Overview and Inventory of HHS Efforts to Assist Incarcerated and Reentering Individuals and their Families
Research reveals that many prisoners return home in need of help to reintegrate into their community and into their families. They lack the proper means to reconnect with family members, acquire housing and jobs, and overcome substance abuse and other health problems. Even worse, ex-offenders are increasingly returning to neighborhoods that are plagued with concentrated social and economic disadvantage. Landing in such communities post-release exacerbates the challenges of reentry and increases the odds of recidivating.
Families are an important source of housing, emotional support, financial resources, and overall stability for returning prisoners, and as such, they play a critical role in the successful reentry of individuals from prison to the community. HHS has a role in ameliorating the effects of incarceration on family formation and functioning, thereby increasing the support that an ex-offender has when he/she returns to the community. The Departments special focus on vulnerable children and families also extends its responsibility to families and communities experiencing distress because of disproportionately high rates of incarceration in poor and minority communities. Family instability, along with poverty, drive the need for many HHS program services, and incarceration is likely to play a direct role for some programs.
Of special concern to HHS are the nearly 7.5 million children, more than 10 percent of children under age 18, who have a parent who is currently incarcerated or on probation or parole (Mumloa, 2006). These children are disproportionately minority and poor (Glaze and Muruschak, 2008). Bruce Western and Christopher Wildeman (2009) estimate that among children born since 1990, four percent of whites and 25 percent of blacks will witness their father being sent to prison by their fourteenth birthday. In 2008, with funding from the National Institutes of Health, Joseph Murray and David Farrington published the results of a Campbell Collaborative Systematic Review of evidenced-based research entitled the Effects of Parental Imprisonment on Child Antisocial Behavior and Mental Health. Reviewing the most rigorously conducted research on the effects of parental incarceration, they found that children of prisoners have about three times the risk of antisocial behavior compared to their peers. Additionally, Steven Raphael (2010) notes that the lifetime likelihood of serving prison time for a black male child born in 2001 stands at 32 percent; whereas, for Hispanic males, the lifetime risk is 17.2 percent, and for white males that risk is six percent.
Over half of parents in prison (40 percent of mothers and 58 percent of fathers) indicated that they were not living with any of their children prior to incarceration, making it highly likely that many parents in prison have child support issues that need to be resolved (Glaze and Maruschak 2008). The Office of Child Support Enforcement (OCSE) has made resolving child support issues for incarcerated noncustodial parents a priority for its discretionary grant funding. Since FY 2000, OCSE funded over a dozen projects that involve collaborations among child support agencies, Departments of Corrections and community-based organizations. The grants provide child support services to individuals participating in the Prisoner Reentry Initiative (PRI), which is administered by the Departments of Justice and Labor (DOJ and DOL).
Incarceration severely affects intimate relationships, including those with partners and children, by creating barriers to intimacy, family involvement, and economic contributions. Western (2004) documents that incarceration affects family formation. Using data from the Fragile Families and Child Well-being Study, he found that formerly incarcerated men are just as likely to have children as other men of the same age; however, they are less likely to marry and those who do are more likely to separate and divorce. In exploratory work, Eirik Evenhouse and Siobhan Reilly (2010) found a positive correlation over time and across Metropolitan Statistical Areas (MSA), between the probability that a mother has had children by more than one man and the lagged arrest rate in her MSA. The correlation is stronger among racial and educational subgroups that experience higher rates of multiple-father fertility. Both poverty and incarceration are factors likely contributing to this finding.
The Office of Family Assistance (OFA), through its Healthy Marriage and Responsible Fatherhood discretionary grant program, has funded 27 projects that provide parenting and family strengthening services to incarcerated and formerly incarcerated fathers and their partners. Some of these grants provide support to increase economic stability, including financial literacy. Twelve of the grant projects are part of a rigorous implementation and impact evaluation managed by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) to determine the effect of family strengthening services on family functioning, recidivism and employment outcomes. The implementation evaluation will be released in the late early fall of 2011. Briefs highlighting interim findings will be published periodically leading up to the release of the final impact study report in 2014.
Empirical evidence shows that most individuals released from prison will return there for new crimes or technical violations within three years of being released (Langan and Levin, 2002). What results, then, is a cycle of removal and return in communities with already large concentrations of social and economic disadvantage. Generally, this phenomenon occurs in poor, predominately minority communities with low levels of educational attainment. The churning population of offenders into and out of the community severely affects the families left behind and the public health of the community at large. Such communities characteristically are areas plagued with high unemployment, staggering crime rates, high rates of substance abuse and mental illness; and a prevalence of fragile families.
In a one state study of families on Temporary Assistance for Need Families (TANF), Kirby, Fraker, Pavetti and Kovac (2003) found that more than one in every three TANF clients (36 percent) had been arrested during the previous six years, and nearly one in every five TANF clients (18 percent) has been convicted of a felony or misdemeanor. Arrest and conviction are considered potential liabilities to increasing family economic stability through employment. The Center for Employment Opportunities (CEO) in New York City supports an employment program for former prisoners that aims to reduce recidivism through steady employment. It is part of the Enhanced Services for the Hard-to-Employ Demonstration and Evaluation project, sponsored by the Office of Planning, Research and Evaluation (OPRE) and ASPE with additional funding from the U.S. Department of Labor. Interim results from MDRCs rigorous impact evaluation of CEO show reduced recidivism in both the first and the second year of follow-up among former prisoners considered to be at highest risk of recidivism (Zweig, Yahner, and Redcross, 2010).
No ongoing data collection system exists to provide information on the health status of prisoners leaving prison or jail. Data are available, although not always systematically, on the health of individuals while they are incarcerated, and one can assume that these health conditions are similarly found in the population of prisoners that are released to the community. However, differences in the health status and access to care may exist between individuals leaving prison and those who cycle in and out of jail. This brief review provides information on both of these populations.
Substantial evidence shows that the use and abuse of illegal drugs and the abuse of legal drugs including alcohol, tobacco/nicotine, and prescription drugs are prevalent health issues in incarcerated populations (Hammett, Roberts, and Kennedy, 2001). This use and abuse has implications for infectious and chronic diseases. A Bureau of Justice Assistance (BJA) report indicates that in 2004, more than 80 percent of state prisoners report ever having used drugs, 70 percent report using drugs regularly, over half report having used drugs in the month before the offense and one-third were using at the time of the offense (Mumola and Karberg, 2006).
Mental illnesses are the second most frequently reported disorders among men and women incarcerated in state prisons. A survey on prisoner mental health completed by the Bureau of Justice Statistics (BJS) found that over half of all prisoners (56 percent of state prison inmates, 45 percent of federal inmates, and 64 percent of those in local jails) reported either a clinically-diagnosed mental condition or treatment for a mental condition in the 12 months prior to the interview (James and Glaze, 2006). Studies have shown that the proportion of individuals with a serious mental illness within the correctional system is two to four times higher than that found in the general U.S. population (Hammett, Roberts, & Kennedy, 2001). Co-occurring disorders (mental health and substance use) are also high: About 74 percent of state prisoners and 76 percent of local jail inmates who had a mental health problem also met criteria for substance dependence or abuse.
The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) funded a total of 42 grants in FY 2009 and FY 2010 for Offender Reentry Program (ORP) projects. The program is designed to address the needs of sentenced substance-abusing juveniles and adult offenders returning to their families and communities from adult or juvenile incarceration facilities including prisons, jails, or juvenile detention centers. ORP projects expand and enhance community-based substance abuse treatment and related recovery and reentry services for sentenced juvenile and adult offenders returning from incarceration. Limited funding may be used for activities within a correctional setting.
Infectious diseases appear at higher rates among inmates than among the general public (Colsher et al., 1992; Fitzgerald et al. 1984; Garrity et al., 2003; Kahn et al, 2004; Lindquist and Lindquist, 1999; Wallace et al., 1991; Hammett et al., 2002). The estimated prevalence of HIV infection in the United States is over two times higher among incarcerated populations than in the general population (Wilper, et. al., 2009). The rate of confirmed AIDS cases is 2.5 times higher among prison inmates than in the general population (Maruschak and Beavers, 2009; McQuillan and Kruszon-Moran, 2005). Further, high proportions of all individuals with serious infectious diseases serve time in a correctional facility (e.g., 20 to 26 percent of individuals living with HIV, 29 to 43 percent of individuals infected with Hepatitis C, and 40 percent of those with Tuberculosis) (Hammett et al., 2002).
The Center for Disease Control and Prevention (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention recently awarded a grant for demonstration and program services to support the development and evaluation of a comprehensive, routine, opt-out jail-based rapid HIV testing initiative. The grantee, the Rollins School of Public Health at Emory University, is working with the Fulton County Jail in Atlanta, Georgia to explore strategies to conduct STD and Hepatitis screenings and provide Hepatitis B vaccinations to inmates who screen preliminary positive for HIV. The services will be provided during an initial health screening or medical intake evaluation.
Few studies look at the prevalence of chronic illness among jail or prison inmates. Although, a National Commission on Correctional Health Care report (2001) states that the prevalence of chronic illnesses and communicable diseases is greater among people in jails and prisons. Hypertension, asthma, and diabetes are among the more common chronic diseases reported; however, their presence varies with the age of the incarcerated population (Wilper et. al, 2009). One study that examines survey data finds, that among federal, state, and jail inmates, nearly 40 percent of each population reports at least one chronic illness (Wilper et. al., 2009). Several older studies indicate that nearly ten percent of jail and prison inmates have physical impairments that limit the type or amount of work they can perform ( Harlow, 1998).
Dental health needs are commonly reported by inmates but information on severity and care is limited. One study finds that over one-third of inmates reported problems with their gums and teeth and less than a quarter of men and two-fifths of women had seen a dentist in the last year. An Iowa study found that the states incarcerated population had more than eight times the amount of untreated tooth decay, when compared with a sample of all U.S. adults (Boyer et al., 2002). Corrections-based dentists in Minnesota reported encountering a condition known as "meth mouth,” which is associated with inmates methamphetamine usage in the community. It is characterized by lost, broken and cracked teeth and gum disease. Methamphetamine is one of the factors that has increased Minnesotas correctional dental health care costs from $1.19 million in 2000 to $2.01 million in 2004 (Brunswick, 2005).
Incarcerated women represent about ten percent of the incarcerated population. While they exhibit many of the same disease patterns as men, there are some additional factors that are worth addressing. First, the rates of mental illness appear to be significantly higher for women than for men; in one study, 73 percent of female inmates had mental health problems compared to 55 percent of male inmates (James and Glaze, 2006). The majority of female offenders have histories of trauma and abuse; 57 percent of women in state prison reported that they were physically or sexually assaulted at some point in their lives (Greenfield and Snell, 1999). Their trauma histories are often catalysts to the cycle of incarceration as victims of trauma are more likely to abuse substances.
The female prison population grew by 832 percent in the last three decades (Womens Prison Association, 2009). As the number of women entering the corrections system continues to increase, attention to issues that affect female ex-offenders becomes increasingly important. The substantial growth of female incarceration highlights the need for gender-specific services that adequately address the unique social, emotional, psychological and physical challenges faced by incarcerated and reentering women.
The Division of Cancer Prevention and Control within the CDCs National Center for Chronic Disease Prevention and Health Promotion, funds the National Breast and Cervical Cancer Early Detection Program. Two state grantees are targeting incarcerated females with outreach activities and screening services.
Where reentry is concerned, the Office on Womens Health is conducting the Incarcerated Womens Transition Project with the purpose of providing a comprehensive set of recommendations to articulate a model for creating, expanding and/or enhancing services that promote successful transition of women and girls back into their respective communities. This will promote better health for the women, their families and their communities which should also help to prevent recidivism.
At any one time, over 7.3 million people are on probation, in jail, in prison, or on parole in the United States . Each year, more than 735,000 individuals return home from prison and nine million cycle through the nations nearly 3,000 jails (Robinson, 2010). The Department supports the reentry of formerly incarcerated individuals into communities through a variety of activities that fall into the broad categories of health and human services needs. Successful reentry begins while an individual is incarcerated. Hence, a number of activities within HHS serve those who are in prison as well as their family members.
Ensuring that an ex-offenders basic needs are met upon reentering society reduces his/her probability of recidivating. The hope then is that by addressing the needs of ex-offenders and their families, the overall health, safety, and economic well-being of communities will improve. The following inventory illustrates HHSs recognition of the critical role of families in the successful reentry of individuals from prison to the community. The activities included in the inventory illustrate the many ways in which HHS strives to increase stability, health, and general well-being for incarcerated and reentering individuals and their families.
Boyer, E.M., Nielsen-Thompson, N.J., & Hill, T.J. (2002). A comparison of dental caries and tooth loss for Iowa prisoners with other prison populations and dentate U.S. adults. Journal of Dental Hygiene, Spring: 76(2), 141-150.
Brunswick, M. (2005, February 6). ‘Meth mouth plagues many state prisoners. Star Tribune. Retrieved on May 8, 2006, from http://www.startribune.com/462/story/64321.html
Colsher, P. L., Wallace, R.B, Loeffelholz, P.L., & Sales, M. (1992). Health status of older male prisoners: A comprehensive survey. American Journal of Public Health, 82: 881-884
Evenhouse, Eirik & Reilly, Siobhan (2010). Multiple-Father Fertility and Arrest Rates. MPRA Paper 22818, University Library of Munich, Germany. <http://mpra.ub.uni-muenchen.de/22818/1/MPRA_paper_22818.pdf>.
Fitzgerald, E.F., D-Atri, D.A., Kasi, S.V., & Ostfeld, A.M. (1984). Health problems in a cohort of male prisoners at intake and during incarceration. Journal of Prison & Jail Health, 4(2, Fall): 61-76.
Garrity, T. F., Hiller, M.L., Staton, M., Webster, J.M., & Leukefeld, C.G. (2003). Factors predicting illness and health services use among male Kentucky prisoners with a history of drug abuse. The Prison Journal, 82(3): 295-313.
Glaze, L.E. & Maruschak, L.M. (2008). Parents in prison and their minor children. Bureau of Justice Statistics Special Report. Washington, DC: Bureau of Justice Statistics.
Greenfield, L.A. & Snell, T.L. (1999) Women Offenders. Washington, DC: Bureau of Justice Statistics.
Hammett, T.M., Harmon, M.P., & Rhodes, W. (2002). The burden of infectious disease among inmates and releasees from U.S. correctional facilities, 1997. American Journal of Public Health, 92(11), 1789-1794.
Hammett, T., C. Roberts, & S. Kennedy. (2001). "Health-Related Issues in Prisoner Reentry." Crime & Delinquency 47(3): 390-409.
Harlow, C.W. (1998). Profile of Jail Inmates 1996. (NCJ 164620). Washington, DC: Bureau of Justice Statistics.
James, D.J. & Glaze, L.E. (2006). Mental Health Problems of Prisons and Jail Inmates. (NCJ 213600) Washington, DC: Bureau of Justice Statistics.
Kahn, R.G., Voigt, R.F., Swint, E., & Weinstock, H. (2004). Early syphilis in the United States identified in corrections facilities, 1999-2002. Sexually Transmitted Diseases, 31(6): 360-364.
Kirby, G., Fraker, T., Pavetti, L. & Kovac, M. (2003). Families on TANF in Illinois: Employment Assets and Liabilities, Washington, DC: Mathematica Policy Research. < http://aspe.hhs.gov/hsp/tanf-il-emp03/report.pdf>.
Langan, Patrick & David Levin. (2002). Recidivism of Prisoners Released in 1994. Bureau of Justice Statistics Special Report. NCJ 193427. Washington, DC: US Department of Justice, Bureau of Justice Statistics.
Lindquist, C.H., & Lindquist, C.A. (1999). Health behind bars: utilization and evaluation of medical care among jail inmates. Journal of Community Health, 24(4): 285-303.
Maruschak, L.M. & R. Beavers. HIV in Prisons, 2007-08. NCJ 228307. Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, 2009. bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf
Maruschak, L.M., & Beck, A.J. (2001). Medical Problems of Inmates, 1997. (NCJ 181644) Washington, DC: Bureau of Justice Statistics.
McQuillan Kottiri GB & Kruszon-Moran D. (2005).The prevalence of HIV in the United States household population: the national health and nutrition examination surveys, 1988 to 2002. National Center for Health Statistics, CDC. Abstract no. 166. Presented at the 12th Conference on Retroviruses and Opportunistic Infections, Boston, MA; 2005.
Mumola, C. (2006). Presentation for the NIDA Research Meeting Children of Parents in the Criminal Justice System: Children at Risk.
Mumola, C.J. & Karberg, J.C. (2006). Drug Use and Dependence, State and Federal Prisoners, 2004. (NCJ 213530). Washington, DC: Bureau of Justice Statistics.
Murray, J., & Farrington, D. P. (2008). Effects of parental imprisonment on children. In M. Tonry (Ed.), Crime and Justice: A Review of Research (Vol. 37, pp.133-206). Chicago: University of Chicago Press.
National Commission on Correctional Health Care. The Health Status of Soon-To-Be-Released Prisoners: A Report to Congress, vol. 1. Chicago: National Commission on Correction Health Care, 2002. www.ncchc.org/pubs/pubs_stbr.html.
Pew Center on the States. (2009). One in 31: The Long Reach of American Corrections. Washington, DC: The Pew Charitable Trusts.
Raphael, Steven. (2010) Incarceration and Prisoner Reentry in the United States . Institute for Research on Poverty Discussion paper no. 1375-10. < http://www.irp.wisc.edu/publications/dps/pdfs/dp137510.pdf >.
Robinson, Laurie. (2010) Remarks of Laurie Robinson, Assistant Attorney General Office of Justice Programs at the Exploring Health Reform and Criminal Justice: Rethinking the Connection between Jails and Community Health Meeting. November 17, 2010.
Teplin, L.A., Abram, K.M., & McClelland, G. M. (1996). Prevalence of psychiatric disorders among incarcerated women: Pretrial jail detainees. Archives of General Psychiatry, 53(6): 505-512.
Wallace, S., Klein-Saffran, J., Gaes, G., & Moritsugu, K. (1991). Health status of federal inmates: a comparison of admission and release medical records. Journal of Prison and Jail Health, 10(9): 133-151.
Western, B. (2004) Incarceration, Marriage, and Family Life. Princeton, NJ. Princeton University Department of Sociology. http://www.hks.harvard.edu/inequality/Seminar/Papers/Western.pdf.
Western, Bruce and Christopher Wildeman. (2009). The Black Family and Mass Incarceration. The ANNALS of the American Academy of Political and Social Science, 621: 221-242.
Wilper, A.P., Woolhandler, S., Boyd, J.W., Lasser, K.E., McCormick, D., Bor, D.H., & Himmelstein, D.U. (2009). The Health and Health Care of US Prisoners: Results of a Nationwide Survey. American Journal of Public Health, 99(4): 666-672.
Womens Prison Association (2009). Quick Facts: Women & Criminal Justice 2009.
Zewig J., Yahner, J. & Redcross, C. (2010). Recidivism Effects of the Center for Employment Opportunities (CEO) Program Vary by Former Prisoners Risk of Reoffending. Washington, DC:
Last updated: 02/25/11