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Self-Perceived Health Improvements Among Prison Inmates

Article in Journal of Correctional Health Care · January 2014

DOI: 10.1177/1078345814558048

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Article
Journal of Correctional Health Care
2015, Vol. 21(1) 59-69
ª The Author(s) 2014
Self-Perceived Health Reprints and permission:
sagepub.com/journalsPermissions.nav
Improvements Among DOI: 10.1177/1078345814558048
jcx.sagepub.com
Prison Inmates

Sung-suk Violet Yu, PhD1, Hung-En Sung, PhD1,

Jeff Mellow, PhD1, and Carl J. Koenigsmann, MD2

Abstract
Despite the extensive resources expended on providing medical care to inmates, inmates’ health
perception is an understudied topic. The current study investigates inmates’ perception of health
status while incarcerated using a sample of 136 soon-to-be released prisoners. Prisoners with poor
health perception prior to their current incarceration were most likely to perceive health improve-
ment. Sociodemographic characteristics were generally not associated with the perceived health
improvement during incarceration. Analysis results suggest correctional institutions may play a vital
role in delivering much-needed medical care to a segment of the prisoner population, including
determining how they feel about their health. It is important to explore the policies and practices
to increase continuity of health care following release to maintain perceived health improvement.

Keywords
prisoner, health improvement, health perception, health policy

Until 2014, the United States was one of the few developed countries without universal health care.
Nevertheless, prisoners in the United States were afforded the constitutional right to receive medical
care at the government’s expense (Estelle v. Gamble, 1976), a right that until 2014 was not provided
to them when living in the community. Given that health perception is associated with health out-
comes (Chilcot, Wellsted, & Farrington, 2011; Petrie & Weinman, 2012), and substantial resources
are expended to provide medical care to inmates (National Commission on Correctional Health
Care, 2002), it is important to examine whether inmates perceive any improvement in their health
during incarceration. The perceived changes in their health status during incarceration may influ-
ence their likelihood of seeking medical care upon release, in turn affecting their health following
release (Freudenberg, Moseley, Labriola, Daniels, & Murrill, 2007). While there are many studies
on inmate health before and after incarceration, whether inmates perceive any changes in their

1
Department of Criminal Justice, John Jay College of Criminal Justice, New York, NY, USA
2
New York State Department of Corrections and Community Supervision, Albany, New York, NY, USA

Corresponding Author:
Sung-suk Violet Yu, PhD, Department of Criminal Justice, John Jay College of Criminal Justice, 524 West 59th Street,
2113 North Hall, New York, NY 10019, USA.
Email: syu@jjay.cuny.edu

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60 Journal of Correctional Health Care 21(1)

health status during incarceration is a largely neglected research topic. The current study sets
out to examine inmate perceptions of health changes and their correlates by analyzing primary
in-person survey data.

Background
The high prevalence of chronic medical conditions of prisoners emphasizes the role correctional
agencies play in providing medical care to prisoners and the demand placed on such agencies
(Hammett, Harmon, & Rhodes, 2002). Prisoners exhibit myriad medical and mental health condi-
tions at higher rates compared to those of the general population, even after adjusting for socio-
demographic characteristics and substance use (Baillargeon, Black, Pulvino, & Dunn, 2000;
Binswanger, Krueger, & Steiner, 2009). Almost half of prisoners have chronic or serious medical
conditions (Maruschak, 2008), 56% of prisoners have mental health problems, and nearly a quarter
meet the clinical criteria for substance dependence (James & Glaze, 2006). Serious mental health
disorders are shown to increase the risks of multiple incarcerations (Baillargeon et al., 2009). Mental
health problems are associated with substance abuse or dependence (74%), homelessness (13%),
past physical or sexual abuse (27%), and having parents with substance abuse problems (39%; James
& Glaze, 2006). These findings suggest that health conditions and recidivism are associated with
each other (Binswanger & Wortzel, 2009; Wilper, Woolhandler, & Boyd, 2009). Therefore, it is
expected that prisoners have higher levels of medical and mental health conditions and require
health care at higher levels than the general population.
It is well documented that the health of recently released prisoners declines steeply and they have
higher mortality rates. In the first week of release, former prisoners are 2.5 times more likely to be
hospitalized than their matched control group (Wang, Wang, & Krumholz, 2013). In the first 2 weeks
of release, death risks of former prisoners are 13 times higher than that of the general population
(Binswanger et al., 2007). Even after the 2 weeks, their risk of death is 3.5 times higher, and the
hospitalization rate is almost twice that of their matched control group. A longitudinal study shows
that incarceration increases risky behaviors associated with infectious diseases such as HIV or sexu-
ally transmitted diseases upon release (Centers for Disease Control and Prevention, 1999; Green
et al., 2012; Schnittker & John, 2007). Incarceration is also linked to a decreased life expectancy
(Patterson, 2013).
Recently released prisoners also face lack of continuity in medical care upon release. Low-
income neighborhoods, where the majority of prisoners live at the time of arrest, and where they
return to, often lack available health care resources (Davis et al., 2009). Inadequate medical care
upon release in the community negatively affects prognosis and management of chronic medical
conditions including diabetes, asthma, HIV-related antiviral treatment, and mental illness (Binswan-
ger & Wortzel, 2009). The majority of recently released prisoners, even those with HIV, report miss-
ing medication (Clements-Nolle, Marx, & Pendo, 2008).
Despite the extensive research studies on prevalence of inmates’ medical conditions and their
health following release, it is often overlooked that the offender population displays a high preva-
lence of medical and mental health conditions prior to their incarceration (American Psychiatric
Association, 2004; Schnittker & John, 2007). Given that correctional facilities are where all prison-
ers have access to health care, it is possible that their health status changes while incarcerated. Addi-
tionally, some inmates may perceive changes in their health status, regardless of objective clinical
measurements. Partly due to a lack of objective pre- and posttest measures of health conditions of
prisoners, limited studies exist on the changes in prisoners’ health while they are incarcerated. A
couple of studies suggest that the incarcerated fare better than their counterparts in the community
(Massoglia & Schnittker, 2009). For example, a study found a lower mortality rate for incarcerated
minorities than their counterparts in the community (Rosen, Whol, & Schoenbach, 2011).

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Yu et al. 61

The current study aims to examine whether inmates perceive any improvement in health status
during incarceration and the correlates related to health perception. Indeed, patients’ perception
of health status and satisfaction with health care services are frequently used measures in health care
settings and research (Hammett et al., 2004; Herman, Hopman, & Rosenberg, 2013). Furthermore,
knowledge of the characteristics associated with perceived changes in health status during incarcera-
tion can be used to inform policy makers and practitioners to deliver effective health care services to
prisoners and provide an opportunity to bridge health care from corrections to community.

Method
Participants
From March 2011 to June 2012, structured in-person interviews were conducted with 136 state pris-
oners housed in a maximum-security correctional facility in the northeastern United States. Research
participants were prisoners who received or expected to receive release approval from the parole
board or those who would have fully served their sentences in approximately 30 days. To recruit
participants, researchers were led to a classroom where prisoners were taking classes to prepare for
their release. After researchers made a brief oral presentation of the study in the classroom, all pris-
oners were asked to fill out a card indicating whether they wanted to participate in the study. An
estimated 80% of eligible prisoners participated in the study.
In this facility, two levels of health appraisals, initial and periodic, are conducted under formal
policies. Within 14 days of admission, prisoners are appraised on their health history to discern risk
factors. The health screening includes history of substance use; sexual orientation; mental health
screening; dental screening; and a complete physical exam including blood tests, urine analysis,
chest X-rays, tuberculosis test, and various immunization tests. After admission, prisoners have
age-dependent periodic health appraisals every 5 years for those 16 to 49 years old and every 2 years
for those aged 50 and older.
The research participants were asked questions about their living situation, medical conditions,
health care coverage, and substance use prior to their incarceration. They also were asked about their
current medical conditions, self-perceived changes in health status upon incarceration, and self-rated
current and previous health status. While the in-person surveys were highly structured, participants
were encouraged to elaborate in their answers. Each interview lasted between 45 and 60 minutes.
Researchers asked questions and recorded the participants’ answers. No compensation was provided
to the study participants.

Dependent Variables
Health encompasses a broad range of meaning and various aspects of life, which may or may not
include existence of illness or disability (see definition of health in the Supplement 2006 to the Con-
stitution of the World Health Organization for an example). Based on existing studies, we operatio-
nalized health in three dimensions: health in general, physical pain, and emotional problems (see
Hammett et al., 2004). The main goal of the study was to examine inmates’ perception of changes
in their general, physical, and emotional health status since incarceration. To achieve this goal, the
participants were asked, ‘‘Would you say your health in general is now improved while in prison, the
same, or worse?’’ This question was repeated for ‘‘physical or bodily pain.’’ Participants also were
asked, ‘‘Would you say your emotional problems such as feeling anxious, depressed, intense worry,
fear, grief, or sad is now improved while in prison, the same, or worse?’’ The three current health
status responses were placed into the following two groups for multivariate logistic analysis: those
who stated that they perceived health improvement since incarceration and those who did not per-
ceive improvement.

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62 Journal of Correctional Health Care 21(1)

Predictors and Procedures

Logistic regression analyses on three health outcomes were performed in SPSS Version 20. The model
included variables measuring medical conditions and sociodemographic characteristics as predictors.
The analyzed demographic characteristics included marital status, ethnicity, race, age, and education.
Also included were living circumstances (being homeless), availability of help from family, and
employment status prior to incarceration. Four health-related variables prior to incarceration were
included in the analysis because we hypothesized that prisoners who had medical conditions or health
care coverage before incarceration may have different perceptions regarding their health since incar-
ceration. The health-related variables include self-reported diagnosable medical and mental health
conditions, and public health care coverage such as Medicare and Medicaid. Lastly, a dichotomous
variable on ‘‘substance use weekly or more’’ was created by combining several variables on illicit hard
drug use such as crack cocaine, powder cocaine, heroin, PCP, or crystal meth.
In addition to the impacts of sociodemographic characteristics on perceived health improvement,
we examined whether inmates’ self-rated health status prior to incarceration had impacts on their
current health perception. Research participants were asked to rate three types of health status prior
to their incarceration on a Likert-type scale. Participants were asked, ‘‘Would you say your health
status before your prison stay in the community was excellent, very good, good, fair, or poor?’’ This
question was repeated for ‘‘physical or bodily pain’’ and ‘‘emotional problems such as feeling anx-
ious, depressed, intense worry, fear grief, or sad.’’ Possible choices for physical pain were no pain,
minimal pain, mild pain, moderate pain, or severe pain. Possible choices for emotional problems
included not at all, slightly, moderately, quite a bit, or extremely. The three types of health status
prior to current incarceration were recoded into three groups: excellent, good, and poor.

Results
Research Participant Characteristics
Characteristics of research participants are presented in Table 1. A startling number of study parti-
cipants were ethnic minorities (66% Black and 35% Hispanic). While less than 20% of the partici-
pants reported being married, 49% reported that a substantial amount of help was available from
their family prior to incarceration. High prevalence of homelessness, substance use, and chronic
medical and mental health conditions was observed. Within the 12 months prior to their incarcera-
tion, 20% of respondents reported being homeless, 18% reported using hard illicit substances at least
weekly, 54% reported having medical conditions including physical disability, and 23% reported
having mental health disorders prior to their incarceration. The reliance on public health insurance
was quite high: 55% of the respondents reported being covered under Medicare and/or Medicaid.1
Almost four out of five respondents (77%) reported having a minimum of high school or equivalent
educational attainment, although only 54% reported working in the year prior to their incarceration.
An analysis of their prior health status showed prevalent health challenges. About a quarter of the
research participants reported suffering from extreme emotional problems even before their incar-
ceration. We also observe that 50% of participants reported having excellent general health, while
20% reported having poor general health. A majority of the participants (79%) reported that they
experienced minimal or no physical pain when living in the community.

Perceived Changes in Health Status During Incarceration

Table 2 presents perceived changes in prisoners’ health status. A majority of the research partici-
pants (55%) reported that their general health had improved since incarceration. The comparable
figures for physical pain and emotional problems were not as positive, however. About a third of

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Yu et al. 63

Table 1. Characteristics of Research Participants (N ¼ 136).

Predictors Number %

Married 22 16.2
Hispanic 48 35.2
Black 90 66.2
High school completion 105 77.2
Age (mean: 32.5, median: 30, range 20–59) — —
Prior to incarceration: Within 12 months
Homeless 27 19.9
Help from family: As much as needed or quite a bit 67 49.3
Employed 73 53.7
Chronic medical conditions including disability 73 53.7
Mental health conditions 31 22.8
Covered under public health insurance (Medicare/Medicaid) 61 55.1
Hard drug use: Weekly or more often 25 18.4
Prior to incarceration: General health statusa
Excellent 68 50.4
Good 40 29.6
Poor 27 20.0
Prior to incarceration: Physical paina
No pain 106 78.5
Mild pain 12 8.9
Severe pain 17 12.6
Prior to incarceration: Emotional problemsa
Not at all 89 65.9
Moderately 14 10.4
Extremely 32 23.7
a
N ¼ 135, 1 missing.

Table 2. Perception of Current Health Status Following Incarceration (N ¼ 136).

Yes: Improved The Same or Deteriorated

Health Improvement Following Incarceration Number % Number %

General health 75 55.1 61 44.9

Physical pain 42 30.9 94 69.1
Emotional problems 44 32.4 92 67.6

the research participants reported lower physical pain (31%) and fewer emotional problems (32%)
during their incarceration. Only 10% of the respondents reported deterioration in their general health
since they were incarcerated. On the other hand, 17% and 28% of respondents reported that their
physical pain and emotional problems, respectively, deteriorated since their incarceration.

Perceived Changes in Health Status and Correlates

Table 3 presents logistic regression analysis results on perceived changes in health status while
incarcerated. Prisoners with self-perceived poor general health status prior to their incarceration
were significantly more likely to perceive that their health improved during incarceration and had
28.02 odds ratios (ORs; 95% confidence interval [CI] [4.77, 164.62]) of reporting improved health
perception versus those who reported having excellent general health prior to incarceration. Only

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64 Journal of Correctional Health Care 21(1)

Table 3. Multivariate Logistic Regression Analysis on Improved Health Outcomes (N ¼ 136).

General Health Physical Pain Emotional Problem

Exp(B) CI (95%) Exp(B) CI (95%) Exp(B) CI (95%)

y
Married 0.35 [0.10, 1.15] 0.33 [0.08, 1.32] 0.88 [0.27, 2.85]
Hispanic 0.63 [0.23, 1.69] 0.57 [0.22, 1.49] 1.02 [0.37, 2.78]
Black 0.74 [0.26, 2.10] 0.5 [0.18, 1.45] 1.65 [0.57, 4.75]
High school completion 0.47 [0.17, 1.28] 0.40y [0.15, 1.03] 0.53 [0.19, 1.49]
Age 0.96 [0.92, 1.01] 1 [0.95, 1.05] 1.03 [0.98, 1.09]
Prior to current incarceration
Ever homeless 1.08 [0.30, 3.88] 1.42 [0.43, 4.66] 1.32 [0.40, 4.38]
Help from family 1.96 [0.80, 4.80] 1.4 [0.60, 3.27] 1.22 [0.48, 3.06]
Employed 1.37 [0.60, 3.10] 1.56 [0.68, 3.54] 1.14 [0.48, 2.67]
Chronic medical conditions 0.8 [0.33, 1.91] 0.73 [0.30, 1.77] 0.77 [0.31, 1.92]
Mental health conditions 0.96 [0.31, 2.99] 1.73 [0.58, 5.18] 1.54 [0.53, 4.42]
Public health insurance 0.55 [0.23, 1.29] 1.35 [0.57, 3.17] 2.81* [1.12, 7.03]
Illegal substance use 2.32 [0.77, 6.95] 1.3 [0.50, 3.43] 1.91 [0.70, 5.19]
Health status
Excellent/very good — — — — — —
Good 1.85 [0.74, 4.67] 2.35 [0.58, 9.63] 3.67y [0.91, 14.76]
Fair/poor 28.02** [4.77, 164.62] 1.69 [0.44, 6.44] 3.04* [1.16, 7.98]
Constant 5.41 0.89 0.05

Cox and Snell R2 .26 .14 .21

Nagelkerke R2 .35 .2 .29
Note. CI ¼ confidence interval.
y
p < .10. *p < .05. **p < .01.

one sociodemographic variable was related to perceived changes in general health: Married partici-
pants were less likely to report that their general health improved since their incarceration (OR ¼
0.35, 95% CI [.10, 1.15]).
For participants with prior emotional problems, improvement was observed more widely, albeit at a
smaller level. Prisoners who had moderate emotional disturbance prior to their incarceration had 3.67
ORs (95% CI [.91, 14.76]) of thinking that their emotional problems improved versus those who reported
no emotional disturbance prior to incarceration. For those who suffered extreme emotional disturbance
prior to their incarceration, their ORs of perceiving improvement was 3.04 (95% CI [1.16, 7.98]). This
result is even more compelling since participants often expressed that they were experiencing increased
apprehension and fear, mixed with excitement, regarding their impending release. Respondents covered
by public health programs prior to their incarceration were more likely to perceive that their emotional
problems improved since incarceration (OR ¼ 2.81, 95% CI [1.12, 7.03]).
In terms of physical pain, prior health status was not associated with perceiving improvement or
deterioration since incarceration. However, this result may be due to only a small number of parti-
cipants experiencing physical pain prior to their incarceration: Only 9% reported experiencing mild
pain and 13% reported moderate to severe pain. Education was the only significant variable for per-
ceived changes in physical pain: Those with a minimum of high school education were less likely to
report that their physical pain had improved since incarceration (OR ¼ .40, 95% CI [.151, 1.034]).

Discussion
The current study examined perceived health improvement by prisoners during incarceration, a
largely neglected research topic. By conducting in-person interviews with soon-to-be-released

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Yu et al. 65

prisoners, it was possible to examine their perceptions regarding whether their health (health in gen-
eral, physical pain, and emotional problems) had improved or deteriorated since incarceration. Con-
sistent with existing literature, research participants in this study reported high rates of
homelessness, unemployment, marital instability, and substance use (Clements-Nolle et al., 2008;
Freudenberg et al., 2007; Khan et al., 2008; MacGowan et al., 2003; Rosen, Schoenbach, & Wohl,
2008). More than half of the participants reported having chronic medical conditions, and 2 out of
every 10 participants reported having a mental health condition prior to their incarceration. How-
ever, the existence of chronic medical and mental health conditions and disability prior to incarcera-
tion was not related to perceived health improvement during incarceration. This finding may reflect
the marginalized status of this population; in the community, they may not have (adequate) access to
health care, precluding them from receiving formal diagnosis or appropriate management of illness.
Review of literature on prisoner health shows that prisoners are often from low-income and minority
communities where medical needs are frequently unmet (Dumont, Brockmann, Dickman, Alexan-
der, & Rich, 2012). This finding also increases the validity of using perception of changes in health
status as a measure of health outcome for this vulnerable population, given the lack of official mea-
sures on health before and after their incarceration.
More importantly, the analysis showed that how participants felt about their health prior to incar-
ceration—not whether they had any chronic illness or disability—was related to the perceived health
improvement during incarceration. Indeed, the prisoners with poor prior health were most likely to
perceive health improvement since incarceration. Specifically, 27 research participants rated their
general health to be poor in the community. Of those, all but two felt that their general health
improved since incarceration. Therefore, prisoners with the worst health appear to believe that their
health improved since incarceration. This finding also corroborates suggestions that mandated med-
ical, mental health, and substance abuse assessment and treatment at intake, structured daily rou-
tines, and the availability of medical care for acute and chronic conditions can decrease the
continuity of morbidity and bring a stable period of health and well-being behind bars (Binswanger
et al., 2011; Rosen et al., 2008).
The study does have some limitations, however. First, as with any research study relying on self-
reporting, the survey data may suffer from underreporting or exaggeration due to social stigma,
social desirability, or memory loss (Heerwegh, 2009). Additionally, there is a risk of recall bias
influenced by the current situation, when participants were asked to remember their past events
including medical conditions. This bias may be more pronounced for mild illness than for severe
or chronic illness. Considering that the participants were housed in a maximum-security prison at
the time of study, it seems unlikely that this systemic bias would have favored their experiences
in the correctional facilities.
Another set of concerns is related to generalizability of the findings. The study sample con-
sisted of volunteers from a maximum-security prison. Therefore, the findings may not be general-
izable to prisoners in lower security prisons or with relatively shorter prison stays. However, given
that about 80% of the eligible population participated in the study, the sample represents this
unique cohort of population. Additionally, our research participants were overwhelmingly ethnic
minorities. While this partially reflects overrepresentation of ethnic minorities in correctional
facilities, the results may not be generalizable to all prisoners or even prisoners in maximum-
security prisons in other regions.
Third, the analysis relied on self-reported measures of medical conditions and perceptions of
health improvement. While they are valid measures for this vulnerable population without ade-
quate access to medical care in the community, the authors plan to use official prison health data
to validate findings of the current study in the future. Finally, due to the relatively small sample
size, it was not possible to examine impacts of specific illnesses on perceived improvement in
health status.

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66 Journal of Correctional Health Care 21(1)

Conclusion
The current study showed that the inmates who had perceived their health to be poor prior to incar-
ceration were most likely to perceive improvement in their health during incarceration. Importantly,
the perceived changes in health status were not related to sociodemographic characteristics or the
presence of chronic medical and mental conditions. The biggest improvement was perceived in gen-
eral health, followed by emotional health.
The paucity of studies on how prisoners perceive their health status while incarcerated
demonstrates a need for a study assessing prisoners’ perception of their health status and their
satisfaction with their medical care during incarceration. The findings from the current study
signal that even prisoners in a maximum-security prison perceive improvement in their health
while incarcerated, and the likelihood of perceiving improvement was influenced by how they
felt about their health prior to their incarceration. While the study did not employ clinical mea-
sures to validate inmates’ perceptions, it demonstrates that inmates are their own agents capable
of recognizing their own health status. There is a growing recognition that perception of an ill-
ness is as important as, if not more important than, clinical measures when it comes to health
outcomes (Chilcot et al., 2011). The relative fluidity of health perception (Devcich, Ellis,
Broadbent, Gamble, & Petrie, 2011) underscores the importance of providing continuity of care
between prison health care and the community.
Without ensuring continuity of care upon release, any health improvement, whether perceived or
real, will dissipate rapidly postrelease. For example, a history of drug abuse and dependency is the
leading predictor of the risk of death postrelease (e.g., 92% of deaths in the first 2 weeks postrelease
are due to overdose; Binswanger et al., 2007). A potentially deadly side effect of improving health of
prisoners through forced abstinence from drug use is that prisoners lose their drug tolerance. A pre-
vious normal dose of heroin prior to incarceration can become fatal postrelease. This lack of assim-
ilation to their new tolerance level, for instance, may explain the steep decline in health measured by
hospital admission (Wang et al., 2013) and mortality rates (Binswanger et al., 2007), despite many
prisoners feeling that their health is better than before their incarceration.
The fact that a substantial proportion of research participants reported improved health status
since incarceration suggests that correctional institutions may play an important role in the public
health field. Unlike other health care environments, in prison all have access to medical care. With
the implementation of the Affordable Care Act, which will reduce the number of uninsured Amer-
icans in the community (Manchikanti, Caraway, Parr, Fellows, & Hirsch, 2011), the findings from
this study may change. However, given that the majority of prisoners will return to their commu-
nities, where they are required to manage their own health, it is important to explore policies to
maintain improved health, whether perceived or real.
In the meantime, it is important to recognize that the closed environment of prison gives health
care workers an ideal opportunity to screen, prevent, and treat diseases that often go unaddressed
in the community for this disadvantaged population. Treatment regimens and medication manage-
ment, for example, are often easier to address in correctional facilities than in the community. We
are doubtful that self-perceived health improvements alone can buffer the recently released pris-
oners from the social and environmental triggers to use drugs so prevalent in many of the commu-
nities to which they return. However, inmates’ perceived health improvement may help case
managers begin the conversation with soon-to-be released prisoners about the importance of
enrolling in a health plan, maintaining a long-term medical regimen, seeking out a primary care
provider or qualified health clinic, and accessing quality substance treatment programs postre-
lease. If inmates do not perceive that their health has improved regardless of objective measures,
they are less likely to realize the benefits of medical care and less likely to seek medical care to
maintain their health following their release.

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Yu et al. 67

Acknowledgments
We thank Mr. Philip Heath, Mr. Paul Korotkin, and Mr. Brian Lane at the New York State Department of
Corrections and Community Supervision for their responsiveness and cooperation. They worked with us to
ensure that our study complied with their department’s research protocols and assisted us with the clearance
and coordination necessary to conduct surveys with our research participants.

Declaration of Conflicting Interests

The authors disclosed no conflicts of interest with respect to the research, authorship, and/or publication of this
article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.

Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication
of this article: Funding for this study was made possible by grant #5P20MD006118 from the National Institute
on Minority Health and Health Disparities. The views expressed in this study do not necessarily reflect the offi-
cial policies of the Department of Health and Human Services, nor does mention of trade names, commercial
practices, or organizations imply endorsement by the U.S. government or John Jay College of Criminal Justice.

Note
1. Medicare is available for people aged 65 and older and those with certain disabilities, and Medicaid is avail-
able for people with low income. The oldest research participant was 59 years old at the time of interview.
However, six participants reported being covered by both Medicaid and Medicare, and two participants
reported being covered exclusively under Medicare. Due to the small number of participants covered under
Medicare program, we combined both groups into one group.

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