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. Author manuscript; available in PMC: 2022 Oct 10.
Published in final edited form as: J Aging Health. 2021 Jun 12;34(1):60–70. doi: 10.1177/08982643211025443

Health and Health Service Needs: Comparison of Older and Younger Women with Criminal-Legal Involvement in Three Cities

Amanda Emerson a, Ashlyn Lipnicky b, Megan Comfort c, Jennifer Lorvick c, Karen Cropsey d, Sharla Smith b, Megha Ramaswamy b
PMCID: PMC9549913  NIHMSID: NIHMS1836819  PMID: 34120499

Abstract

Objectives:

We profiled the health and health services needs of a sample of older adult women (age 50+) with criminal-legal system (CLS) involvement and compared them with younger women (age 18–49), also CLS-involved.

Methods:

Using survey data collected January-June 2020 from adult women with CLS involvement in three U.S. cities, we profiled and compared the older adult women with younger women on behavioral and structural risk factors, health conditions, and health services access and use.

Results:

One-third (157/510) were age 50+. We found significant differences (p < .05) in health conditions and health services use: older women had more chronic conditions (e.g., hypertension, stroke) and more multimorbidity and reported more use of personalized care (e.g., private doctor, medical home, health insurance).

Discussion:

Although older women with CLS involvement reported good access to health services compared with younger women, their chronic health conditions, multimorbidity, and functional declines merit attention.

Keywords: older adults, vulnerable populations, women’s health, health services use

On any given day, there are over 2.3 million persons in prisons, jails, and other detention facilities in the United States (Sawyer & Wagner, 2020) and about 4.3 million in community corrections (Maruschak & Minton, 2020).1 About 12% of those incarcerated are women (Sawyer & Wagner, 2020), including approximately 101,000 women in local-, county-, or state-run jails and 115,000 in state or federal prisons (Kajstura, 2019). Approximately 60% of women incarcerated in state prisons and 80% of women in jails are held for non-violent offenses (Kajstura, 2019). Another one million women are on probation and serving their sentences in the community (Pew Charitable Trusts, 2018). From 1980 to 2019, the number of women incarcerated overall (jail or prison) rose 700% (Sentencing Project, 2020), while the number in community corrections doubled (Pew Charitable Trusts, 2018). The other growing CLS population in the United States is older adults. From 1999 to 2016, the imprisonment of persons age 55 and older grew by 280% (McKillop & Boucher, 2018). About 40% of the increase in female rates of incarceration in state prisons between 1993 and 2013 was owing to increases in the incarceration of females over age 55 (Carson & Sabol, 2016). The shifting age and gender demographics of those incarcerated or serving sentences in community corrections have led to concerns about the capacity of carceral and probationary systems safely to accommodate their needs (Aday & Farney, 2014; Golembeski et al., 2020). Our goal in this analysis was to contribute to what is known about the health risks, health conditions, and health services access and use of older adult women (age 50 and older, hereafter 50+) who have a history of criminal-legal system (CLS) involvement. By comparing older with younger adult women, we sought to learn where significant differences exist for the older female population in order to highlight where future research and interventions might be focused to better support the health of CLS-involved women across the lifespan.

The number of women age 50+ with CLS involvement is increasing and is expected to continue to rise in coming years, thus putting pressure on systems that were poorly designed to meet women’s needs and even less so older women’s needs. Researchers have consistently found that women with CLS involvement have poorer health and are more frequent users of health services than men. For example, 63% of women in prisons and 67% of women in jails report at least one chronic medical problem, compared with 50 and 48% of men, respectively (Maruschak et al., 2015). Women incarcerated in jails are 1–8 times more likely than men to report hypertension, diabetes, and cancer (Binswanger et al., 2010). Women in both jails and prisons report more infectious disease (Maruschak et al., 2015), and women in jails report more visual, dental, and mental impairments (Maruschak, 2006) than men. Compared with men in the CLS, women’s drug dependence and psychiatric disorders such as depression and psychosis are more prevalent, though not alcohol dependence and personality disorders (Fazel & Baillargeon, 2011). Aday and Farney (2014) found that women in prison were 2.5 times more likely to use health services than male prisoners. Women with a history of CLS involvement are also more likely to die prematurely. Massoglia and colleagues (2008; 2014) analyzed the long-term effects of CLS involvement on men and women and found that women who experienced jail incarceration—of any duration—were later more likely to die prematurely than either women with no history of jail incarceration or men with or without such history. Patterson (2013) demonstrated a positive dose-dependent effect of time served in prison on likelihood of mortality in the 12 months following a paroled release, though unlike the jail effect on mortality found by Massoglia (2008), the prison effect was stronger for men than women.

Women who have a history of CLS involvement also have more health problems than women who do not have a history of CLS involvement. After controlling for covariates, Udo (2019) found women with a background of incarceration were significantly more likely than women without such history to report ever having had anemia, arthritis, bowel problems, cancer, fibromyalgia, lung problems, osteoporosis, sexually transmitted infections, sleep difficulty, and stomach ulcers. Sexually transmitted infections, including HIV and syphilis, are more prevalent in women in CLS-involved groups than community samples (Wiehe et al., 2015). Other work has documented significantly higher rates of hypertension and hepatitis and 4–5 times higher rates of cervical cancer in adult women incarcerated in either jail or prison compared with community samples (Binswanger et al., 2009). Women living in the community who a significant lifetime history of CLS involvement have greater odds of unmet physical and mental health needs (Lorvick et al., 2018).

While we know that the health of adult women who have involvement with the CLS is comparatively poor on many counts (relative to men and to non-CLS-involved women), we know much less about older adult (age 50+) women with CLS involvement. Adults of either sex who have a history of incarceration experience aging-related health changes 10–15 years earlier than other adults (Greene et al., 2018; Humphreys et al., 2018; Williams et al., 2012). Most (though not all) health research in CLS-involved populations for this reason cites age 50 as the cut point for an older adult group (Merkt et al., 2020), while government agencies typically use ages 55 or 65, which results in difficulty in making comparisons. Health challenges faced by older adults with CLS involvement at an earlier age than other adults include reduced mobility, increased disease burden and multimorbidity, vision and hearing declines, mental health impairment, and cognitive decline (Barry et al., 2017; Bedard et al., 2016; Greene et al., 2018). We found a number of systematic reviews of studies reporting on interventions for older adult prisoners (Canada et al., 2019; Hornby-Turner et al., 2017; Negin et al., 2014; Stevens et al., 2018), but we located only scattered empirical work to establish the health services needs, access, and use of older adult women with CLS involvement.

Exceptions include Handtke et al.’s (2015) study of health conditions in women imprisoned in Switzerland, which found older women (age 50+) reporting on average 6.6 chronic diseases compared with the 3.5 reported on average by younger adult women. Older women experienced significantly more endocrinal and metabolic disease and more musculoskeletal and connective tissue disease. Williams et al. (2006) found older adult women (age 55+) in California prisons experienced reduced mobility and functionality at higher rates than age-matched community samples, and those impairments were significantly associated in the CLS-involved group with comorbidity and self-reported poor overall health. Aday and Farney (2014) surveyed 237 women, age 50–77 in seven prisons, and found 64% described their health as only fair or poor, and 89% indicated they had problems walking independently. In further analysis of the same data, Aday and Dye (2019) reported that 46% of the women scored either high or severe for depression on the Brief Symptom Inventory. In focus groups conducted by Barry et al. (2019) with prison health providers, findings indicated that older adult women presented for care with more cognitive barriers, required more health services time and resources, and showed a progressively greater need for “soft” services like empathy than younger women. Health services research suggests that systems may not be adjusting to meet older women’s needs. In a 2004 survey of state and federal prisons, Reviere and Young (2004) found few significant differences in the availability of health services relevant to older adult women’s needs when they compared facilities with higher percentages of older adult women (relative to younger women) with facilities that had lower percentages of older adult women.

Recent position papers and narrative reviews have usefully organized what work there is and have called for more study (Bedard et al., 2016; Golembeski et al., 2020). Yet the paucity of empirical research is evident in reviews like Skarupski et al. (2018) where just two of 20 studies was focused on older adult women’s health needs, or that of Loeb and AbuDagga (2006), who did not even report the gender of samples as a characteristic of the studies in their review, noting only one comparative result (men and women) in one study from 1990. Beyond the basic empirical gaps in our understanding, additional study is needed to untangle how the health and health care of older adult women differs by type of CLS involvement (prison, jail, community corrections), by dose or degree of involvement (e.g., long-term, short-term, repeated/episodic), and by time lapsed since involvement. Work is needed to parse out intersectionality and the variations in how racism, gender binarism, and other expressions of hegemony inflect CLS involvement at all points (arrest, arraignment, etc.) and at all levels. In this first step, we sought to profile a diverse sample of older adult (age 50+) women with a varied history of CLS involvement in three U.S. cities and compare that group with younger adult (age 18–49) women. We examined the prevalence of various health conditions, health care utilization, and structural and behavioral characteristics related to health in this sample. Our goal was to offer an empirical basis to inform future research, leading eventually to interventions to better support the health of CLS-involved women across the life span.

Method

Design, Setting, and Sample

We analyzed baseline data collected in the first year of an ongoing longitudinal (2019–2024) natural history study with women with CLS involvement in three U.S. cities. The purpose of the Tri-City Cervical Cancer Prevention Study among Women in the Justice System (2019–2024) is to understand how women with CLS involvement navigate individual-, social-, and community-level systems to maintain cervical health and prevent cancer in varied funding and healthcare access environments. The current study uses Tri-City survey data collected January-June 2020 from women age 18 and older (n = 510).

Participants in the Tri-City study were recruited from ongoing projects in Birmingham, Alabama; Kansas City, Kansas/Missouri; and Oakland, California. Women in the Birmingham sample were recruited from an outpatient community corrections facility using methods similar to those found in Cropsey et al. (2015); the Kansas City cohort was initially recruited for a jail-based intervention with follow ups after release (Ramaswamy et al., 2017); and the women in Oakland were recruited from the county probation office and community outreach (Hemberg et al., 2020). All participants were age 18+ and had a history of CLS involvement (i.e., jail, prison, probation or parole). Currently incarcerated women were excluded from the study. Inclusion criteria did not specify a specific amount or type (“dose”) of CLV involvement, since studies indicate that women at all levels of CLS involvement have amplified health risk (Lorvick et al., 2018; Lorvick et al., 2015), and for those whose CLS history includes incarceration, studies have shown that exposure, not length of stay, is associated with ill health effects—including premature mortality (Massoglia et al., 2014).

The Tri-City study protocol was reviewed and approved by the University of Kansas Medical Center (KUMC) Institutional Review Board (Approval #00142054), with reliance agreements between KUMC and the University of Alabama at Birmingham and KUMC and RTI International. Informed consent was obtained from all participants. The surveys were administered in person or by telephone by trained study staff in all three sites according to practices previously established with each cohort. All surveys were scanned and stored in REDCap. The women received $50 to thank them for their time.

Measures

The 288-item Tri-City survey addressed factors related in the literature to women’s cervical health, cervical health beliefs, and cervical and other health care services access and use. Questions from the Tri-City survey that were analyzed for this analysis were either yes/no or Likert-scale items, all of which were adapted from the National Cancer Institute’s Health Information National Trends Survey (NCI HINTS) (2020).

We selected variables related to aging and health services use in three categories: (1) structural and behavioral characteristics, (2) health conditions, and (3) health services access and use. In selecting variables, we were guided by the literature on the health of women with CLS history in general and, wherever possible, on older women with CLS history. Structural and behavioral characteristics included variables for economic need, employment, homelessness (Kelly et al., 2014), and neighborhood insecurity or violence (Ramaswamy et al., 2011), as well as sexual risk behaviors, history of sexually transmitted diseases (STDs) (Knittel et al., 2019), and health risk behaviors like smoking (Cropsey et al., 2004). In the category of health conditions, we included chronic cardiovascular and respiratory conditions (Aday & Farney, 2014; Maruschak et al., 2015), as well as variables of particular relevance to older adult women, such as arthritis, chronic pain, and visual impairment (Bedard et al., 2016). In the category of health access and use, we included variables that would indicate where women received care, from what type of provider, and with what kinds of assistance. We also included variables that were related to the women’s use of prevention services like screening for cervical and breast cancer and immunization for influenza.

Analysis

To conduct the bivariable analysis, we grouped the women into younger (age 18–49) and older (age 50+) groups, following common practice for the age cut point (Merkt et al., 2020). For several variables that were select all that apply on the Tri-City survey, the women were given numerous options (i.e., 11 for current employment). These we dichotomized to preserve population relevant distinctions without providing an entire distribution. For example, because so many women with CLS involvement do struggle with high economic disadvantage, we dichotomized the 11 employment options by whether they were for pay and thus brought in income or not. All “don’t know” and “prefer not to answer” responses were recorded as missing data. Further description of the preparation of the data can be found in Supplemental Table S1.

Frequencies and means were calculated for the demographic measures from the social and behavioral characteristics domain. Bivariable analyses were conducted using Mantel-Haenszel chi-square and t-tests (p < .05) to determine differences between women over 50 years of age and women under 50 years of age on the independent variables. Certain participant demographic characteristics, like race and employment status, were then broken down by site to determine significant associations. These variables were explored due to their potential variation by site and subsequent impact on the various outcome variables. Based on this analysis, we found race, employment status, and jail status to differ by site. Analysis System (SAS), version 9, was used.

Results

Characteristics of Participants

Women in the sample (N = 510) were on average 42 years of age, ranging from 18 to 77 (Table 1). Thirty-one percent (157/510) were 50 or older (Table 2). Over half the sample identified as African American or Black (57.3%). Most of the women had completed high school education (74.9%) and a third reported they were currently employed. All the women in the sample had at some point been either incarcerated or in community corrections, with 98% (256/260) of the women having been incarcerated for at least one year cumulatively (Table 2). Of the older women who had any history of incarceration, all had been incarcerated cumulatively for at least one year, and 38% had been incarcerated cumulatively 6 years or more. Most of the women in the study reported they had had stable housing (73.5%) in the previous year. But some indicated that they sometimes or often had trouble finding a place to sleep (18.6%), wash (19.4%), or use the restroom (16.7%). A quarter of the total sample reported sometimes or often having a hard time getting enough to eat (24.3%) or having enough clothing (26.1%). Over 40% sometimes or often had trouble with transportation, or “getting where they needed to go” (Table 2).

Table 1.

Characteristics of Participants by Site

Total (N=510) Kansas City (N=108) Birmingham (N=164) Oakland (N=238) pa
Race <0.001
 White 157 (30.8) 47 (43.5) 87 (53.0) 23 (9.7)
 Black 292 (57.3) 37 (34.3) 63 (38.4) 192 (80.7)
 Other 61 (12.0) 24 (21.70) 14 (8.5) 23 (9.7)
Age (average) 42 38.57 40.43 45.35
 18–49 36.16±7.87 35.71±6.96 35.84±7.98 36.76±8.36 .529
 50 & older 56.45±4.46 54.41±2.81 56.26±4.05 58.86±4.76 .106
Current Employment 173 (33.9) 49 (45.4) 54 (32.9) 70 (29.4) 0.010
High school or more 382 (74.9) 85 (78.7) 125 (76.2) 172 (72.3) 0.215
Stable housing 375 (73.5) 82 (75.9) 119 (72.6) 174 (73.1) 0.612
Jail in the past year 133 (26.1) 33 (30.6) 68 (41.5) 32 (13.4) <0.001
Cumulative time in jail/prison 0.072
 Less than 1 year 4 (1.6%) 3 (3.9) 0 (0) 1 (0.9)
 1–5 years 172 (66.1%) 52 (68.4) 44 (66.7) 76 (64.4)
 6–10 years 43 (16.5%) 16 (21.1) 10 (15.2) 17 (14.4)
 More than 10 yrs 41 (15.8%) 5 (5.6) 12 (18.2) 24 (20.3)
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a

Boldface p values <.05.

Table 2.

Bivariable Analysis Comparing Women 50+ Years to Women 18–49 Years on Selected Variables

Total (N=510) 18–49 (N=353) 50 & older (N=157) pa
Race <.001
 White 157 (30.8%) 126 (35.7%) 31 (19.7%)
 Black 292 (57.3%) 175 (49.6%) 117 (74.5%)
 Other 61 (11.9%) 52 (14.7%) 9 (5.7%)
Structural and Behavioral
Current employment 173 (33.9%) 144 (40.8%) 29 (18.5%) <.001
High school or more 382 (74.9%) 262 (74.2%) 120 (76.4%) .692
Stable housing 375 (73.5%) 256 (72.5%) 119 (75.8%) .504
More than sometimes had trouble
 Finding a place to sleep 95 (18.6%) 70 (19.8%) 25 (15.9%) .272
 Getting enough to eat 124 (24.3%) 97 (27.5%) 27 (17.2%) .011
 Having enough clothing 133 (26.1%) 101 (28.6%) 32 (20.4%) .047
 Finding a place to wash 99 (19.4%) 75 (21.2%) 24 (15.3%) .110
 Finding a place to use the bathroom 85 (16.7%) 59 (16.7%) 26 (16.6%) .947
 Getting someplace you needed to go 211 (41.4%) 147 (41.6%) 64 (40.8%) .842
Neighborhood fear 212 (41.6%) 148 (41.9%) 64 (40.8%) .744
Jail in past year 133 (26.1%) 116 (32.9%) 17 (10.8%) <.001
Cumulative time spent in jail/prison 260 (51%) 184 (52%) 76 (48%) <.089
 Less than 1 year 4 (1.6%) 4 (2.2%) 0 (0%)
 1–5 years 172 (66.1%) 125 (67.9%) 47 (61.8%)
 6–10 years 43 (16.5%) 32 (17.4%) 11 (14.5%)
 More than 10 years 41 (15.8%) 23 (12.5%) 18 (23.7%)
Has steady partner 253 (49.6%) 196 (55.5%) 57 (36.3%) <.001
More than 2 male sex partners, past year 363 (71.2%) 277 (78.5%) 86 (54.8%) <.001
Sex exchange ever 53 (10.4%) 44 (12.5%) 9 (5.7%) .023
Always used condom, past year 72 (14.1%) 51 (14.4%) 21 (13.4%) .787
STDs ever 267 (52.4%) 192 (54.4%) 75 (47.8%) .141
Smoke ever 359 (70.4%) 242 (68.6%) 117 (74.5%) .173
Daily or near daily substance use, past 30 days 106 (20.8%) 78 (22.1%) 28 (17.8%) .301
Substance use (not alcohol), past 30 days 124 (24.3%) 86 (24.4%) 38 (24.2%) .959
Health Conditions
Hypertension 164 (32.2%) 80 (22.7%) 84 (53.5%) <.001
High cholesterol 97 (19.0%) 47 (13.3%) 50 (31.8%) <.001
Asthma 165 (32.4%) 105 (29.7%) 60 (38.2%) .060
Stroke 33 (6.5%) 14 (4.0%) 19 (12.1%) .001
COPD 56 (11.0%) 16 (4.5%) 40 (25.5%) <.001
Diabetes/high blood sugar 64 (12.5%) 37 (10.5%) 27 (17.2%) .035
Cancer 44 (8.6%) 26 (7.4%) 18 (11.5%) .132
Dental Problems 261 (51.2%) 158 (44.8%) 103 (65.6%) <.001
Chronic pain 200 (39.2%) 101 (28.6%) 99 (63.1%) <.001
Arthritis 190 (37.3%) 85 (24.1%) 105 (66.9%) <.001
Multi-morbidity (3 or more chronicconditions) 221 (43.3%) 101 (28.6%) 120 (76.4%) <.001
Mental health diagnosis
 Depression 360 (70.6%) 243 (68.8%) 117 (74.5%) .145
 Schizophrenia 62 (12.2%) 36 (10.2%) 26 (16.6%) .046
 Bipolar disorder 189 (37.1%) 131 (37.1%) 58 (36.9%) .836
Health Services Access and Use
Personal doctor or nurse 315 (61.8%) 182 (51.6%) 133 (84.7%) <.001
Medical home 416 (81.6%) 277 (78.5%) 139 (88.5%) .004
Health insurance 345 (67.6%) 214 (60.6%) 131 (83.4%) <.001
Received healthcare in past year
 At a clinic by an appointment 373 (73.1%) 241 (68.3%) 132 (84.1%) <.001
 At a clinic by dropping in 165 (32.4%) 119 (33.7%) 46 (29.3%) .367
 At an urgent care 81 (15.9%) 61 (17.3%) 20 (12.7%) .197
 At an emergency room 297 (58.2%) 203 (57.5%) 94 (59.9%) .704
Received mammogram 261 (51.2%) 121 (34.3%) 140 (89.2%) <.001
Ever had Pap test 487 (95.5%) 332 (94.1%) 155 (98.7%) .019
Ever had abnormal Pap test (Abpap) 58 (11.9%) 46 (13.9%) 12 (7.7%) .044
Received follow-up care for Abpap 40 (69.0%) 28 (60.9%) 12 (100.0%) .009
Flu vax past year 189 (37.1%) 119 (33.7%) 70 (44.6%) .019
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a

Boldface p values < .05.

Univariable and Bivariable Results

Structural and Behavioral Characteristics

Among the statistically significant differences between the older and younger women in our sample, older women were less likely to report ever exchanging sex for resources such as money, drugs, or life necessities (5.7%: 12.5%; p=.02) and less likely to have had more than two male sex partners in the past year (54.8%: 78.5%; p<.001). Also significantly lower was the percentage of older women who reported currently having a steady partner (36.3%: 55.5%; p<.001). Among women age 50+, 17.8% reported daily substance use and only 13.4% who had intercourse with a man in the past year reported they always used a condom. Differences between older and younger women on these measures were not statistically significant.

Health Conditions

The most significant differences between older and younger women were clustered in areas of health care conditions and health care access and use. Older adult women reported chronic illnesses at significantly higher percentages than the younger women, except asthma and cancer. These included significantly higher percentages of women age 50+ reporting diagnoses of hypertension (53.5%: 22.7%; p<.001), high cholesterol (31.8%: 13.3%; p<.001), and stroke (12.1%: 4%; p=.001). The proportion of women age 50+ with multimorbidity was much higher, with a near 40-percentage-point spread between those reporting three or more chronic conditions in the older (76.4%) and younger (28.6%) groups. Among women age 50+, there was a much higher prevalence of conditions like chronic pain (63.1%: 28.6%; p<.001), arthritis (66.9%: 24.1%; p<.001), and dental problems (66.9%: 44.8%; <.001), which can affect mobility or limit activities of daily living. Finally, though not significantly different from the younger women, a high percentage of the women age 50+ reported having ever been diagnosed with depression (74.5%) and a substantial proportion with bipolar disorder (36.9%). Significantly more older women than younger women had been diagnosed with schizophrenia (16.6%: 10.2%; p=.046).

Health Services Access and Use

Women age 50+ indicated better access to health care in general than women age 18–49, with significantly higher percentages of the older group reporting they had a “personal” or primary care doctor or nurse (84.7%: 51.6%; p<.001), a medical home (88.5%: 78.5%; .004), and health insurance (83.4%: 60.6%; p<.001). Women age 50+ were significantly more likely than younger women to receive care at a health clinic by appointment (84.1%: 68.3%; p<.001). Ever having screened for cervical cancer did not differ significantly between the groups but was very high for both the older group (98.7%) and the younger (94.1%) women. Women age 50+ reported ever having obtained follow-up care following an abnormal Pap (Papanicolaou) test more than younger women (100%: 60.9%; p=.009), but the counts were small, and the older women would have had more opportunity for these services over time. Receipt of an influenza vaccination in the previous year was reported by a significantly higher percentage of the older than younger women (44.6%: 33.7%; p=.019).

Discussion

This analysis helps address gaps in the research about older women involved in the CLS system, by examining their health and health services use and comparing them with younger adult women in the CLS system in three U.S. cities. Overall, we found a much higher prevalence of chronic health conditions among women 50 and older, along with higher levels of health services use. While in some ways this might mirror what occurs in the general population, the prevalence of chronic illness was much higher in both groups of CLS involved women.

Health Services Access and Use

Women in the older group were much more likely to have a stable health care source than the younger women, as reflected in the significantly higher percentages of women age 50+ who reported they received health care by appointment, had a “personal” (i.e., primary care) doctor or nurse, had a medical home, and had health insurance—all above 80% among the older adult women. We did not find significant differences between the groups in the use of urgent or emergent health services, though nearly two-thirds in both groups reported they had received care in an emergency department in the previous year. Other researchers have found similarly high rates of health care use by older adults in both community and CLS settings (Barry et al., 2019; Committee on the Future Health Care Workforce for Older et al., 2008). That more of the older adult women (84.7%; 51.6%; p<.001) in our sample had a primary care provider made sense given that a portion of the older group would be over age 65 and eligible for Medicare coverage, improving their access to care. Additionally, in Oakland, a majority of the group age 50–64 was covered by health insurance through Medicaid expansion. Other research suggests that healthcare utilization by older adults is high in general, but there is good evidence that that use varies widely within older samples, with Medicare-covered persons in the highest tier of healthcare use (1.9%; 69,739/3 million users) accounting for around 12% of overall Medicare cost (Wells et al., 2016). Wells et al. found that older adults in a highest needs-cost group, on average, each year made 68 health care visits, saw 16 different providers, and were prescribed medications from greater than 20 different drug classes by seven or more providers. Though not specific to a CLS involved population, these findings suggest the complexity of managing healthcare for a group of older adults that overlaps demographically with our sample.

We were encouraged to find that most of the older women in our study at some point in their lives accessed preventive health services, including mammograms (89.2%), Pap tests (98.7%), and, when necessary, follow-up visits for abnormal Pap tests (100%). Other studies with women in the CLS have reported lifetime mammogram rates of around 75%, with up-to-date screenings (i.e., within 2 years) closer to 40% (Pickett et al., 2018). Our findings related to Pap screenings may not be representative of all CLS-involved older adult women, since participants in one of the three cohorts (the Kansas City group) had participated in a previous interventional study to increase those rates. The 44.6% of older women who reported influenza vaccination in our study was low compared with findings in the community. Shen et al. (2020), drawing on a representative sample of older adults (n ~ 14,000 community, plus 1,000 facility patients) in the Medicare Current Beneficiary Survey, documented influenza vaccinations at 75%.

Health Conditions

Older women in our sample not surprisingly reported significantly higher rates than younger women for chronic illnesses and conditions. The high percentages reporting health problems was generally congruent with data on older women with CLS involvement as reported by Aday and Farney (2014) and Fazel and Baillargeon (2011). We found high percentages of the older women reporting chronic pain (63%), arthritis (67%), and dental problems (66%) as well. For incarcerated older persons in particular, mobility and pain issues can be especially challenging (Williams et al., 2014; Williams et al., 2006), and most correctional facilities were not designed to accommodate the needs of those with aging-related functional decline (Bedard et al., 2016; Reviere & Young, 2004). The prevalence of dental problems is also noteworthy, because basic Medicare makes no provision for dental care and inadequate oral health in older adults has been associated with malnutrition, bone loss, and pneumonia (Azzolino et al., 2019; Kusama et al., 2019). In general, multimorbidity is a distinctive problem for older adults, with one recent review finding that 44% of those age ≥ 65 years manage 3 or more comorbidities, with greater prevalence of multimorbidity found in women compared with men (Ofori-Asenso et al., 2019). We know that managing multiple chronic diseases even in the best of circumstances can be challenging (Koch et al., 2015). Older women with CLS involvement face additional, unique barriers in coordinating or maintaining continuity of care, including access to multiple prescribed medications and therapies as they transition from community to jail or prison and back into the community—sometimes repeatedly (Mallik-Kane & Visher, 2008; Sered & Norton-Hawk, 2013).

Potentially compounding such difficulties in access to therapies and therapeutics for older adult women are cognitive status decline and/or mental health conditions. Though we did not ask about cognitive changes in our survey, recent literature cites early-onset cognitive decline, including but not limited to dementia, as a key issue affecting health in incarcerated older men (Combalbert et al., 2018) and women (Barry et al., 2019). Incarcerated older adults who experience cognitive impairment at any level often avoid or delay care and may be more vulnerable to isolation and injury (Aday & Krabill, 2011). Also important was the three-quarters of women age 50 and over in our study who reported depression. Depression and suicide are known risks for older adults who experience incarceration (Prins, 2014; Sturup-Toft et al., 2018).

Structural and Behavioral Characteristics

We found that most structural and behavioral factors did not differ significantly between older and younger women with a history of CLS involvement. This was itself somewhat concerning in that it meant, for example, that 18% of the women age 50+ reported “daily or near daily” use of substances other than alcohol (e.g., marijuana, crack, methamphetamines, etc.) over the past 30 days. This finding is broadly congruent with results from a systematic review conducted by Fazel et al. (2006), which estimated a 30.3 to 60.4% point prevalence for “drug abuse and dependence” in older adult women in prisons across six studies (albeit with high heterogeneity). Elsewhere, Haugebrook et al. (2010) found 80% of their sample of 114 older adult prisoners (both sexes) reported substance use disorder, and Humphreys et al.’s (2018) study of emergency department use by adults in the six months after a short jail incarceration found that among 101 participants age 55+, of which only seven were women, 70% had substance use disorder.

Behaviors with linked sexual health risk may also pose an area of concern for older adults with CLS involvement, though age- and sex-specific data is difficult to find for sexual health in this population. Research in correctional settings tends to focus on younger women, and, even in the community, entities like the Centers for Disease Control (CDC) report STD data related to older adults only sporadically and rarely break it down by sex. In 2019, in their full report of STD surveillance for 2017–2018, the CDC included statistics on older adults for syphilis only. There rates of increase among persons age 55–64 (21.1%) and >65 years (28.6%) outpaced younger groups (Centers for Disease Control and Prevention, 2019). In our survey, while 55% of the older women reported having had sex with more than two men in the previous year, only 13% reported always using a condom. Older adults with a history of CLS involvement remain at risk for sexually transmitted diseases and sexual violence and are more likely than community samples to have life circumstances that are associated with those risks, including homelessness, past or present drug use, a history of intimate partner or other traumatic violence, and use of survival sex (Ramaswamy et al., 2011; Santa Maria et al., 2018).

This study had limitations that affected our ability to detect relationships and the strength of the conclusions. First, Tri-City was not planned with the intention of comparing older and younger subsamples. As a result, some questions for which data would have been useful in the present study were not part of that survey (e.g., activities of daily living, mobility and cognitive decline, number of prescribed medications taken, and diagnosis with heart disease). Second, the recruitment and sampling procedures in the three cities were not uniform, because the cohorts came from pre-existing studies. Though we controlled for significant differences between the cohorts, there may have been undetected features in the original sampling and in the retention of the groups that affected responses, possibly introducing social desirability bias, especially since many participants were familiar with the site staff who administered the surveys. Third, we were administering the surveys when the COVID-19 emergency began. It is not clear if or how the rapid, unprecedented social and economic changes that marked the early months of pandemic response might have affected results, though recent publications have underscored the many ways COVID-19 might differentially impact older adults in correctional settings (Prost et al., 2021). It would have been useful to explore relationships between various health indicators and the types and amounts of CLS involvement for older adult women, as well as intersectional differences, especially to gauge the differential impacts of systemic racism. Even with the limitations and paths not yet taken, our study boasted a robust sample—both geographically and racially diverse—that enhanced the generalizability of the results and allowed us to contribute much needed empirical evidence of the health and health needs of an understudied, vulnerable group of older adults.

Implications

Although older and younger women with a history of CLS involvement in our study shared many aspects of structural and behavioral risk, health conditions, and health services access and use, this study showed that they also diverged from one another in important respects that could inform areas of emphasis for future research and health intervention. Based on the differences we found, there is particular need for programs or processes that offer wraparound services for older adult women who manage chronic illness—especially multimorbidity (Golembeski et al., 2020). Women as they age may also require more intensive services when they leave incarceration, including long-term care services, which can be especially difficult for persons with CLS involvement to coordinate and afford (Boucher et al., 2021). Our results, though not groundbreaking, offer a solid contribution to the evidence demonstrating that older adult women with CLS involvement have high needs and may require additional assistance managing their health care challenges, as well as age-targeted health promotion programming to reduce substance use and support sexual health. We found reason to conclude that older adult women have distinctive health services needs that call for more attention than they currently receive, chief among them specialized support for managing multiple chronic conditions, mobility and pain issues, substance use, and depression.

Supplementary Material

Supplemental File

Acknowledgements

The authors gratefully acknowledge the contributions of the entire Tri-City C.R.E.W. team and especially Alexandra Faust, Jordana Hemburg, and Joi Wickliffe.

Funding

The authors disclosed receipt of the following financial support for the research: This work was supported by the National Cancer Institute/National Institutes of Health [R01CA226838], the National Institute of Minority Health and Health Disparities/National Institutes of Health [R01MD010439], and a National Institute of Aging/National Institutes of Health award [R24AG065175] through the ARCH (Aging Research in Criminal Justice & Health) Network. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conflicting Interests

The authors declare no conflict of interest

1

Prisons are long-term state or federal facilities that hold persons who are convicted of felonies or other offenses and are sentenced to a year or more. Jails, run by states, counties, and municipalities, hold persons for shorter periods of time and include those remanded prior to a hearing or sentencing and those serving sentences of less than one year (Zeng, 2020). Community corrections involves a variety of arrangements, such as probation and residential treatment, and usually comes with limitations on residency, movement, and social contact along with drug testing and regular, mandatory visits with court designated officials (Kaeble & Glaze, 2016). Categories of incarceration along with the demographic metrics by which they are measured and reported vary by institution and administering agency, a factor that hampers comparisons.

Data Sharing

The data that support the findings of this study are available from the corresponding author at emersonam@umkc.edu, upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental File
NIHMS1836819-supplement-Supplemental_File.docx (18KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author at emersonam@umkc.edu, upon reasonable request.

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