In this cross-sectional study of 172 recently released male prisoners, we found that 42% reported a lifetime history of criminal record discrimination by healthcare workers. To our knowledge, criminal record discrimination by healthcare workers has not previously been examined. Prior studies have reported rates of general societal discrimination based on criminal record between 34-51% (Crawford et al. 2013; Young et al. 2005). These studies were conducted among active drug users in New York City and assessed self-reported discrimination based on criminal record in any setting. Our findings support and extend this work by focusing on self-reported discrimination based on criminal record experienced during interactions with doctors, nurses, psychiatrists and other healthcare workers.
Our study adds to a growing field of research on discrimination in healthcare. To date, much of this work has examined discrimination attributed to race/ethnicity (Krieger 1999). Across these studies, Blacks and Latinos more frequently report race/ethnicity-based discrimination as was the case in our sample (data not shown) (Shavers et al. 2012). Discrimination based on criminal record demonstrated a different pattern in our sample, however, as more than half of White participants reported criminal record discrimination compared to 41% of minority participants. Also, individuals who reported a history of healthcare discrimination based on criminal record were more likely to have obtained some post-secondary education.
Both findings may reflect the increased salience of the experience of discrimination among these relatively advantaged groups. These groups may also have experienced discrimination for the first time due to incarceration. Alternatively, less advantaged groups may be less likely to report discrimination because it is a common event in their lives. Groups with lower social statuses, such as racial minorities or those with lower education levels, often experience discrimination prior to incarceration and higher levels of discrimination overall compared with higher social status groups (Williams & Mohammed 2009). Further, among groups with multiple stigmatized identities (e.g., a high school dropout and an ex-prisoner), there may be some uncertainty as to which stigmatized characteristic to attribute an experience with discrimination (Major & O’Brien 2005). These multiple stigmatized identities may have an additive, negative effect on healthcare experiences as has been demonstrated in studies examining experiences in the job market (Pager 2003; Pager et al. 2009a) though we did not find evidence of a significant interaction between criminal record and racial/ethnic discrimination in this sample.
Individuals who reported a history of criminal record discrimination by healthcare workers were older and had more extensive incarceration histories. This finding may reflect greater time spent incarcerated and therefore at risk of discrimination associated with incarceration. Alternatively, unmeasured factors associated with length and frequency of prior incarceration may also be associated with self-reported discrimination. For example, more serious criminal offenses result in longer sentences and may be associated with differential or "unfair" treatment by healthcare workers. Longitudinal linkages between more granular criminal justice and health-related data, though challenging, are essential both for testing such a hypothesis as well as for clinical quality improvement (Matejkowski et al. 2012).
In this examination of the relationship between criminal record discrimination by healthcare workers and healthcare utilization, we found an association between self-reported criminal record discrimination by healthcare workers and increased ED utilization after adjustment for clinically relevant covariates and self-reported racial/ethnic discrimination. This finding has several potential explanations. The ED is often the initial point of contact for incarcerated individuals who need to be transferred outside the correctional system to receive healthcare. Providers caring for a patient in an orange jumpsuit and shackles likely bring biases, whether explicit or implicit, to these encounters. Implicit, or unconscious, bias based on race/ethnicity has been shown to negatively impact patient-provider interactions and deserves further study in the context of the care of incarcerated patients (Cooper et al. 2012). Alternatively, ex-prisoners in the community who perceive discrimination in healthcare settings may choose to utilize the ED more frequently given the episodic, relatively anonymous nature of these interactions. In general, while disparities in emergency care have been documented (Pletcher et al. 2008), patient-reported discrimination of all kinds in emergency settings requires further study.
Similar to prior studies, we also found a significant association between discrimination based on race/ethnicity and infrequent primary care utilization. Prior work has shown that self-reported racial/ethnic discrimination is associated with decreased adherence to recommended care, decreased utilization of preventive services and barriers to patient-provider communication (Benjamins 2012; Blanchard & Lurie 2004; Casagrande et al. 2007; Hausmann et al. 2011; Hausmann et al. 2008; Trivedi & Ayanian 2006; Van Houtven et al. 2005) though these studies have not included former prisoners. Contrary to our hypothesis, we did not find an association between criminal record discrimination by healthcare workers and infrequent primary care utilization. We believe the impact of criminal record discrimination on the patient-provider relationship warrants further study given its potential to both mediate the significant health risks following release from prison as well as to provide a point of intervention to improve health outcomes for this vulnerable group.
The results of this study should be considered in light of its limitations. First, study data are cross-sectional and therefore do not allow inferences of causation. Though we hypothesized that experiences of criminal record discrimination affect healthcare utilization patterns, we cannot rule out reverse causation, in which greater ED utilization increases exposure to criminal record discrimination. This latter explanation would still highlight a need to better understand the healthcare experiences of individuals in correctional custody, particularly those experiences occurring in ED settings. Second, participants were each in male-female relationships, were recently released from prison and were recruited from a single region in California and therefore may not be generalizable to other ex-prisoner populations or settings. Specifically, men in romantic relationships report less discrimination than their counterparts not in relationships (Kessler et al. 1999). However, recent release from prison may make experiences of discrimination more salient and thereby overestimate this exposure compared to individuals with more remote criminal justice involvement (Kressin et al. 2008). Of note, important attributes of our study sample such as rates of common chronic diseases and reported use of correctional healthcare are similar to those found in the prison population nationally (Wilper et al. 2009). Third, the small size of our sample raises the possibility of a Type II error. Inclusion of individuals with criminal justice involvement and assessment of criminal history in larger data collection efforts is needed (Ahalt et al. 2012). Next, the survey tool used to measure discrimination based on criminal record in our study was adapted from a validated measure previously used to assess racial/ethnic discrimination, the General Ethnic Discrimination Scale. The findings of this pilot study are hypothesis-generating but do highlight the need for such instruments to be validated in criminal justice populations. Finally, as validated measures of healthcare utilization were not present in our data, we used the most clinically relevant utilization outcomes available. Further study using validated measures and confirmed by medical record or claims data is needed.