University of Connecticut

OpenCommons@UConn
Master's Theses University of Connecticut Graduate School

12-12-2016

The Relationship Between Emotional Support and

Health Related Self-Efficacy in Older Inmates
Deborah N. Steciak-Noujaim
University of Connecticut, dnoujaim@[Link]

Recommended Citation
Steciak-Noujaim, Deborah N., "The Relationship Between Emotional Support and Health Related Self-Efficacy in Older Inmates"
(2016). Master's Theses. 1026.
[Link]

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

Deborah Nicole Noujaim

B.S., University of Connecticut, 2012

A Thesis

Submitted in Partial Fulfillment of the

Requirements for the Degree of

Master of Public Health

At the

University of Connecticut

2016

i
 Copyright by

Deborah Nicole Noujaim

2016

ii
 APPROVAL PAGE

Masters of Public Health Thesis

The Relationship between Emotional Support and Health Related

Self-Efficacy in Older Inmates

Presented by

Deborah Noujaim, B.S.

Major Advisor
Lisa C. Barry, Ph.D., MPH

Associate Advisor
Richard Fortinsky, Ph.D.

Associate Advisor
Dorothy Wakefield, M.S.

University of

Connecticut 2016

iii
Table of Contents

Abstract…………………………………………………………………………………………………………………………………..v

Introduction………………………………………………………………………………………………………………………..…. 1

Background……………………..………………………………………………………………………………………………………2

Older Inmates…………….…………………………………………………………………………………………….… 3

Self-Efficacy …………………………………………………………………………………………………………….… 4

The Relationship between Emotional Support and Self-Efficacy………………………….……...5

Potential Gender Differences……………………………………………………………………………………..6

Specific Aims and Hypothesis ……………………………………………………………………………………………..… 8

Methods…………….……………………………………………………………………….……………………….………………...9

Setting and Recruitment……………………………………………………………………………………….….…9

Data Collection and Management………………………………………………………………………………11

Study Variables……………………………………………………………………………………………………………12

Statistical Analysis ………………………………………………………………………………………………….….16

Results ……………………………………………………………………………………………………………………………..……17

Discussion ………………………………………………………………………………………………………………………..……24

Limitations …………………………………………………………………………………………………………………29

Conclusions and Recommendations …………………………………………………………………………………….. 32

References……………………………………………..………………………………………………………………………………33

Appendices …………………………………………………………………………………………………………………………….41

iv
Abstract

Inmates age 50 and older are the fastest growing segment of the prison population.

Because the majority of inmates return to the community, adequate self-care is essential for

managing their overall health. Studies among older community-living persons indicate that

emotional support is associated with improved efficacy for managing one’s health (e.g., health

related self-efficacy). Data collected from the “Physical Functioning and Mental Health of Older

Prisoners” study were analyzed to determine if emotional support is associated with health-

related self-efficacy among older inmates in Connecticut. Even after controlling for

demographic, incarceration and clinical/behavioral factors, older inmates reporting lower levels

of emotional support were more likely to have poor health related self-efficacy. This

relationship did not differ by gender. Identifying factors associated with poor health related

self-efficacy in the older inmate population may inform the development of interventions

focused on maximizing health related self-efficacy in this vulnerable population.

v
Introduction

The United States prison population has grown exponentially in the past four decades

(National Research Council, 2014). The Federal Bureau of Justice Statistics reports that in 1978,

about 300,000 inmates were incarcerated in both state and federal correctional facilities

(Bureau of Justice Statistics, 2014). By 1994, the prison population had grown drastically to

approximately one million (Bureau of Justice Statistics, 2014). This population has continued to

grow at an alarming rate in more recent years, in 2012 there were more than 1.5 million

inmates incarcerated in either jails or prisons (Bureau of Justice Statistics, 2014). The growth in

the United States prison population is not only extremely costly, but it also places a

considerable strain on the Department of Correction’s staff and resources (National Research

Council, 2014).

Inmates age 50 and older (i.e., older inmates) are the fastest growing segment of the

prison population (Williams et al., 2007). Older inmates have high rates of chronic health

conditions including diabetes, chronic lung disease, and hepatitis C (Binswanger et al., 2009).

This could be due, in part, to the life circumstances of these individuals both before and during

incarceration (e.g. drug abuse, alcohol abuse, poor access to healthcare, etc.) (Binswanger et

al., 2009; Williams et al., 2007). Because the majority of inmates will eventually return to the

community, adequate health related self-efficacy is essential for managing their overall health

(Freudenberg, 2001).

As will be discussed, health related self-efficacy has been shown to be an essential

component to managing overall health among older persons in the general population

(Bodenheimer et al., 2002; Panagioti et al., 2014). In the older inmate population, better

1
health related self-efficacy while in prison may be associated with better health-related

outcomes after prison release. However, little is known regarding factors associated with

health related self-efficacy in older inmates. In the general population, it has been shown that

low levels of emotional social support are associated with a decline in feelings of self-efficacy

among older persons (McAvay, Seeman & Rodin, 1996; Seeman et al., 1999; Steptoe, Shankar,

Demakakos, & Wardle, 2013). This same relationship will be analyzed in the older inmate

population for this study. Improved understanding of factors that may be associated with older

inmate’s health related self-efficacy can help to inform interventions to enhance self-care

abilities. These types of interventions may aid this growing population to manage their health

while in prison, as well as when they transition back to the community.

Background

The immense growth of inmates age 50 and older over the past four decades could be

the result of multiple circumstances. Studies have suggested that longer sentences, newly

instated minimum sentencing laws, the observed increase in the number of individuals arrested

at later ages, and population aging could all be potentially contributing factors (Luallen &

Cutler, 2015; Williams et al., 2007). If the rate of incarcerated older persons continues to grow,

this population may comprise 1/3 of the United States prison population by the year 2030

(Chettiar, Bunting & Schotter, 2012). Due to the high rates of chronic illness and mental health

diagnoses in older inmates, this population places great tension on the prison system in terms

of healthcare management and cost (Mitka, 2004). Developing specific ways to manage this

population is vitally important in maintaining the safety and infrastructure of the United States

Correctional System (Mitka, 2004; National Research Council, 2014).

2
Older Inmates

In the general population, older persons are considered to be anyone who is age 65 and

older. However, due to the many lifestyle differences of individuals in the prison population,

inmates age 50 and older are considered to be “older” (Mitka, 2004; Williams et al., 2007).

Inmates’ accelerated aging stems from stresses of living in the prison environment and

unhealthy lifestyles (e.g. high risk behaviors) and inadequate healthcare while outside of prison

(Conklin et al., 2000; Fellner & Vinck, 2012; Mitka, 2004). The older inmate population also has

significantly greater health problems when compared with the general population (Williams et

al., 2012). It has been shown that older inmates have high rates of untreated mental health

conditions, chronic illnesses and functional impairments (Barry, Wakefield, Trestman, &

Conwell, 2016; Binswanger, Krueger, & Steiner, 2009; Fazel et al., 2004; Mitka, 2004, Williams

et al., 2006). Consequently, older inmates utilize a disproportionate amount of correctional

healthcare services when compared to their younger counterparts (Bureau of Justice Statistics,

2014). In Connecticut, the annual healthcare cost for inmates, age 18-49, is approximately

$4,000. The healthcare costs of older inmates are about two to three times more expensive

(Ahalt et al., 2013). The total healthcare expenses for inmates in the year 2012 in Connecticut

were $86.9 million; this includes both medical and dental care (Bureau of Justice Statistics,

2014). With the rates of incarcerated individuals steadily growing over the past three decades

and the rise in the older inmate population, the projected healthcare costs in prisons is also

expected to rise (Bureau of Justice Statistics, 2014).

The Bureau of Justice Statistics (2006) reports that over 95% of all inmates are

eventually released back into the community. In the “Physical Functioning and Mental Health

3
of Older Prisoners” study, approximately 30% of the 167 older inmates participating in the

study were expected to return to the community within 2 years. Due to the fact that so many

older inmates will eventually become community-dwelling adults, it is important to evaluate

their self-efficacy in managing their own health, and the factors that may affect their health

related self-efficacy.

Self-Efficacy

Self-efficacy is defined as an individual’s confidence in his/her capability to successfully

manage the events in his/her life (Wood & Bandura, 1989). In the general population, greater

feelings of self-efficacy have been shown to lead to better health outcomes and lower rates of

hospitalizations and emergency room visits (Daltroy, 1993; Scherer, & Bruce, 2001). Whereas

individuals with low health related self-efficacy are more likely to have poor health outcomes,

including disability and depression, especially among those with chronic health conditions and

chronic pain (Arnstein et al., 2009; Gallant, 2003). Furthermore, numerous studies show that

for older community-dwelling adults, it is imperative to maintain the ability to perform basic

self-care activities in order to achieve a good quality of life and maintain independence (Borg et

al., 2006; Golden et al., 2009). For the purposes of this study, self-care will be referred to as

health related self-efficacy.

To date, research on the health of older inmates is minimal, and few studies have

evaluated the various factors that may affect health related self-efficacy in the older inmate

population. Susan J. Loeb, Ph.D., Assistant Professor at Pennsylvania State University has been a

pioneer in the field of self-efficacy among older inmates. In a 2010 study, Loeb and associates

evaluated the association between older inmates’ self-rated health and self-efficacy (Loeb et

4
al., 2010). Findings showed that there was a significant positive relationship between self-

efficacy and one’s self-rated health. In another study, Loeb and Steffensmeier (2006) found a

significant positive relationship between self-efficacy and self-care behaviors in a sample of

older male inmates. Self-care behaviors observed in this particular study included exercising,

eating fruits and vegetables, brushing teeth, and taking prescribed medications. Older inmates

with greater self-efficacy were more likely to attempt positive behaviors, whereas those with

low self-efficacy were more likely to try to avoid these behaviors (Loeb & Steffensmeier, 2006).

These findings help to illustrate the potential importance of health related self-efficacy for

maintaining inmates’ health. However, the factors that may affect inmates’ feelings of health

related self-efficacy, and can be potentially modified to improve health related self-efficacy,

remain unknown.

The Relationship between Emotional Support and Health Related Self-Efficacy

Social support is defined as a person’s perception that they are cared for and have the

support of a person or persons when making important decisions (Uchino et al., 2006). It also

includes an individual’s perception that they are part of a social network, or linkages to a group

of people in their community (Wills & Ainette, 2012). Social support has been shown to be

essential for maintaining both physical and mental health (Ozbay et al. 2007). It has been

suggested that having social support can improve resilience to stress and even reduce medical

morbidity and mortality (Southwick et al. 2005). Lack of social support has also been shown to

negatively affect the mood and wellbeing of community-dwelling older adults (Golden et al.,

2009).

5
 Social support has been categorized into four main types: emotional, instrumental,

informational and appraisal (Heaney & Israel, 2008). For the purposes of this project we will

focus on emotional support; Dr. Barry’s study only collected information on an inmate’s

emotional support. Emotional support is defined as support that involves the establishment of

empathy, love, trust and caring (Heaney & Israel, 2008). In the general population, it has been

shown that low levels of emotional social support are associated with a decline in feelings of

self-efficacy among older persons (McAvay, Seeman & Rodin, 1996; Seeman et al., 1999;

Steptoe, Shankar, Demakakos, & Wardle, 2013). It has also been suggested that low emotional

support can lead to poor levels of self-efficacy for managing chronic illnesses like diabetes

(Gallant, 2003). Diabetes is increasingly prevalent among all older adults (Kirkman et al., 2012).

Individuals diagnosed with diabetes, similar to many other chronic illnesses, perform a variety

of self-care tasks such as dietary management, exercise, blood glucose testing and foot care

(Gallant, 2003). It has been suggested that because these healthcare activities may be new to

an individual, having another individual’s emotional support while learning and performing

these tasks may be vitally important to maintaining health (Gallant, 2003).

Potential Gender Differences

Females, in general, are more family centered and relationship oriented, and thus

typically report higher levels of emotional support than males (Harris, 1993; Jiang & Winfree,

2006). Female inmates have also been shown to report higher levels of emotional support than

male inmates (Jiang & Winfree, 2006). Consequently, it is possible that greater feelings of

emotional support among female inmates may translate to better health related self-efficacy in

this group. Furthermore, the number of older female inmates in the U.S. has grown

6
considerably in the past decade. It is estimated that more than 15,000 older female inmates

were incarcerated as of the year 2014 (Carson, 2014). However, there is still a paucity of

research on the health of the older female prison population and few existing studies report on

the emotional support of female inmates because they are largely limited to studying men. It is

important to perform studies that include samples of both males and females, so that the

mechanism by which emotional support may impact older inmate’s health related self-efficacy

can be assessed in both genders.

The public health problem addressed in this project centers around the fact that the

older prisoner population continues to grow, and that many of these individuals will eventually

be released back into the community. Due to their many healthcare needs, this population is

very expensive to care for both while incarcerated and when they are released back into the

community. Understanding factors associated with health-related self-efficacy will be

important to determining who may or may not be better at maintaining their health upon

prison release. Specifically, this analysis will focus on the effect emotional support may have on

older inmate’s feelings of health-related self-efficacy based on Bandura’s Social Cognitive

theory. This theory states that an individual’s self-efficacy along with their goals, expectations

of results, and perceived barriers interact to determine an individual’s health behavior

(Bandura, 2004). Findings from this project could lead to interventions aimed at increasing

emotional support in order to maintain older inmate’s health related self-efficacy; which in turn

could benefit both the older inmate population as well as the community that cares for them.

7
Specific Aims and Hypothesis

According to Bandura’s Social Cognitive theory, the establishment of support from

others appears to facilitate an individual’s belief in the types of activities in which they can

successfully engage in (Bandura, 1981, 1986, 1988). This theory has been demonstrated in the

general population in studies evaluating the relationship between social support and self-

efficacy (McAvay, Seeman & Rodin, 1996; Seeman et al., 1999; Steptoe, Shankar, Demakakos, &

Wardle, 2013). Using Bandura’s theory, it is important to evaluate this relationship within the

aging prisoner population. This information could be used to develop interventions aimed at

increasing older inmate’s emotional support which in turn could increase their health related

self-efficacy. As previously stated, this population is rapidly growing and is extremely costly to

care for. These types of interventions could potentially aid Department of Correction’s staff in

their management of older inmates’ overall health, as well as the inmates themselves when

they transition back to the community and are fully responsible for managing their own health.

This study aims to determine if emotional support is associated with health-related self-

efficacy (e.g., confidence in managing one’s own health) among older inmates in Connecticut.

To attain this objective, the following Specific Aims in a sample of older inmates were pursued:

 Specific Aim 1: To evaluate the association between emotional support and health

related self-efficacy in older inmates overall and according to gender.

 Specific Aim 2: To determine how demographic, incarceration and

clinical/behavioral factors impact the relationship between emotional support and

health related self-efficacy.

Based on the literature review conducted prior to this analysis it is hypothesized that

8
higher levels of emotional support will be associated with higher health related self-efficacy

among older inmates and that this relationship will be stronger in females when compared to

males. It is also hypothesized that several demographic, incarceration and clinical/behavioral

factors will impact the magnitude of the relationship between emotional support and health

related self-efficacy, but that emotional support will remain significantly associated with health

related self-efficacy.

Methods

This is a cross sectional study based on a secondary data analysis from the “Physical

Functioning and Mental Health of Older Prisoners” study (PI: Lisa C. Barry, Ph.D., MPH, Assistant

Professor of Psychiatry at the University of Connecticut Health Center). This research was

funded by the American Foundation for Suicide Prevention (SRG-0-092-11). Information

collected included face-to-face interviews and reviews of medical charts and CT Department of

Correction (CTDOC) data. The University of Connecticut Health Center Institutional Review

Board (IRB) initially approved this project on December 21, 2011; the study is still open for data

analysis. Permission to use this data was given by Dr. Lisa Barry and was analyzed in a de-

identified format under her supervision.

Setting and Recruitment

Study participants were recruited between September 2012 and August 2014. The

study sample included 167 older inmates, aged 50 and older, (66% male) from 3 correctional

facilities in Connecticut (MacDougall-Walker, Osborn, and York Correctional). In the year 2012,

when the study began, there were approximately 765 inmates housed in these 3 facilities who

were age 50 and older. York Correctional is the only institution in Connecticut that houses

9
female inmates. The study sample included 57 females from York Correctional, 61 males from

Osborn, and 49 males from MacDougall-Walker Correctional. The eligibility requirements are

summarized in Table 1.

A list of inmates meeting the eligibility criteria was provided quarterly by Correctional

Managed Healthcare (CMHC) staff at the University of Connecticut Health Center. Information

included the inmate’s name, housing unit and facility name. The Research Assistant (RA) would

then randomly select batches of 50 inmates at each

facility to send recruitment letters. Recruitment

letters were dropped off at each facility and placed in

each inmate’s mailbox. Interested participants wrote

their name on page 2 of the recruitment letter and left

it in the Mental Health Request box, located in each

facility’s medical wing. The staff psychologist at each

facility would then notify Dr. Barry when completed

forms were available.

The recruitment strategy for this study is

summarized in Figure 1. Recruitment was focused on

one facility at a time. The RA’s began recruitment at Osborn Correctional, and then moved to

York Correctional and MacDougall. Each day that the RA was scheduled to conduct interviews,

the RA would submit visitation forms to the facility visitation coordinator with a list of the

10
interested inmates that would be approached the following day; a maximum of 4 inmates were

interviewed per day. When the RA arrived at each facility, they would submit the visitation

pass again to the correctional officer (CO) at the front gate. Inmates were then called down one

by one from their housing units to the visitation room. The RA, along with the inmate, would

then be escorted by a CO into the professional visit room where screening, consent and the

study interview would take place. The inmates were informed that a CO was stationed outside

the interview room at all times for safety.

Data Collection and Management

After screening was complete, each inmate was then consented into the study. The RA

would hand the inmate a copy of the consent and read through the document line by line with

him/her and answer any potential questions. The RA would then perform the same process

with the study’s HIPAA documents. Once the inmate was consented into the study, the RA

would immediately begin the study interview. Each interview took approximately 2 hours to

complete. In the event that the entire interview could not be completed in one sitting (i.e. the

facility was put on lockdown, the inmate had to attend chow, etc.), the RA would schedule a

time to return to complete the remaining parts of the interview with the inmate.

In total, 167 interviews were completed over the course of 23 months. After each

interview was completed, chart reviews and review of CTDOC data were completed for all

participants. Chart reviews were conducted in the medical wing of each prison, where inmate

medical charts are routinely stored. Information collected during these chart reviews included

chronic conditions, current medications, mental health diagnoses, current mental health

treatment, hospitalizations and emergency room visits. CTDOC data was collected from the

11
online CTDOC medical database. CTDOC-specific data included admit date for current

incarceration, end of sentence date, estimated parole date, and current offense.

Data collected from the face-to-face interviews, medical chart reviews, and DOC data

were then entered into a Microsoft Access database developed by the project data manager.

The database was password protected and stored on password protected computers at the

Center on Aging at the University of Connecticut Health Center. Data was also double keyed in a

separate database and run through error-checking programs. Any errors were then routinely

corrected by the study RA’s to ensure accurate data collection.

Study Variables

a. Independent Variable

Emotional Support: Emotional support was assessed using 7 questions from the Medical

Outcomes Study Social Support Survey (Appendix A) (Sherbourne et al., 1991).

Participants were asked how often particular types of support are available to them

(e.g., “Someone you can count on to listen to you when you need to talk”). Potential

responses included “none of the time”, “a little of the time”, “some of the time”, “most

of the time”, or “all of the time”. Scores range from 7 to 35, with a higher score

indicating a greater level of emotional support.

b. 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: “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 et al.,

12
 2011). Responses were coded as a scale of 1 (not at all confident) to 5 (completely).

Given the non-normal distribution of responses, with responses for both questions

highly skewed to the left (Figure 2), responses from both questions were collapsed to

form a dichotomous variable. Participants responding that they were “not at all”, “a

little,” or “fairly” confident in either of these 2 variables were considered as having poor

health related self-efficacy. Otherwise, study participants were coded as having good

health related self-efficacy unless a response was missing for both questions (n=1).

c. Additional Variables

Demographic Characteristics: Participants were asked “how old are you?”, “what race

do you consider yourself?”, and “what is your ethnicity”. Age was operationalized as a

continuous variable. Race was categorized as: White/Caucasian, Black/African American,

Hispanic/Latino, Asian, Native Hawaiian/Pacific Islander, and Other, but for the purposes

of this study was further collapsed into three categories: White/Caucasian, Black/African

13
American, and Hispanic/Latino/Other. Education level was assessed by asking: “what is

the highest grade or year of regular school that you have completed” and was

dichotomized as less than high school (i.e., did not graduate from high school) and high

school graduate or greater. Gender is recorded based on which facility the inmate is

housed in; York Correctional is the only female prison in the state of Connecticut.

Incarceration-related characteristics: Prison-related characteristics were retrieved from

the CTDOC Offender Based Information System. Data included time served for the

current offense, if the inmate is a repeat offender, and the type of offense (e.g., violent

vs. non-violent). Examples of violent offenses include assault and battery, homicides,

domestic violence, robbery, and sexual assault and abuse.

Clinical/Behavioral Characteristics:

Chronic Conditions: During the chart review for each participant, chronic conditions

were noted. These conditions include: high blood pressure/hypertension, heart

attack/myocardial infarction, congestive heart failure, stroke/transient ischemic attack,

cancer/malignant tumor, diabetes, hip fracture, arthritis/rheumatism, chronic lung

disease (chronic bronchitis, asthma, COPD or emphysema) HIV/AIDS, hepatitis C, and

sexually transmitted diseases. The total number of chronic conditions was summed.

Alcohol Abuse: The CAGE, a 4-question screening test for alcohol dependence was

administered to participants indicating alcohol use (Bust et al., 1987). This test includes

four questions which ask if you have ever felt that you should “cut down on your

drinking”, if “people annoyed you by criticizing you about your drinking”, if “you felt bad

or guilty about your drinking”, and if “you had a drink first thing in the morning to

14
steady your nerves or get rid of a hangover”. Two positive responses indicate alcohol

dependence and participants were coded as having or not having alcohol dependence.

Chronic Pain: Chronic pain was assessed using the question “during the past 6 months,

have you experienced pain on most days of every month for at least 3 months in a row”.

Participants were coded as having chronic pain if they reported having pain for most

days of the month for at least 3 consecutive months.

Depressive Symptoms: The Physician Health Questionnaire (PHQ-9) was used to assess

depressive symptoms. The PHQ-9 is a 9-item measure that assesses the symptoms used

to evaluate DSM-IV criteria for Major Depressive Disorder by asking participants how

often in the past two weeks they have been bothered by problems including “feeling

down, depressed, or hopeless,” and “feeling tired or having little energy.” Potential

responses included “not at all”, “several days”, “more than half the days”, or “nearly

every day”, and scale scores range from 0 to 27 with higher scores indicating worse

depressive symptoms (Kroenke, Spitzer, & Williams, 2001).

Poor Hearing: Hearing was assessed with the following question: “how would you rate

your hearing”. Potential responses included: poor, fair, very good, excellent, and legally

deaf. Participants indicating poor, fair, or legally deaf were coded as having poor

hearing.

Poor Vision: Vision was assessed using two questions. The first being “how would you

rate your eyesight”, responses included: poor, fair, very good, excellent, and legally

blind. The second question was “do you have difficulty seeing ordinary newsprint, even

with glasses”. Participants indicating their vision was fair, poor, legally blind, or reported

15
 “yes” to having difficulty reading ordinary newsprint even with glasses; were coded as

having poor vision.

PADL Disability: Prison activities of daily living (PADLs) disabilities were assessed using a

modified version of the Williams PADL Disability Index (Williams et al., 2006).

Participants rated their level of difficulty performing six activities of daily living in prison:

dropping to the floor for alarms, climbing on and off the top bunk, hearing orders from

staff, walking while wearing handcuffs, standing in line for medications, and walking to

chow (dining hall). Potential responses included “not difficult”, “somewhat difficult”,

“very difficult”, and “cannot do, even with help”. Participants reporting one or more

PADLs as “very difficult” or “cannot do, even with help” were considered as having PADL

disability.

Statistical Analysis

Descriptive statistics were calculated for participants’ characteristics. χ2 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 versus 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. The adjusted model was adjusted sequentially for groups of variables (i.e.

demographic, incarceration) that were associated with emotional support and/or health related

16
self-efficacy at the p < .10 level, in bivariate analyses (≤0.10 two-tailed), with the exception of

age and gender that were forced into the model, and the variables “number of years in prison”

and “repeat offender” as these variables were highly correlated with age. The analyses were

also re-run after stratifying by gender. The data were analyzed using the SAS Analytics

Software Version 9.0.

Results

There were 52 (31%) study participants who reported poor health related self-efficacy.

As shown in Figure 3, older inmates who reported poor health related self-efficacy had

significantly lower mean emotional support scores as compared to those with good health

related self-efficacy (19.3±8.0 versus 23.5±8.2; p = 0.002). The average emotional support

score for this study population was 22.1 (±8.3, range 7.0-35.0).

Table 2 summarizes the characteristics of the overall study population, and according

to health related self-efficacy (poor versus good). The study population consisted of 167 older

inmates that were racially diverse. The mean age was 57.2 (±6.9); 92 (55.1%) were

White/Caucasian, 51 (30.5) were Black/African American, 23 (13.7) were Hispanic/other; 56

were (33.7%) female; and 121 (72.9%) graduated from high school. On average, the study

population had served 7.8 (±8.9) years for their current offense, approximately 60% were

serving for a violent offense, and 68% were repeat offenders. Those with poor health related

self-efficacy (n=52) were more likely to report chronic pain (p=0.04), have higher depression

symptom scores (p=<0.001), have poor hearing (p=0.003), have poor vision (p=0.02), and have

PADL disability (p=0.006). Number of chronic conditions and prior alcohol abuse were not

associated with health related self-efficacy.

17
18
19
 Table 3 summarizes the bivariate associations between categorical variables and

emotional support. Females had significantly higher mean emotional support scores when

compared to their male counterparts (p = 0.004) and those convicted of a violent offense had

lower emotional support scores than those who were not incarcerated for a violent offense (p

= 0.008). Table 4 summarizes the bivariate associations between continuous variables and

emotional support. Years in prison for current offense (p=0.006) and PHQ-9 depression score

were both strongly associated with emotional support. As number of years in prison and

depression scores increased, the emotional support scores decreased, respectively.

20
21
 Table 5 presents the results from the multivariable model evaluating the association

between health related self-efficacy and emotional support. In the unadjusted analysis (Model

#1), emotional support was strongly associated with poor health related self-efficacy (OR =

0.94, 95% CI 0.94, 0.98). Controlling for demographic factors (i.e. age and gender) did not

impact the magnitude of the association (OR = 0.94, 95% CI 0.90, 0.98). Emotional support

remained significantly associated with health related self-efficacy even after controlling for

incarceration and clinical/behavioral factors (OR =0.94, 95% CI 0.88, 0.99). Variables that were

independently associated with health related self-efficacy were: prior alcohol abuse (OR=5.06,

95% CI 2.14, 12.00), poor hearing (OR=2.45, 95% CI 1.07, 5.58), and PADL disability (OR= 2.51,

95% CI 1.01, 6.27).

Tables 6 and 7 present the results from the multivariable model evaluating the

association between health related self-efficacy and emotional support according to gender.

Table 6 shows that poor health related self-efficacy was not associated with emotional

support among the females in either the unadjusted analysis (Model #1) or the adjusted

model. In contrast, Table 7 shows that poor health related self-efficacy was significantly

associated with emotional support among the males in the unadjusted analysis (Model #1).

However, this association was no longer significant after controlling for demographic,

incarceration and clinical/behavioral factors. Although non-significant, the odds ratios for

both females and males were similar and were in the hypothesized direction.

22
23
Discussion

This project focused on evaluating the association between emotional support and

health-related self-efficacy among older inmates in Connecticut. Even after controlling for

demographic, incarceration and clinical/behavioral factors, older inmates reporting lower

levels of emotional support were more likely to have poor health related self-efficacy.

Whereas women reported higher levels of emotional support in comparison to the men, the

association between emotional support and health related self-efficacy did not differ

according to gender. Furthermore, with the exception of prior alcohol abuse, poor hearing,

and PADL disability; other factors (demographic, incarceration and clinical/behavioral) were

not associated with poor health related self-efficacy.

The finding that emotional support was associated with health related self-efficacy is

consistent with previous research conducted with community dwelling older adults (McAvay,

Seeman & Rodin, 1996; Seeman et al., 1999). It has been suggested that the establishment of

emotional support from others appears to facilitate an individual’s belief in the types of health

maintenance activities they can successfully engage in (i.e. taking prescribed medications,

exercising and eating healthy foods), the effort they expend during those activities, and their

perseverance in the face of difficulties (Bandura, 1981, 1986, 1988; McAvay, Seeman & Rodin,

1996; Seeman et al., 1999). Consequently, individuals reporting higher levels of emotional

support may have greater likelihood of successful health management (McAvay, Seeman &

Rodin, 1996; Seeman et al., 1999). Having emotional support may be particularly important for

individuals who are facing difficulties related to their health. For instance, individuals could be

diagnosed with a chronic condition such as diabetes and have trouble successfully managing

24
their illness due to lack of knowledge or confidence in their capabilities. If individuals have

someone to talk to about themselves and their problems, they could gain knowledge

regarding how to better manage their illness or even gain confidence to help them with self-

care.

These aforementioned studies were all conducted in community dwelling older adults;

however, the explanations as to why emotional support has such a strong effect on health

related self-efficacy could be similar in the older prisoner population. Several types of

emotional support measured in this study (i.e. “someone you can count on to listen when you

need to talk”, “someone to confide in or talk about yourself and your problems”, and

“someone to help me make decisions”) may be important in facilitating an individual’s belief

that they can participate in health promotion activities. For instance, for inmates who have

been diagnosed with chronic conditions, it would be important to speak to friends or family

members about their health problems and to make decisions about how they will manage

their chronic illness. Without the emotional support from others, there is the possibility that

they may not have confidence in their ability to manage their own health (McAvay, Seeman &

Rodin, 1996; Seeman et al., 1999).

The finding regarding the positive association between emotional support and health

related self-efficacy in older inmates suggests that interventions targeting emotional support

may be useful in the prison environment. Researchers have made several attempts to develop

interventions focused on increasing social support among community dwelling adults. The

interventions that have been tested have mixed findings on their impact on the older adult

population (Steptoe, Shankar, Demakakos, & Wardle, 2013). Furthermore, many of these

25
interventions are not viable in the prison environment. For example, in recent years, multiple

studies focused on internet usage among older adults as a means of increasing feelings of

emotional support through increased communication with family and friends (Cotten,

Anderson, & McCullough, 2013; Wright, 2000). This approach would not be viable in the prison

environment because inmates do not have access to computers; some may be incarcerated for

internet-related crimes. Hence, further research is needed to develop interventions that are

feasible in the prison environment. A possible intervention could be focused on support groups

specifically for older inmates. These support groups could simply be an outlet for older inmates

to come talk about themselves and their problems to individuals who can understand their

feelings and issues. To the best of our knowledge, support groups targeting older inmates are

not conducted in the three prisons included in this study. Inmates may find social support (not

just limited to emotional support) in a variety of different ways including participating in group

activities, prison education programs, mental health programs, religious services, and spending

time with friends or family that may come and visit (Jiang & Winfree, 2006; Kerley & Copes,

2008). It has been suggested that by participating in these types of activities which can improve

social support, inmates may experience positive outcomes including improved self-esteem,

fewer rule violations, reduced their idle time, and improved basic literacy (Jiang & Winfree,

2006). In the present study, the types of groups offered within each prison and whether or not

the participants attended these groups was not available.

Older prisoners also tend to have fewer visitors and are more isolated than younger

prisoners. Therefore, lack of emotional support may be particularly challenging for this group

of individuals (Bond, Thompson, Malloy, 2005). Several prisons in the United States have

26
begun segregate older inmates from younger inmates (McCarthy & Rose, 2013). In fact,

Osborn Correctional, one of the facilities included in the present study, has a geriatric unit.

Elderly housing units are separate from other housing units in the prison and are often times

modified to be more conducive to older individuals. For instance, some elderly housing units

have no top bunks, are closer to public areas like the dining hall, and have staff or other

inmates trained to help older inmates with everyday tasks (McCarthy & Rose, 2013). Living

together in the same unit may help to increase emotional support among older inmates.

However, these units are only feasible in prisons with high older inmate populations, and

enough room to house the rest of the population in separate units. Due to these reasons, they

are not readily adopted. Future research should determine if living in a prison geriatric unit

has a positive impact on emotional support and if it subsequently increases health related self-

efficacy.

PADL disability, hearing, and alcohol abuse were associated with health related self-

efficacy. Studies have shown that feeling of self-efficacy is significantly associated with older

adults’ ability to independently conduct activities of daily living (ADLs) in the general

population (Seeman, Unger, McAvay, & de Leon, 1999). In the prison environment, individuals

are faced with many of the ADLs experienced by community-dwelling adults, as well as

additional and unique functional abilities related to their life in prison (Barry, Wakefield,

Trestman, & Conwell, 2016; Williams et al, 2006). Inmates who have difficulty walking to the

chow line, walking to the yard, or standing in line for medications may have a more difficult

time managing their own health; hence, they report lower health related self-efficacy. The

same relationship was found in regards to poor hearing and prior alcohol use. Hearing

27
impaired older adults have been shown to report lower self-efficacy in the general population;

perhaps due to their inability to successful hear vital information (Kramer, Kapteyn, Kuik, &

Deeg, 2002). This would cause problems for older inmates who are required to hear orders

from staff and healthcare professionals. Older adults who abuse alcohol have also been shown

to have lower self-efficacy in the general population (Hyde, Hankins, Deale, & Marteau, 2008).

Many interventions have been developed aimed at increasing self-efficacy in order to alter

addiction behaviors that would be beneficial in the prison environment such as intensive

group-based interventions (Hyde, Hankins, Deale, & Marteau, 2008).

Whereas prior studies of older community-living persons have shown that self-efficacy

is associated with factors including poor vision and chronic pain, this study did not find these

same associations. For instance, chronic pain has been shown to be associated with poor

health related self-efficacy among community dwelling adults (Arnstein et al., 2009; Gallant,

2003). Successful self-management approaches have been developed to combat the effect

chronic pain has on self-efficacy (Barlow, Wright, Sheasby, Turner, & Hainsworth, 2002). Poor

vision has been shown to decrease self-efficacy in older community dwelling adults, due to the

diminishment in their ability to balance and change direction while walking and performing

health management activities (Stevenson, Hart, Montgomery, McCulloch, & Chakravarthy,

2004). It is possible that we did not find these same relationships in the study population for

several reasons. Older inmates have a stigma in the prison environment of being weak,

helpless and in need of particular care (Fattah & Sacco, 2012). Consequently, they may be

more likely to underreport conditions such a chronic pain and poor vision for fear of being

victimized. Another reason that the relationship between these modifiable variables and

28
health related self-efficacy were not found could be the sample size. Perhaps performing this

same analysis on a larger sample will show different results.

In this study, females had significantly higher emotional support scores when

compared to males. This is consistent with research conducted in the general population that

has shown that women typically have a greater amount of emotional support when compared

to their male counterparts (Antonucci & Akiyama, 1987; Lin, Dean, & Ensel, 2013). This finding

may reflect women’s tendency to be more nurturing and more positively expressive (i.e. less

quarrelsome and unfriendly), and hence seek more emotional support and more meaningful

relationships with others when compared to men (Jiang & Winfree, 2006; Lin, Dean, & Ensel,

2013). We found that gender was associated with emotional support. However, after

stratification by gender, the association between emotional support and health-related self-

efficacy did not differ in males and females in the adjusted models. This finding was surprising

considering the research in the general population that suggests females report greater

amounts of emotional support. However, this finding indicates that in older prisoners,

interventions focused on improving emotional support may have beneficial effects in both

men and women. As only 57 (34%) females participated in this pilot study, a larger scale

study would be useful to confirm these findings and inform future interventions focused on

improving emotional support among both female and male inmates.

Limitations

There are several important limitations to this study. As previously stated, this is a

cross-sectional study based on a secondary data analysis. Temporality of the association

cannot be determined in a cross-sectional study. It is suggested that in the future, a

29
prospective study design that collects data on inmates over several years would better assess

direction and causality between the independent and dependent variables of this study:

emotional support and health-related self-efficacy.

Because this was a pilot study, it only examines a relatively small sample (n=167) of

older inmates from one state. These facts raise the question of whether or not this study is

generalizable. However, despite the relatively small sample size, the age distribution and

racial composition of this study sample was similar to that of inmates age 50 and older in the

United States (American Civil Liberties Union (ACLU), 2012). However, only one facility in this

study housed female inmates. In the United States, females compromise 6% of the 50 and

older inmate population; in this study, females compromised 34% of the study population

(ACLU, 2012). Furthermore, we compared the characteristics of the study sample and the total

population of older inmates in the three participating CTDOC facilities. The mean age and

mean number of years in prison did not differ significantly between the study sample and the

population in the three facilities. However, the average number of years until expected release

date was significantly shorter for the study sample; 6.6 (±10.7) years versus 13.6 (±14.9) year

(p<.001). It is possible that the results would have differed among those with longer sentences

(e.g., “lifers”). It would be interesting to replicate these analyses in samples of older inmates

who are new to prison, are repeat offenders, and who have aged in prison.

Another important limitation of this study is that other types of social support were

not explored, such as instrumental support and participation in prison activities (ie.

involvement in organized groups and holding a job) (Lin, Dean, & Ensel, 2013). These types of

activities have been shown to increase feelings of social support in the general population (Lin,

30
Dean, & Ensel, 2013). In the prison environment, there are limitations to the types of activities

one can participate in; however, there are organized services and jobs available to inmates.

For example, there are socio-cultural activities, educational courses, sports, and vocational

training (Brosens, De Donder, Dury, & Verté, 2015). Having instrumental support includes

being able to count on someone to providing care or help performing certain activities

(Malecki & Demaray, 2003). In the prison environment this could include inmates or prison

staff helping the older inmates walk, shower, eat; or obtain materials they need such as

walkers and wheelchairs. Whereas these types of support were not explored in this research

study, it would be beneficial in the future to evaluate how both participation in prison

activities and instrumental support may affect older inmates health related self-efficacy.

The last limitation of this study deals with the questions that were selected to assess

older inmates health related self-efficacy. In this pilot study, only two questions were asked

that addressed inmates’ health related self-efficacy. There is the potential that these two

questions may not fully assess “poor” and “good” health related self-efficacy. In future studies

it would be beneficial to use questionnaires such as the “Self-Efficacy for Managing Chronic

Disease 6-Item Scale” developed by researchers at the Stanford Patient Education Research

Center (Lorig et al., 2000). This questionnaire uses a 6-item scale that was adopted from

several self-efficacy scales in order to be much less burdensome on subjects. It has been

tested in many settings including the “Chronic Disease Self-Management study”, a randomized

clinical trial evaluating the outcomes of a chronic disease self-management program (Lorig et

al., 2000).

31
Conclusions and Recommendations

Inmates age 50 and older are the fastest growing segment of the prison population

(Williams et al., 2007). This population places a considerable strain on the Department of

Correction’s staff and resources due to their many health issues and dependencies in

healthcare management (National Research Council, 2014). Finding ways to better manage

this growing population while they are in prison is vitally important; however, many of these

inmates will eventually return back to the community where they will be fully responsible for

managing their own health (Freudenberg, 2001).

This study fills an important gap in current research. We found that older inmates

reporting lower levels of emotional support were more likely to have poor health related self-

efficacy. However, studies investigating the mechanism by which emotional support impacts

older inmate’s health related self-efficacy are warranted. Understanding the relationship

between these variables, and further examining risk factors for poor health related self-

efficacy in older inmates, could ultimately lead to interventions targeted to help this

vulnerable population.

32
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