Our results suggest support for a relationship between compounded health strain and institutional misconduct. The present findings indicate that, in addition to the strain of dealing with one type of condition, those in prison may experience a form of compounded strain in which co-occurring conditions increase the likelihood of misconduct. Cumulative health strain is likely worsened by being in prison, where the individual may already be dealing with significant, non-health-related strains in their day-to-day life. Thus, poor health may be a strain that is further intensified when one experiences it in an environment not necessarily conducive to overall well-being.

Notably, the experience of co-occurring health problems is largely associated with an increase in non-serious misconduct, which includes behaviors like possession of an unauthorized object, verbal assault, and being out of place. This suggests that co-occurring health ailments may not provide a strain substantial enough to increase the likelihood of serious misconduct. However, suffering from both a chronic and an acute condition increases the risk of serious misconduct, suggesting that an acute condition may be enough of a strain to increase the risk of serious misconduct even in the face of a chronic condition. In all cases, the greatest increase in misconduct risk is associated with the experience of all three types of conditions together.

We find that combinations of conditions increase the likelihood of misconduct where certain single measures of health condition type do not. After accounting for all forms of conditions and co-occurrence, mental disorder is not associated with serious misconduct alone. This is significant given the body of literature that finds that mental disorder is associated with serious misconduct (e.g., Adams, 1986; Carr et al., 2013; Felson et al., 2012; Houser et al., 2012; Matejkowski, 2017; McCorkle, 1995; Steiner & Wooldredge, 2009; Steiner et al., 2014; Stewart & Wilton, 2014; Wood, 2012; Wood and Buttaro Jr., 2013). However, much of this work does not account for physical conditions and comorbidity. Our results suggest that, compared to healthy individuals in prison, those suffering from a mental disorder that co-occurs with a chronic or acute physical condition are at a significantly higher risk for non-serious misconduct. However, mental disorder appears to only be a risk factor for serious misconduct when it co-occurs with both an acute and chronic condition. Given high rates of physical conditions comorbidity for those with a mental disorder, it may be that the unique strain of a significant physical condition on top of a mental disorder diagnosis is responsible for the increased risk for misconduct, rather than the experience of a mental disorder alone.

The findings also suggest that those dealing with a chronic condition alone are less likely to engage in both types of misconduct. However, when a chronic condition co-occurs with a mental disorder, acute condition, or both, these combinations all increase the risk of non-serious misconduct. Though mental and chronic conditions may not be associated with an increase in particular types of misconduct, co-occurring conditions compound the strain of being unhealthy and may lead to increased risk of misconduct. While previous research has suggested those with a dual diagnosis of a mental disorder and a substance use disorder are more likely to engage in misconduct (Houser et al., 2012; Wood, 2012; Wood and Buttaro Jr., 2013), our findings support expanding the definition of a co-occurring diagnosis to include acute and chronic physical health conditions. This provides a more nuanced understanding of the relationship between health and crime while accounting for physical health processes that researchers may not have considered when only examining the combination of mental disorder and substance abuse.

Implications for prison healthcare

In addition to improving the lives of those living in prison, our results suggest that efforts to enhance prison healthcare may assist in reducing inmate misconduct. The combination of mental and physical conditions appears to be particularly problematic for misconduct. This cumulative health-related strain may be worsened by poor prison conditions, the inability to access efficient healthcare, and the lack of resources to help cope with being ill. Given this, it may be particularly important for those in prison to receive fast care for acute conditions such as dental problems, illnesses like colds and viruses, and accidental injuries. These health problems likely do not require long-term and specialized care, but appear to be some of the most influential when it comes to misconduct risk. Greater access to outpatient care without long waits and financial burdens for short-term health problems may help to decrease the likelihood of misconduct by removing an important yet amendable strain in the lives of those incarcerated. Relatedly, improvements to medical record management and data retrieval processes across facilities are essential. Improved quality control, accountability, and access to records can ensure that those living in prison, especially if they have spent time in or transferred from another facility, receive appropriate and timely care that is pertinent to their health history.

It is possible that those in prison dealing with acute conditions do not seek out medical services, especially if the services are not readily available or are cost prohibitive. Though these individuals might be in pain or struggling with an illness, they may choose to deal with the symptoms on their own without receiving medical attention. This is problematic if the pain or illness persists and causes continuous discomfort or frustration for the individual. That discomfort may frustrate or anger the person, leading to a “shorter fuse” that may result in certain types of misconduct like a verbal confrontation, insubordination, or citations for not following the rules. Thus, in addition to making outpatient services available for short-term physical health conditions, those in prison should be appropriately educated about all healthcare services available to them so that they are inclined and encouraged to utilize them. All people incarcerated should receive the necessary medical attention and it is possible that failure to do so for acute conditions may create further problems for the individual and the security of the prison.

In addition to an increased focus on improving access to care and utilization for acute conditions, prison healthcare should work to provide improved care for those dealing with co-occurring conditions. These individuals are not only the most ill within the prison population, but they may also be at the highest risk for misconduct if they are dealing with multiple conditions simultaneously. The majority of research related to health and misconduct has focused on mental disorder and its co-occurrence with substance use disorders. Prison healthcare professionals should continue to address this type of comorbidity, while also taking seriously the co-occurrence of mental disorders with physical conditions, even those ailments that officials might deem acute or minor in nature. Although strains are abundant within a prison environment, our results indicate that poor health may be a particularly salient strain when it comes to the day-to-day lives of those in prison and why they engage in misconduct.

Situated within the larger field of epidemiological criminology (Akers & Lanier, 2009), we believe it is increasingly important to assess issues of health and crime alongside one another. Recent research illustrates complex pathways between health behaviors, health outcomes, criminal participation, and exposure to the criminal justice system that require further investigation (Vaughn et al., 2012; Vaughn et al., 2014). Given recent work suggesting that the promotion of health equity may be a pathway towards crime reduction (Jackson & Vaughn, 2018), policymakers and prison healthcare professionals have the opportunity to work towards improvements in inmate healthcare that may serve to also decrease misconduct participation.

Study limitations and future research

There are certain limitations to this study. We use data from 2004, drawn from a nationally representative sample of state inmates. The results discussed, then, can only be generalized to those individuals in state institutions, rather than federal facilities. Although the data are 14 years old, they represent the most up-to-date data for a nationally representative sample of individuals in state prisons. However, one specific change in prisons has occurred in the last 14 years that has great implications for prison healthcare and potentially the results of this study. In particular, the U.S. prison system has seen the greatest growth in those in prison aged 55 and older, a group more likely to experience poor chronic health than their younger counterparts (Carson, 2016). With a more recent dataset, then, we would expect to see a similar rise in chronic conditions among those in prison. Though smaller, more recent surveys of those in prison have been conducted in the past five years, they are not always nationally representative and do not include in-depth items regarding misconduct and health conditions. Once updated representative data is available that includes sufficient measures of health and misconduct, researchers should examine whether the findings presented here are replicable.

The data are cross-sectional, making it difficult to confirm the direction of causality between inmate health conditions and misconduct. It is possible that causality runs in both directions. It is also possible that misconduct increases the risk of poor health instead of the direction theorized here (see Piquero et al., 2007; Piquero et al., 2011). Despite this possibility, recent research using longitudinal data (Ford, 2014; Kort-Butler, 2017; Stogner & Gibson, 2010, 2011) provides support for a GST argument where health problems lead to greater crime and misconduct. Future studies assessing this relationship among inmates should strive to collect longitudinal data to confirm the directionality of these results. Although longitudinal data collection can be potentially challenged by transfers between facilities, this research can ultimately help determine appropriate policy recommendations to improve health and misconduct within prisons. Similarly, another avenue to better understand the relationship between health conditions and misconduct would be to conduct in-depth interviews with those in prison. These narratives would provide researchers with rich, detailed context surrounding the onset of the health disorder, the potential directionality of the relationship between health and misconduct, as well as how that condition may have influenced his or her misconduct.

Our variables are limited in certain aspects. The misconduct outcomes measured here only account for behaviors that have been reported and sanctioned. Thus, these measures do not capture misconduct that may have taken place but was either not reported or not disciplined.

The data do not include other noted correlates of misconduct such as self-control, association with peers that engage in misconduct, and social control within the prison facility. The measure of acute conditions does not include ailments like joint pain, headaches, migraines, and general pain that are utilized in past studies of acute health and crime (Stogner & Gibson, 2010, 2011). In addition, despite prior research indicating that institutional-level factors influence inmate misconduct (Gendreau et al., 1997; Steiner et al., 2014), our data do not include facility- and institutional-level variables such as population density, facility size, or prison security level. Given that the analyses were restricted to individuals, we could not account for correlated error across respondents nested within the same facility. No details were available regarding where respondents are housed (e.g. specific treatment or medical facilities, solitary confinement), which may influence an individual’s capacity to engage in misconduct. For example, the lack of significant findings between mental disorder alone and serious misconduct might be because those in prison with mental disorders are disproportionately more likely to be housed in solitary confinement (Fellner, 2006; Gilligan & Lee, 2013). Additionally, facility-level characteristics like overcrowding, high security levels and poor confinement conditions may independently contribute to poor health. According to the World Health Organization (2014), overcrowded facilities become breeding grounds for the transmission of communicable, chronic and acute disorders like tuberculosis and influenza. Relatedly, inhumane solitary confinement conditions increase the presence and enhancement of mental disorders (see Metzner & Fellner, 2010) and amplify various physiological symptoms like hypertension, weight loss, lethargy, and insomnia (Haney, 2003; Smith, 2006; Shalev, 2008). Future research should strive to conduct multi-level analyses while taking into account institutional-level factors that may influence misconduct and health separately and impact the relationship between health and misconduct as explored here. Finally, no robust measures of healthcare utilization or medication usage were available in the data, making it difficult to assess how those in prison are being treated for particular conditions.