily living disability (yes/no), history of alcohol abuse (yes/no), and depression (yes/no).

Models included adjustment for multiple comparisons based on a 5% false discovery rate.

Because greater proportion of emotional support provided by another inmate was potentially associated with poor health-related self-efficacy, we wanted to explore whether or not prisoners who mostly receive support from other prisoners may be a particularly vulnerable group. Consequently, we created a dichotomous variable to indicate those participants who get the majority (>50%) of their emotional support from another inmate. We found that a total of 31(22%) of the study participants had the largest proportion of their emotional support coming from other inmates. These prisoners were less likely to report having any visitors than those reporting less than 50% of their total support as coming from other inmates (23.3% vs. 52.8%, p = .004). They were also less likely to report receiving any emotional support from their spouse/family (32.3% vs. 85.3%, p < .001) or a clinician (19.4% vs. 43.1%, p = .02). In multivariable analysis, older prisoners with the majority of their emotional support being provided by another inmate were significantly more likely to have poor health-related self-efficacy (OR = 5.13, 95% CI = [1.54, 17.08]).

Discussion

Older prisoners are a unique subpopulation of incarcerated persons, often having a complex interplay of chronic illnesses. As the number of older prisoners in the United States continues to grow, creative approaches may be needed to optimize their health care. Through face-to-face interviews with 140 prisoners age 50 and older who have a chronic medical illness, we found that nearly 32% had poor health-related self-efficacy. We also found that higher global emotional support scores, and greater proportion of emotional support provided by clinicians, were associated with higher likelihood of having good health-related self-efficacy among older prisoners. Furthermore, those reporting that the majority (>50%) of their emotional support came from other prisoners were more likely to have poor health-related self-efficacy. Finally, we found that health-related self-efficacy was unrelated to the amount of emotional support provided by family members.

The finding that a higher emotional support score was associated with a greater likelihood of having good health-related self-efficacy is consistent with previous research conducted with community-dwelling older adults (Maeda, Shen, Schwarz, Farrell, & Mallon, 2013; McAvay et al., 1996; T. E. Seeman et al., 1999). Although it remains uncertain whether the mechanisms by which emotional support affects health-related self-efficacy among older prisoners are the same as among community-living older adults, there are several potential explanations for our results. Perceiving that there is someone to confide in or someone whom you can count on to listen to you, for example, may facilitate confidence in one’s abilities to manage his or her health. Higher ratings of emotional support may also positively affect health-related self-efficacy through perceived feelings of encouragement (Maeda et al., 2013) and may buffer stress associated with chronic illness (Sayers, Riegel, Pawlowski, Coyne, & Samaha, 2008). In the context of aging in prison, emotional support may serve as a safeguard from ongoing stresses of the prison environment that may exacerbate chronic illness symptoms. Research is needed to tease out how the prison environment may interact with emotional support to influence self-efficacy in older prisoners.

During the face-to-face interviews, we asked the study participants to indicate who provided them with the seven components of emotional support that comprised the overall scale. This sample of older prisoners most frequently reported a spouse or family member as a source of emotional support. Consequently, these individuals who have been living in prison for this offense for an average of nearly eight years still largely rely on relatives “on the outside” as a significant source of emotional support. Yet, a considerable proportion of emotional support is also being provided by other prisoners; of the total number of supports reported across all study participants, another prisoner was indicated more than 25% of the time.

Although emotional support from family members was the most frequently reported source of emotional support, we found that the proportion of one’s total amount of emotional support derived from family was not associated with health-related self-efficacy. It is possible that even if emotional ties with family members are maintained throughout the course of incarceration, the stress of being unwillingly separated from one’s family and the restrictions imposed on these ties through prison-specific rules regarding visitation hours or telephone contact may counterbalance any positive impact familial support may have on older prisoners’ health-related self-efficacy. During incarceration, one implication of these findings is that family members might be able to engage with clinicians in prisons to work together on approaches to improve older prisoners’ self-care and chronic illness management strategies. Further research is needed to determine whether, after release from prison, stronger family ties might help improve health-related self-efficacy among older prisoners with chronic illness.

We also found that greater proportion of emotional support provided by other inmates was associated with higher likelihood of experiencing poor health-related self-efficacy among older prisoners. Those with the majority of their support coming from other prisoners may be particularly vulnerable. It is possible that these prisoners have come to rely so much on other prisoners for emotional support that they feel less confident in their own ability to engage in health-promoting behaviors such as managing their health care or speaking with a physician. In future studies, it would be useful to determine whether those reporting higher proportions of emotional support provided by other prisoners are more likely to live in geriatric units within the prison. With the increase in the number of older prisoners, housing units are increasingly being developed that are closer to public areas such as the dining hall, have no top bunks, and have staff or other inmates trained to help older inmates with everyday tasks (McCarthy & Rose, 2013; Williams, Stern, Mellow, Safer, & Greifinger, 2012). While living together in the same unit may help to increase emotional support among older prisoners, it is possible that it may also negatively affect health-related self-efficacy if one is too reliant on his or her peers. It is also possible that the association between greater proportion of emotional support provided by other inmates and higher likelihood of experiencing poor health-related self-efficacy may be driven by unmeasured confounders that may influence both source of emotional support and health-related self-efficacy. For example, personality traits corresponding to manipulation, impulsivity, and antisocial behavior that are overrepresented in incarceration populations (Schaich Borg et al., 2013; Spaans, Molendijk, de Beurs, Rinne, & Spinhoven, 2017) may account for this finding. Those with the majority of support coming from other prisoners were also less likely to have visitors and to have support from spouse/family. Thus, these older prisoners who largely rely on other prisoners for support and do not have a support network outside of prison may be inherently different from older prisoners, perhaps in terms of unmeasured personality traits.

In contrast, as older prisoners’ proportion of emotional support provided by a clinician increased, likelihood of having good health-related self-efficacy also increased. It is possible that those older prisoners who had more frequent clinician visits also reported a higher proportion of emotional support coming from a clinician. Thus, the finding that higher proportion of emotional support coming from a clinician was associated with better health-related self-efficacy may be an artefactual relationship (i.e., more frequent clinician visits translates to higher self-efficacy) rather than a causal relationship. However, because the three prisons included in this study each function under the same standardized policies and procedures (https://health.uconn.edu/correctional/policies-and-procedures/), prisoners across these facilities should have similar opportunity to access medical care. In addition, we controlled for conditions such as chronic pain, vision and hearing impairment, and depression that may elicit more clinician visits. Furthermore, by limiting our sample to only those older prisoners who had a chronic illness, we attempted to control for potential differences in frequency of clinician visits that may occur in persons with chronic conditions compared with healthy persons. Some chronic conditions (e.g., diabetes) may require more clinician contact than other chronic conditions; therefore, disease-specific analyses in larger samples of older prisoners may help to build our understanding of this relationship between emotional support from clinicians and health-related self-efficacy.

Older prisoners who view their clinicians as a source of emotional support may feel more empowered to ask questions and ultimately understand more about managing their chronic illness. These findings may have implications for developing interventions. Efforts to build and strengthen trusting relationships between clinicians and older prisoners with chronic medical illness may positively affect health-related self-efficacy. Furthermore, perceiving clinicians as providers of emotional support may also have implications for prison release. Establishing sound relationships with health care providers as older prisoners transition from prison back to the community may improve their belief that they can manage their chronic illness even without the routine oversight of correctional health care. Future research is needed to determine whether older prisoners who have a higher proportion of support from clinicians are also better able to independently conduct self-care tasks both “on the inside” and after prison release. Overall, more studies are needed to identify older prisoners’ concerns regarding managing their health so that interventions focused on maximizing self-efficacy, and ultimately promoting self-care, can be developed and tested.

Consistent with findings from community-dwelling samples indicating that disability in activities of daily living is associated with worse self-efficacy (T. E. Seeman et al., 1999), we found that older prisoners with disability in PADLs, including walking to the chow line, climbing on and off a top bunk, or standing in line for medications, were more likely to have poor health-related self-efficacy. If older prisoners experience difficulty conducting activities needed for day-to-day living in prison, it follows that they are less likely to have confidence in their ability to adequately manage their health. Research is needed to confirm whether PADL disability is associated with one’s ability to conduct self-care behaviors. Establishing this link may then help to develop interventions to minimize PADL disability as individuals age in prison. Finally, and also consistent with existing literature (Hyde, Hankins, Deale, & Marteau, 2008), we found that a history of alcohol abuse was associated with poor health-related self-efficacy. However, despite being strongly associated with health-related self-efficacy, emotional support was still significant.

While our study provided a unique opportunity to enhance knowledge regarding older prisoners, who have been largely understudied, there are several potential limitations to acknowledge. The somewhat low participation rate and subsequently small sample size may, in part, reflect the inherent challenges of conducting research in correctional settings and recruiting prisoners (Cislo & Trestman, 2013). For example, prisoner interviews had to be scheduled around headcount and “chow.” It is possible that those with poor self-efficacy had greater concerns regarding how to handle the possibility of missing chowtime or a disruption of their routine and therefore chose not to participate. It is also conceivable that the prisoners who opted to participate in the research study may have been more inherently social, and thus had more perceived social support, than those who chose not to participate. Consequently, our sample may have overrepresented those with better social support and higher self-efficacy in comparison with the population of older prisoners in the United States.

Another inherent challenge of conducting research in prisoners is that instruments validated in the general population may not be applicable to prisoners. As such, the scale from which our two self-efficacy items were selected, the Stanford Chronic Disease Self-Efficacy Scale, includes several items that are not relevant for prisoners, for example, “How confident are you that you can get information about your disease from community resources?” Hence, although the two items used in our study have been validated within the context of a larger scale, they have not been validated together as a stand-alone assessment of health-related self-efficacy. Given the large number of incarcerated persons in the United States, development of validated measures to assess health outcomes in prisoners is encouraged.

We found that nearly 70% of the older prisoners in our study reported having good health-related self-efficacy, despite the constraints of prison life. Whereas this finding is promising, further research is needed to confirm that higher health-related self-efficacy translates to a higher likelihood of engaging in self-promoting health behaviors. Relatedly, among those considered as having poor health-related self-efficacy, we do not know why self-efficacy is low. Prisoners may be capable of managing their own health. Yet, limits on choice and personal control that are inherent challenges of the prison setting may have affected their responses regarding self-efficacy.

We were also unable to evaluate other types of social support, such as instrumental support and participation in organized prison activities (e.g., vocational training, self-help groups, sociocultural meetings). Future research should evaluate how these types of social support may affect older prisoners’ health-related self-efficacy and their subsequent ability to engage in self-care behaviors. Finally, the cross-sectional study design limited our ability to make causal inferences regarding the relationship between emotional support and health-related self-efficacy.

Our findings indicate that even in the unique context of prison, emotional support is associated with health-related self-efficacy. As emotional support is potentially modifiable, efforts to bolster emotional support in older prisoners with chronic illness may positively affect confidence in their abilities to manage their chronic conditions. In particular, we found that the more that older prisoners perceived clinicians as providing emotional support, the less likely they were to have poor health-related self-efficacy. We realize that these are cross-sectional relationships; however, one potential implication of these results is that efforts to build trusting relationships between clinicians and older prisoners may subsequently help improve prisoners’ health-related self-efficacy during their prison stays or after their release. Furthermore, maximizing health-related self-efficacy in older prisoners may also offer a first step toward helping them to manage their chronic conditions upon release.

Footnotes

Acknowledgements

The authors gratefully acknowledge Krystle Sullivan, MA for her assistance with data collection; Dorothy B. Wakefield, MS, for assistance with data management; and collaboration and support from the Connecticut Department of Correction.

Authors’ Note

The views expressed in this publication do not necessarily reflect the policies or views of the Connecticut Department of Correction.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the American Foundation for Suicide Prevention (L. Barry) under Grant SRG-092-1 and the National Institutes of Health (L. Barry) under Grant R01 MH106529.

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