Impacts of Incarceration on Health Focusing on Minority Males: Considerations for COVID-19 and Future Pandemics

Abstract

Long-standing health and social inequalities associated with minorities have increased their risk for infection, hospitalization, and death related to COVID-19. This disparity is further exacerbated with incarcerated individuals, yet little attention, both prepandemic and presently, has been devoted to collecting up-to-date data. This study uses the 2004 Survey of Inmates in State Correctional Facilities (SISCF), the most recent data, to explore the general offender population and self-reported chronic and medical health conditions to highlight how COVID-19 will impact marginalized populations. Results from the four binary regression models found that minority males are more likely to have chronic illnesses which increase in probability with longer sentences, number of incarcerations, and advancement in age. Our findings advocate for the development of recent data sets on inmate health, particularly minority individuals, as well as the construction of more precise health measures to address these health disparities, including COVID-19.

Keywords

correctional health care COVID-19 corrections special populations

Introduction

To date, extensive literature has been collected highlighting the racial disparities across both the criminal justice system and the continuum of medical care in disease prevalence, prevention, management, and outcomes (Binswanger et al., 2011; Dumont et al., 2012; B. A. Williams et al., 2012). Comparatively, little attention has been directed at understanding how these population health disparities directly impact the criminal justice system, specifically with regard to correctional health care and the recent emergence of the coronavirus (COVID-19) (Adler & Newman, 2002; Binswanger et al., 2009, 2011). Although the prevalence of chronic illness and COVID-19 are seen across all racial and ethnic groups, in general, minority males receive poorer care when compared to their white counterparts (Binswanger et al., 2011; Wilper et al., 2009). The Centers for Disease Control and Prevention (CDC) (2021) has consistently highlighted that race and ethnicity serve as risk markers for factors that increase the likelihood of having underlying health conditions due to their connection with socioeconomic status, access to health care, and increased exposure to illness due to employment. Interestingly, health disparities within the COVID-19 pandemic are beginning to mirror that of pre-existing health gaps seen within the general population, specifically groups that have been marginalized by race/ethnicity are now more likely to be affected by the COVID-19 pandemic.

Despite the known rates of racial disparity, little knowledge exists with regard to the emerging large-scale health care costs associated with COVID-19 and medical professionals within correctional settings ability to both mitigate or potentially exacerbate current health disparities among racial groups. It has been identified that COVID-19 circulates rapidly inside locked institutions. Thirty-nine out of the 50 largest COVID-19 outbreaks in the United States were within prisons or jails (Wang et al., 2020). In addition, the death rate for COVID-19 is higher inside jails and prisons. Specifically, incarcerated people have a five and a half times higher infection rate and an overall COVID-19 death rate three times higher than nonincarcerated people (Saloner et al., 2020). Recent findings from correctional facility COVID-19 testing have reported higher prevalence rates of the virus among minority inmates, which may conceivably be linked to the aforementioned pre-existing racial health gap (Gibson, 2020). Specifically, incarcerated black inmates displayed a 3.5 greater COVID-19 prevalence rate, while Hispanic inmates displayed a prevalence rate of 5.9 when compared to white inmates (Gibson, 2020). In addition, in May 2020, black inmates accounted for 60% of the COVID-19 deaths in the New York prison system despite making up only 50% of the state’s incarcerated population (D. R. Williams & Cooper, 2020). Furthermore, compounding the risk for contracting COVID-19, previous exploratory studies focusing on epidemiology have confirmed that prison inmates, principally minority males, experience higher rates than the general population of transmission of disease, substance abuse, and chronic health conditions including hypertension, diabetes, asthmas, and cancer, even when adjusting for confounders, such as age (Binswanger et al., 2011; Dumont et al., 2012; Harzke & Pruitt, 2018). The Pew Charitable Trusts (2014) has attributed this increase in health conditions to challenges faced by correctional staff stemming from improper staffing, greater disease prevalence, older inmates, and the location of prison facilities. Consequently, inmates often experience multiple transfers stemming from health-related rationales once involved in the criminal justice system, which can result in complications accessing an adequate continuity of care including proper treatment, access to medication, and delayed treatment (Binswanger et al., 2011; Dumont et al., 2012).

As a result of these known detrimental effects of the correctional system combined with the recent COVID-19 pandemic, scholars and medical professionals across the nation are calling for more attention toward addressing the prevalence of chronic illness among incarcerated minority males and the communities to which they will return. By addressing the illnesses that widen the racial health disparity gap and its influence on COVID-19 transmission, medical professionals can better identify pre-existing chronic conditions through improved medical documentation and data collection in an effort to discover methods that can result in risk reduction for both current and future pandemics. Therefore, this article contributes to the on-going correctional health care response to the COVID-19 pandemic and explores the potential impact of pre-existing chronic conditions among minority males. It examines the minority health gap within state correctional facilities using a nationally representative sample addressing chronic illness and medical conditions in an effort to address the potential impact of COVID-19 and better prepare future pandemics. By examining the minority male health gap among those incarcerated prior to the COVID-19 pandemic, we advocate for the development of more recent data collection regarding correctional health care and chronic illness prevalence, as well as more precise health measures.

Background

Correctional facilities present themselves as institutions that can provide a positive influence by linking an underserved population to proper health care services (Dumont et al., 2012). In 2015, the Bureau of Justice Statistics (BJS) found that incarcerated individuals are receiving health care services and almost half (48%) of prisoners reported that the health care they received while incarcerated was better or similar to the care they received a year prior to admission (Maruschak et al., 2015). However, this perception of correctional health care is largely attributed to the absence and lack of participation in health care services prior to incarceration, given that correctional health care services represent the first experience of health care for majority of incarcerated individuals (Dumont et al., 2012; Harzke & Pruitt, 2018; Maruschak et al., 2015). This access to health care services can be seen most prominently since the 1979 Supreme Court ruling, Estelle v. Gamble, which mandated that correctional facilities must provide timely and sufficient medical care to all inmates (Ahalt et al., 2013; Dumont et al., 2012). Following Estelle v. Gamble (1976), the United States Department of Corrections has seen an annual increase in prison spending of approximately 77 billion dollars, with over 10% of the funds being used for health care purposes (Ahalt et al., 2013). Despite this increase in health care funding and increased access to health care services, correctional facilities are still being faced with logistical difficulties of health services implementation, insufficient staffing protocols, and reluctant administers as a result of prison overcrowding (Dumont et al., 2012; Harzke & Pruitt, 2018; Maruschak et al., 2015).

In 2018, it was estimated that over 1.4 million individuals were serving time within state and federal correctional facilities (Carson, 2020), allowing for those incarcerated to become more vulnerable to disproportionate health outcomes in areas of chronic illness, due to the unhealthy environments in which they are exposed (Cloud et al., 2014). The BJS (2015) found that 44% of incarcerated persons experience at least one chronic health condition, such as high blood pressure, diabetes, asthma, hypertension, tuberculosis (TB), hepatitis, or cirrhosis of the liver (Maruschak et al., 2015). Of those diagnosed with a chronic health condition, 66% were identified as suffering from a health condition that required health care assistance, such as prescription medication or professional medical care (Maruschak et al., 2015). More concerning is the consistent increase in chronic medical conditions among institutionalized individuals over time (Maruschak, 2006, 2008; Maruschak et al., 2015). Since the initial wave of the Bureau of Justice survey in 2006, hypertension has increased from 13.7% to 23%, asthma from 8.9% to 11.9%, and diabetes from 4.1% to 7.4%. Likewise, 24% of imprisoned individuals reported having multiple chronic conditions. For example, 7% of inmates reported having both high blood pressure and diabetes, which result in an increased risk for cardiovascular disease (Maruschak et al., 2015).

Although there are health care services within correctional facilities to combat chronic illness, the quality of these services is insufficient when compared to the standard level of care provided to the general population (Cloud et al., 2014; Harzke & Pruitt, 2018). Currently, over 40% of the incarcerated population has reported ever having a chronic condition, compared to less than one-third of the noninstitutionalized population (Harzke & Pruitt, 2018; Maruschak et al., 2015). Incarcerated persons have been found to be diagnosed at significantly higher rates than the general population for high blood pressure, stroke-related problems, diabetes, heart disease, asthma, and cirrhosis of the liver (Harzke & Pruitt, 2018; Maruschak et al., 2015). This health disparity and current deficiency in quality of care can be attributed to the overwhelming rate of individuals entering into the correctional environment with pre-existing chronic medical conditions combined with limited correctional medical staffing (Cloud et al., 2014; Harzke & Pruitt, 2018; Maruschak et al., 2015). Approximately 73% of imprisoned individuals reported knowledge of having their chronic condition prior to incarceration and 27% of inmates’ are diagnosed upon admission (Maruschak et al., 2015). Scholars have suggested that the present health divergence seen among the incarcerated population may be a result of one’s lifestyle prior to entering the criminal justice system coupled with the detrimental effects of prison overcrowding (Cloud et al., 2014; Harzke & Pruitt, 2018). Harzke and Pruitt (2018) note that persons involved in the criminal justice system suffer from higher rates of disadvantage than noninvolved persons, particularly in poverty, educational attainment, lowered employment, homelessness, food insecurity, and limited physical activity. As a result, these individuals report a higher likelihood of engaging in risky health behaviors, typically related to substance abuse, while having also lowered health literacy, limited health care access, and a lack of health insurance (Harzke & Pruitt, 2018). Given these pre-existing risk factors associated with the offender population, it is not surprising individuals are entering correctional facilities with chronic health conditions. However, with over half of incarcerated persons being released from correctional facilities annually combined with the recent emergence of the COVID-19 pandemic, correctional facilities across the nation are being faced with unique health care challenges, placing those with pre-existing chronic conditions at risk (Carson, 2020; Hagan et al., 2020; Wallace et al., 2020).

Correctional Health Care and COVID-19

The recent emergence of the global COVID-19 pandemic has presented a mass threat to public safety across the world as a result of its sudden onset and rapid transmission rate. Due to the virus’s threat to individuals, communities, and social institutions, countries around the globe have been faced with hospitals overcapacity, stay-at-home orders, and historic levels of unemployment. The United States in particular has appeared to be vastly underprepared for the effects of the COVID-19 pandemic, exceeding all other countries in confirmed cases, with more than 3.2 million confirmed cases and 954,603 deaths from the virus, while on-going data are still being collected (John Hopkins University of Medicine, 2021). The recent crisis faced by the public health care system has revealed unprecedent disparities in the U.S. population’s access to health care (Gold et al., 2020; Hsu et al., 2020). As COVID-19 continues to disrupt nearly all social institutions within the United States, systems are being forced to acknowledge the present pressures, vulnerabilities, and disparities facing the country (Abraham et al., 2020; Oladeru et al., 2020).

The United States corrections system represents one institution that has been faced with unique ramifications from the COVID-19 pandemic (Hagan et al., 2020; Oladeru et al., 2020; Wallace et al., 2020). With the United States having the highest incarceration rate in the world, 678 per 100,000 residents intermingling with over 450,000 correctional staff and prison health care professionals, incarcerated people, and those in contact with them are at an increased risk for COVID-19 exposure (Abraham et al., 2020; Hagan et al., 2020; Oladeru et al., 2020; Wallace et al., 2020). High prevalence of chronic disease among the incarcerated population (Harzke & Pruitt, 2018) mixed with population-dense housing, restricted access to hygiene facilities and supplies, and limited space for quarantine procedures, early detection and diagnosis of COVID-19 within correctional facilities has become critical (Hagan et al., 2020; Wallace et al., 2020). More concerning is the inability for closure, allowing for the transmission of the virus to the surrounding community through staff, visitors, and inmate admission, transfer, and release to community supervision (Hagan et al., 2020; Wallace et al., 2020).

In response to the heightened risk correctional facilities pose for public safety, the CDC (2021) has begun COVID-19 testing throughout the nation’s correctional facilities. In March of 2020, the Louisiana Department of Health (LDH) began implementing surveillance for COVID-19 among correctional facilities in Louisiana, detecting and reporting outbreaks within many facilities (Wallace et al., 2020). Findings from this examination found that between March to April, Louisiana correctional facilities confirmed 489 COVID-19 cases, including 37 hospitalizations, and 10 deaths among incarcerated persons (Wallace et al., 2020). In addition, 253 cases, including 19 hospitalizations, and four deaths were reported among staff members (Wallace et al., 2020). Of the tested correctional institutions, administrators reported that they had an awareness of the virus and CDC guidelines to preventing transmission (Wallace et al., 2020). However, due to the uniqueness of the prison environment, challenges related to limited space for quarantine procedures and the inability for social distancing became apparent (Wallace et al., 2020). The CDC (2021) expanded its efforts by implementing a mass testing event among 15 jurisdictions throughout the United States in an effort to determine an estimated prevalence rate among the incarcerated population, reporting a median rate of 29.3% in 16 adult facilities (Hagan et al., 2020). Prior to this mass testing initiative, 15 of the 16 facilities identified at least one confirmed COVID-19 case, reporting a total increase in the number of known cases from 642 to 8,239 (Hagan et al., 2020). As of May 2021, “A State-by-State Look at Coronavirus in Prisons” (2021) reported that approximately 397,982 incarcerated individuals had tested positive for COVID-19 throughout the nation, resulting in 2,683 deaths. The states with the highest infection rates are California, Texas, and Michigan, while California, Texas, and Florida have the highest death rates from COVID-19 among incarcerated individuals. Regarding staff, the Marshall Project has also found that 113,169 correctional staff within the United States were infected with COVID-19 resulting 206 deaths (“A State-by-State Look at Coronavirus in Prisons,” 2021).

To combat transmission of the virus while maintaining supervision protocols, many facilities have focused their efforts on preventing the virus from entering the correctional setting by containing present outbreaks through admission restrictions and mass testing of all inmates, including those who are asymptomatic (Abraham et al., 2020; Aspinwall & Neff, 2020). For example, Colorado and Illinois have issued orders refusing the admission of new inmates into state prison facilities (Abraham et al., 2020). Whereas, Arkansas is allowing only staff members who test positive with no symptoms to remain at work (Gill, 2020). According to CDC (2021) recommendations for Correctional and Detention Facilities in May 2021, transfers between jurisdictions and facilities should be limited unless necessary for medical treatment, safety and security issues, release, or due to overcrowding. In addition, the CDC also recommends suspending all visitation, volunteers, and tours from facilities to limit exposure along with requiring exposed staff to quarantine regardless of test results. Despite the current efforts and transmission of the virus, United States correctional facilities still remain underprepared for the impact COVID-19 will have on the incarcerated population and its staff.

Prison Confinement, COVID-19, and the Minority Male Health Gap

Long-standing health and social inequalities associated with people of color have increased their risk for infection, illness, and death related to COVID-19 (CDC, 2021; Moore et al., 2020). The public health care system within the United States has recognized that the health of minority males within the general population is disadvantaged relative to whites (Price-Haywood et al., 2020) as minority males are more likely to live their lives with a chronic illness, experience shorter lifespans, and both contract and transmit illnesses when compared to their white counterparts (Massoglia, 2008; Schnittker et al., 2011). Interestingly, similar disease transmission and hospitalization rates of disproportionality among black and Hispanic minority groups related to COVID-19 are beginning to emerge in the general population (CDC, 2021; Hsu et al., 2020; Moore et al., 2020). Morbidity and mortality findings from the CDC (2021) on the virus report that older adults, black or Hispanic individuals, and homeless persons are overrepresented among hospitalized patients across the United States (Hsu et al., 2020), placing communities of color at risk for infection, severe illness, and death from COVID-19 (Moore et al., 2020). Specifically, black individuals are being diagnosed with the virus at rates 2.6 times greater than that of whites. They are also seeing high hospitalization and death rates, 4.7 and 2.1, respectively (CDC, 2021). Whereas, Hispanic individuals are 2.8 times more likely to be diagnosed, 4.6 times more likely to be hospitalized, and 1.1 times more likely to experience death compared to white individuals (CDC, 2021). As the racial health disparity gap related to COVID-19 among the general population continues to widen, institutionalized populations are receiving more attention from medical professionals due to the disproportionate incarceration rates seen among persons of color increasing the risk for disease transmission (Hagan et al., 2020; Jordan & Wilson, 2020).

Scholars have suggested that the recent effects of the COVID-19 pandemic have brought to light the decades of health disparities and injustices embedded within the United States Criminal Justice System (Abraham et al., 2020). Previous literature has well established the disproportionate impact harsh sentencing and mass incarceration has had on minorities and the communities in which they reside, suggesting that the worsened health status of incarcerated minority males may be a result of the implementation of punitive criminal justice initiatives (Abraham et al., 2020; London & Myers, 2006; Massoglia, 2008). Due to correctional facilities representing an environment that is both confined and prone to violent behavior, institutionalized individuals, as well as correctional staff, are at a higher health risk for the transmission of chronic conditions and unique illnesses not commonly diagnosed in the general population, such as tuberculous and hepatitis C (Harzke & Pruitt, 2018; Maruschak et al., 2015). Although inmates have been found to have significantly higher diagnoses of chronic health conditions, which also serve as a health risk for COVID-19 diagnoses, than the general population (Harzke & Pruitt, 2018; Maruschak et al., 2015), 51.9% of black inmates, 40.6% of Hispanic inmates, and 49.4% non-white/other inmates have reported ever having a chronic condition (Maruschak et al., 2015). Similar to the disproportionality reported within minority groups within the general population contracting COVID-19, correctional facilities are beginning to reflect similar transmission patterns of disparity among inmates (Gibson, 2020). Studies examining the COVID-19 effects on minority males by Gibson (2020) found that black inmates were 3.5 times more likely and Hispanic inmates were 5.9 times more likely to contract the virus when compared to their white counterparts. This leads to a large number of persons becoming infected with COVID-19 within correctional settings when considering that currently 928, 200 of incarcerated individuals identify as males belonging to a minority group within both state and federal correctional facilities. This is further compounded with the BJS (2020) report that an estimated 6% of white males aged 18 to 24 were sentenced to state and federal prisons, compared to the 12% of black and 10% of Hispanic male prisoners (Carson, 2020). Minority males entering the correctional system with disproportionate rates of chronic conditions (Harzke & Pruitt, 2018; Maruschak et al., 2015), in additional to residing in an environment already prone to poor health (Wallace et al., 2020), prison facilities are placing this population and their communities at a higher risk for both contracting and transmitting COVID-19 (Gibson, 2020; Hagan et al., 2020).

Study Objectives

This study examines the minority male health gap within state correctional facilities with regard to chronic illness among a nationally representative sample of inmates. By examining the minority male health gap prior to incarceration, we highlight the need for the development of up-to-date data sets on inmate health, as well as the construction of more precise health measures to address current and future pandemics and their overarching and inordinate impact on minority males. Our first objective explored if minority males disproportionately experienced chronic conditions while incarcerated? Chronic conditions included TB, diabetes, and cancer. As previously stated, chronic conditions place an individual at a higher risk of both contracting and dying from COVID-19. Incarceration coupled with having a chronic condition would place minority males in exceptional jeopardy during the current pandemic. The first two research hypotheses stem from this objective. Hypotheses 1 and 2 predict that minority males will have higher rates of chronic illness diagnosis compared to their white counterparts with regard to sentence length and number of incarcerations. The second objective examines medical conditions, given the high rate of health conditions needing medical assistance among inmates and the limited access to medical care within correctional facilities. COVID-19 has highlighted the under preparedness of the United States correctional facilities to handle the current pandemic, much less traditional medical and chronic conditions. This unreadiness combine with the existing health disparities for minorities males, both in and out of prison, placed minorities at a greater risk of dying during the current and future pandemics. The second objective generated the final two hypotheses that posited that minority males are more likely to report a health condition that required routine medical treatment, again, with regard to sentence length and number of incarcerations. Also, a number of factors related to incarceration, demographics, and health were explored, such as number of incarcerations, sentence length, substance abuse, socioeconomic status, age, race, and education level.

Method

This study uses secondary data collected by the United States Department of Justice as part of the 2004 Survey of Inmates in State and Federal Correctional Facilities (SISCF). The SISCF represents a nationally representative, stratified, systematic sample to gather data on inmates held within both State and Federal prisons in the United States. The survey is representative of respondents of at least 18 years of age who had been held in a correctional facility from October 2003 to May 2004. The SISCF was selected from the BJS (BJS) 2000 Census of State and Federal Correctional Facilities, which included a sampling frame of 1,549 state facilities collected by the United States Department of Justice. The 2004 sample contained 297 participating male state facilities, with 11,569 completed individual state interviews for the SISCF (see Table 1). Following the interviews, the state facilities were each grouped into eight strata, defined by census regions as Northeast, New York, Midwest, South, Florida, Texas, West, and California. The sample was conducted using a two-stage sampling frame, in which prisons were selected in the first stage and inmate survey selection was conducted in the second stage. Survey findings accounted for more than 14,752 variables, which provided information about the inmate’s current offense and sentence length, criminal background, personal characteristics, health, and prior drug and alcohol substance abuse treatment. This survey is of special interest in that it is the most recent, nationally representative data set that contains data pertaining to offenders at all risk-levels (violent and nonviolent) and the identification of chronic illness, highlighting the need for more recent large-scale inmate health data collection.

Table 1.

Descriptive Characteristics (N = 11,569).

Variables	N (%)	M (SD)
Age		2.257 (1.117)
Race
White	34.6 (4,002)
Non-white	65.4 (7,548)
Socioeconomic status		6.53 (3.224)
Substance abuse
Yes	11.5 (1,332)
No	88.5 (10,237)
Length of incarceration		1,028.80 (2,814.551)
Number of incarcerations		1.94 (2.224)
Chronic illness
Yes	12.2 (1,140)
No	87.8 (10,159)
Current medical diagnosis
Yes	41.8 (4,832)
No	58.2 (6,737)

Four binary logistical regressions were conducted controlling for relevant factors. Specifically, the first bivariate logistic regression examined the relationship between length of incarceration and chronic illness. The second logistic regression measured the relationship between an individual’s reported number of incarcerations and chronic illness. The third logistic regression assessed the relationship between length of incarceration and current medical conditions. The final logistic regression measured the relationship between an individual’s number of incarcerations and current medical conditions.

Dependent Variables

Our analyses included two dependent variables. To operationalize chronic health diagnoses, a variable was created based on the following question: “Have you ever had: Cancer, Tuberculosis, or Diabetes?” Responses were collapsed and dichotomized with yes coded as 1 and no coded as 0. Due to the sensitivity and restrictions on correctional health care diagnosis data only select chronic illnesses were available for analysis. Descriptive statistics for individuals were as followed: 1, 140 males (12.2%) within state correctional facilities reported having a chronic illness during their confinement, whereas 87.8% did not report having a chronic illness at the time of data collection.

The second and final dependent variable examined the presence of a current medical condition requiring treatment while imprisoned. Medical condition was operationalized by the response to the following question: “Do you have a current medical problem?” Reponses were dichotomized whereby yes was coded as 1 and no was coded as 0. Of those who identified as having a medical condition while incarcerated, approximately half 41.8% selected that they currently have a medical condition during the recall period compared to the 58.2% that did not have a medical condition.

Independent and Control Variables

With the recent attention surrounding COVID-19 and its impact on communities of color (CDC, 2021; Hsu et al., 2020; Moore et al., 2020), studies have reported that a racial disparity in disease transmission is beginning to emerge within correctional facilities (Gibson, 2020; Wallace et al., 2020). Therefore, the prominent focus of this study was to investigate the current prevalence rate of chronic illnesses among minority male inmates in state correctional facilities throughout the nation in an effort to better advocate for recent data sets in addressing populations at risk for COVID-19 and future pandemics. Due to the limited knowledge of the overall prevalence rate of chronic conditions within correctional facilities, length of incarceration and number of times an individual has been incarcerated were selected as the primary independent variables within the study to determine the impact incarceration has on disease transmission among male inmates.

Length of incarceration was selected due to the well-established relationship between sentence length and its propensity for exacerbating present health conditions (Massoglia & Pridemore, 2015). Specifically, correctional health care scholars have found a link between incarceration and increased disease transmission, suggesting that the correctional environment exposes individuals, particularly minority males, to a number of chronic diseases such as HIV, hepatitis B, hepatitis C, and TB and increases one’s exposure to stress (Harzke & Pruitt, 2018; Maruschak et al., 2015). Therefore, for the purpose of this study, length of incarceration was operationalized as the respondent’s self-reported months served at the time of data collection to explore the role of long-term incarceration exposure on the minority male health gap. Descriptive statistics displayed that on average, respondents served a sentence length of 1,028.80 months.

The second independent variable explored in the analysis was number of incarcerations. Given that prior literature has shown the exposure to incarceration can increase one’s risk for developing a chronic health or a treated medical condition at a greater rate than sentence length and has been linked to the minority health gap in the general population, number of incarcerations was examined to assess the role of multiple exposures of incarceration on health outcomes among minority males and its ability to influence community health upon release (Harzke & Pruitt, 2018; Maruschak et al., 2015; Massoglia & Pridemore, 2015). Therefore, number of incarcerations was coded as the respondent’s self-reported times entering a correctional facility at the time of data collection. Descriptive statistics found that respondents reported a mean of 1.94 number incarcerations, suggesting that on average individuals within the sample were entering state correctional facilities twice in their lifetime.

Each of the four analyses controlled for race, age, education level, socioeconomic status, and substance abuse. Race was recoded into a binary variable containing two categories: white (34.6%, N = 4002), non-white (65.4%, N = 7548). Age was self-reported in years at the initial data collection period and collapsed into the following categories: (a) <25 years, (b) 25 to 33, (c) 34 to 44, (d) 45 to 54, (e) 55 to 64, and (f) 65 to 95, with a mean age of participants between 24 and 35. Collapsing the age of respondents was to account for older inmates and their disproportionate prevalence rates of chronic illness. Education was operationalized by respondents self-reported education level, starting with “0” for those who never attended or attended kindergarten only to “18” which was labeled as graduate school for 2 or more years, in addition to “19,” attended school in other country/system not comparable to grades, displaying a mean education level of 10th grade. Socioeconomic status was measured through categorical attributes based on an individual’s monthly income prior to incarceration to determine a respondent’s socioeconomic status. The variable was coded as followed: “0” no income, “1” $1-199, “2” 200-399, “3” 400 to 599, “4” 600 to 799, “5” 800 to 990, “6” 1,000 to 1,199, “7” 1,200 to 1,499, “8” 1,500 to 1,999, “9” 2,000 to 2,499, “10” 2,500 to 4,999, “11” 5,000 to 7,499, and “12” 7,500 or more. On average, those imprisoned received a monthly wage between 1,000 to 1,199 prior to entering a correctional facility.

The final control variable used in the analyses was substance abuse. Substance abuse was operationalized and recoded as a dichotomous variable with “0” representing inmates who had not been admitted to a treatment facility for substance abuse treatment prior to their arrest or since admission to a prison facility and “1” being those individuals that had been admitted to a treatment facility for substance abuse treatment. Of the respondents in the survey, 11.5% (N = 1,332) reported having been admitted for substance abuse treatment prior to arrest or since their admission to the prison facility compared to 88.5% (N = 10, 237) reporting they had not been diagnosed or admitted to a treatment facility.

Findings

The first objective was to explore the role of incarceration on the role of the minority male health gap as it relates to chronic illness prevalence. Therefore, the first and second hypotheses predicted that minority males will have higher rates of chronic illness diagnosis compared to their non-white counterparts with regard to sentence length and number of incarcerations (see Table 2). Results from the binary logistic regression showed that substance abuse, race, age, education, and sentence length were statistically significant in the likelihood of being diagnosed with a chronic illness. Each one unit increase in the one’s report of substance abuse was associated with a 1.34 times greater likelihood of reporting a chronic illness while incarcerated (b = 0.29). Those who reported as a minority male were 1.43 times more likely to have a chronic illness when compared to their white counterpart (b = 0.35). A relationship with age was also present, as an inmate aged they were 1.77 (b = 1.77) times more likely to develop a chronic illness. Level of education displayed a relationship with chronic illness and incarceration, as an individual’s educational level increased, their likelihood for developing a chronic illness decreased by .05 (b = −0.05). Finally, the length of one’s sentence appeared to influence the development of a chronic illness among minority males, specifically minority males that reported serving longer sentences had higher levels of chronic illness, b = 0.00; Exp(b) = 1.00.

Table 2.

Model 1: Chronic Illness and Length of Sentence (N = 11,299).

Measure	B	SE B	Exp(b)
Race	0.359***	0.071	1.432
Age	0.571***	0.029	1.770
Education	−0.053***	0.012	0.949
Socioeconomic status	−0.003	0.010	0.997
Length of sentence (months)	0.000*	0.000	1.000
Substance abuse	0.299**	0.096	1.349
χ²		(465.737; p < .001)
−2 log likelihood	6,447.825
Cox and Snell R²	.049
Nagelkerke R²	.093
Hosmer–Lemeshow	(χ² = 11.437; p = .178)

p < .05. **p < .01. ***p < .001.

When exploring rates of chronic illness among minority males with regard to number of incarcerations, results from the binary logistic regression model found that race, age, substance abuse, and education proved to be statistically significant predictors of the development of a chronic illness (see Table 3). Minority males displayed a 1.46 (b = 0.38) higher risk of obtaining a chronic illness than that of their white counterparts. Similar to model 1, as an inmate aged, their likelihood of developing a chronic illness increased by 1.79 (b = 0.58). Males that reported substance abuse were also at a 1.35 (b = 0.30) greater likelihood of developing a chronic illness while incarcerated. Similarly, level of education remained significant when predicting the likelihood of being diagnosed with a chronic illness, as an individual’s education level increased, their likelihood to have chronic illness decreased by .05 (b = −0.05).

Table 3.

Model 2: Chronic Illness and Number of Incarcerations (N = 11,299).

Measure	B	SE B	Exp(b)
Race	0.384***	0.071	1.468
Age	0.585***	0.028	1.795
Education	−0.053	0.012	0.948
Socioeconomic status	−0.003	0.010	0.997
Number of incarcerations	0.003	0.007	1.003
Substance abuse	0.307***	0.095	1.359
χ²		(475.866; p < .001)
−2 log likelihood	6,551.530
Cox and Snell R²	.049
Nagelkerke R²	.093
Hosmer–Lemeshow	(χ² = 15.039; p = .058)

p < .05. **p < .01. ***p < .001.

The second objective explored in the analysis was the relationship between incarceration and minority males’ propensity for medical conditions requiring treatment. Thus, the third and fourth hypotheses posited that minority males were more likely to report a health condition that required routine medical treatment with regard to sentence length and number of incarcerations. Contrary to our hypothesis, results of the binary logistic regression did not display differences in medical conditions among minority males (see Table 4). However, results from our third binary logistic regression model found that substance abuse, age, and sentence length were statistically significant predictors of developing a medical condition while incarcerated. Incarcerated males who reported substance abuse were 2.30 (b = 0.83) times more likely to have a current medical condition. Older incarcerated males were also at a greater likelihood of reporting a medical condition, displaying a likelihood of 1.77 (b = 0.00) times higher than their younger counterpart. Finally, individuals serving prolonged sentences were at a higher risk of developing a medical condition, b = 0.00; Exp(b) = 1.00.

Table 4.

Model 3: Medical Condition and Length of Sentence (N = 11,569).

Measure	B	SE B	Exp(b)
Race	−0.066	0.047	.936
Age	0.572***	0.022	1.772
Education	−0.010	0.009	0.990
Socioeconomic status	−0.011	0.007	0.989
Length of sentence (months)	0.000*	0.000	1.000
Substance abuse	0.835***	0.069	2.304
χ²		(1,031.524; p < .001)
−2 log likelihood	11,744.165
Cox and Snell R²	.104
Nagelkerke R²	.140
Hosmer–Lemeshow	(χ² = 6.218; p = .623)

p < .05. **p < .01. ***p < .001.

The final binary regression model displayed explored the relationship between medical conditions and the number of incarcerations an individual had received in their lifetime. Results from the model found that age, substance abuse, and number of incarcerations remained statistically significant (see Table 5). Each one unit increase in a male inmate’s age was associated with a 1.78 (b = .58) times greater likelihood of reporting a current medical condition. Of those who reported substance abuse, males were 2.31 (b = .83) times more likely to have a current medical condition. Finally, males that have been incarcerated more than once were 1.02 (b = .02) times more likely to have a current medical condition.

Table 5.

Model 4: Medical Condition and Number of Incarcerations (N = 11,569).

Measure	B	SE B	Exp(b)
Race	−0.055	0.046	.946
Age	0.581***	0.021	1.788
Education	−0.011	0.009	0.989
Socioeconomic status	−0.013	0.007	0.988
Number of incarcerations	0.022**	0.006	1.22
Substance abuse	0.838***	0.069	2.311
χ²		(1,060.413; p < .001)
−2 log likelihood	11,956.205
Cox and Snell R²	.105
Nagelkerke R²	.141
Hosmer–Lemeshow	(χ² = 13.534; p = .095)

p < .05. **p < .01. ***p < .001.

Discussion

The offender population has been cited as entering correctional facilities with disproportionate rates of chronic health conditions before, during, and after incarceration (Harzke & Pruitt, 2018; Maruschak et al., 2015). Exploratory studies concerning COVID-19 transmission suggest that pre-existing chronic health conditions in conjunction with the prison environment are significantly impacting the United States correctional facilities, particularly for persons of color (Gibson, 2020; Hagan et al., 2020; Wallace et al., 2020). Using the SISCF to explore the unforeseen impact of COVID-19 on the minority male health gap, this study identified racial differences in chronic illness diagnosis among a nationally represented sample who cited having medical health care needs. Results indicated that after controlling for age, education level, socioeconomic status, substance abuse, length of incarceration, and number of incarcerations, minority males were more likely to be diagnosed with a chronic health condition. We also found that incarcerated individuals declaring longer sentence lengths and multiple incarcerations were more likely to report a medical condition requiring medical treatment during their incarceration. Thus, the disproportionate prison rates of minority males coupled with the pre-existing prevalence of chronic illness and medical conditions requiring medical treatment during incarceration may be a contributing factor to the increased rates of COVID-19 transmission for incarcerated persons of persons of color, placing minorities at a higher risk for a COVID-19 diagnosis (Gibson, 2020; Hagan et al., 2020; Wallace et al., 2020).

Correctional health care findings regarding COVID-19 have found that minority males are diagnosed with COVID-19 at a rate double that of their white counterpart (Gibson, 2020) and may be linked to persisting chronic conditions (CDC, 2021; Moore et al., 2020). Medical studies assessing COVID-19 diagnosis predictors have found that pre-existing conditions including diabetes, cancer, cardiovascular illness, and hypertension are associated with a great risk of COVID-19 infection, as well as death (CDC, 2021; Parohan et al., 2020). Given that being diagnosed with a chronic condition serves as a direct risk factor for COVID-19 transmission, we predicted that minority males would have higher rates of chronic illness compared to their non-white counterparts with regard to sentence length and number of incarcerations. Findings confirmed this hypothesis, displaying that minority males presented higher rates of chronic illness such as cancer and diabetes with regard to sentence length and number of incarcerations correlating with the findings of previous studies (Binswanger et al., 2009, 2011; Harzke & Pruitt, 2018). This relationship between incarceration and increased chronic conditions among minority males is critical for disease prevention and may be directly influencing the disproportionate diagnosis of COVID-19 among persons of color within correctional settings and impact the communities where they return upon release. Given that correctional institutions have consistently expressed difficulties in health services implementation, insufficient staffing protocols, reluctant administers prior to the pandemic, and have now been identified as a breeding ground for negative outcomes associated with COVID-19 (Oladeru et al., 2020), the health of minority males is likely to be severely impacted (Harzke & Pruitt, 2018; Maruschak et al., 2015). Specifically, with minority males representing a large portion of the correctional system (Carson, 2020) coupled with correctional institutions lack of preparation to address COVID-19 and health care needs, it is likely that the minority health gap will continue to widen as practitioners seek the necessary protocols for disease containment.

Similarly, with COVID-19 predominantly impacting incarcerated persons of color and the historically limited medical treatment accessible within correctional facilities (Gibson, 2020; Hagan et al., 2020; Wallace et al., 2020), having a current medical condition may serve as a barrier for COVID-19 prevention and access to medical services for minority males. Therefore, we predicted that minority males were more likely to report a health condition that required routine medical treatment with regard to sentence length and number of incarcerations. Contrary to our hypothesis, results from the binary logistic regression models did not display that minority males were more likely to experience increased medical conditions when compared to their white counterparts. Interestingly, recent national findings regarding incarceration statistics report that minority males both serve longer sentences and are more likely to be incarcerated when compared to white males (Carson, 2020). Therefore, we attribute this lack of prevalence among persons of color to the limited up-to-date national representative data collection on health conditions within correctional facilities (Harzke & Pruitt, 2018; Prost et al., 2019). This absence of current national data regarding inmates and health-related factors is concerning, given the growing health disparity among incarcerated minority males related to COVID-19 and may be a contributing factor to the lack of preparedness in combatting the transmission (Dumont et al., 2012; Harzke & Pruitt, 2018; Maruschak et al., 2015). Our analyses did display significant results when examining sentence length and number of incarcerations. Individuals within our sample that reported longer sentences and multiple imprisonments were more likely to report a medical condition while incarcerated. This heightened risk for medical conditions while institutionalized is critical for implementing correctional COVID-19 and future pandemic protocols, given that medical conditions do exacerbate the risk for transmission (CDC, 2021; Moore et al., 2020). Moreover, correctional professionals should take into consideration the impact the correctional setting may have on the development of a medical condition, in that it may further strain medical care resources aimed at containing COVID-19 transmission.

With the current disproportionality of COVID-19 transmission among minority males within the correctional setting, chronic illness and medical conditions requiring treatment are important risk factors for correctional practitioners. This is particularly true, given that on-going data collection has found that prison populations are experiencing unprecedented rates of known COVID-19 cases (Hagan et al., 2020; Wallace et al., 2020), and that minority male inmates are disproportionately being diagnosed with the virus within correctional facilities (Gibson, 2020). Correctional health care professionals need to consider the challenges the impact of these conditions present for minority males when developing preventive measures for COVID-19. Therefore, correctional institutions developing protocols for COVID-19 through discussions of the deincarceration of low-risk offenders, limiting personal contact, and providing adequate preventive care also need to factor in race/ethnicity and health history/status when addressing the current and future pandemics.

The CDC’s recommendation of social distancing has proven difficult to implement within correctional settings because many are currently experiencing overcrowding, either were above capacity prior to the pandemic or from the inability to transfer inmates within systems due to the pandemic. This need for limiting personal contact/social distancing has been translated in limiting the number of offenders within a given institution leading to the advocation for the deincarceration of low-risk offenders to reduce the transmission of COVID-19 (Abraham et al., 2020). In addition, by decreasing the number of offenders within correctional systems, proper quality of care can be more effectively carried out. Specifically, both of these elements, incarceration and lack of health care services, previously have disproportionately impacted minority males. Therefore, an understanding of these topics, including the prevalence of illness as a health risk for COVID-19 among incarcerated minority males, is crucial for protecting communities of color that are already facing disproportionate rates of transmission (Hsu et al., 2020; Moore et al., 2020). Specifically, data collection and knowledge of the current rate of health conditions among the incarcerated population remains largely absent and may be contributing to the increased rates of COVID-19 seen among persons of color (Gibson, 2020; Hagan et al., 2020; Wallace et al., 2020). Therefore, correctional institutions need to address the impact of pre-existing chronic illnesses among the institutionalized population as criminologists advocate for early release among low-risk offenders to curb the transmission of COVID-19 within correctional facilities (Abraham et al., 2020).

While our research advances the literature on the potential challenges of COVID-19 on the minority male health gap in the correctional setting, there are a number of important study limitations to consider for future research. First, the most critical limitation is that the SISCF data collection period was conducted over a decade ago. Unfortunately, given that there is no available national data set on prisons/inmates that contains such measures of health, the SISCF remains the most updated comprehensive national data set addressing chronic illness and medical conditions among minority male inmates in the United States and has continued to be used as a sufficient national measure of inmate health conditions that may be impacted by COVID-19 (Edgemon & Clay-Warner, 2019; Notworthy et al., 2017). Likewise, the SISCF relies on self-reported health data which are limited in identifying certain types of health conditions that may influence minority males’ propensity for contracting COVID-19 due to the restrictions on individualized health care information associated with the Health Insurance Portability and Accountability Act (HIPAA). However, self-report health data are essential and commonly used as a source of health indicators in correctional health care literature and gives credence to the need for the construction of more precise health care variables from partnerships with health care providers to measure the full scope of the impact chronic illness and medical conditions may have on COVID-19 in the correctional setting. Related, the data are cross-sectional and does not provide insight on the onset of health conditions related to the minority male health gap that may be influenced by COVID-19. That is, this study is unable to account for the timing of a diagnosis, severity, or quality of care offered that may influence the transmission of COVID-19. Future research should examine the influence of the correctional setting on minority males’ health longitudinally to determine its role in the transmission of COVID-19 and the overarching impact it will have on minority communities.

As the racial health disparity associated with COVID-19 continues to widen within the United States, this study adds to the limited correctional literature examining the prevalence of chronic illness and medical conditions and its overarching impact on COVID-19, while taking the variable of race into account. With correctional facilities representing a critical setting for providing health interventions with regard to prevention and treatment of physical illness among the underserved population (Hagan et al., 2020; Wallace et al., 2020), we posit that greater attention should be given to the current health status of minority males and racial inequalities among inmates, as well as better documentation of pre-existing chronic conditions to address the COVID-19 racial health disparity gap emerging among the prison population. This imperative is underscored by the need for more recent data collection and the construction and collection of precise health variables, given that our data set represents the most recent comprehensive national representative sample.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Mary H. Hughes is a Doctoral Candidate in the School of Criminal Justice and Criminology at the University of Arkansas at Little Rock. She holds a BS in Criminology and Criminal Justice from Western Carolina University and a MA in Criminology from East Tennessee State University. Her research interests include health & crime, correctional healthcare, rural crime, prison re-entry programs, race, gender, and inmate inequality, and special populations.

Dr. Nicole Prior is an associate professor in the department of Criminal Justice and Criminology at East Tennessee State University. Her research interests include corrections, specifically officer-inmate relations and correctional treatment programs, juvenile delinquency, criminological theroy, gangs, and hate crimes.

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