Health care needs and service use among male prison inmates in the United States: A multi-level behavioral model of prison health service utilization

BACKGROUND The purpose of this study is to apply Andersen's Behavioral Model of Health Service Use to men's prisons to assess the direct and indirect effects of inmate predisposing characteristics through multiple types of need. Also examined are the effects of prison-specific enabling factors and the variation in use of health services across prisons. This study uses a nationally representative U.S. sample of men incarcerated in state prisons (n = 8816) and generalized structural equation and multilevel modeling. Five types of need-medical condition, illness, dental problem, unintentional injury, and intentional injury-are assessed for their association with use of health services. RESULTS Findings indicate that a number of inmate predisposing (age, race, education) and vulnerability (mood/anxiety disorder,) characteristics are associated with use of health services but are partially mediated by enabling and need factors. Each type of medical need has strong direct effects with mood/anxiety disorder emerging as the strongest total effect (including both direct effects and indirect effects through need). There is significant variation in rates of health service utilization across prisons that is not accounted for by the prison-level factors included in the multilevel model. CONCLUSIONS The varying patterns of health service use across prisons suggest that incarceration may be an important circumstance that shapes health. In other words, where someone is incarcerated may influence their ability to access and use services in response to medical need. It is important that prisons provide integrated services for inmates with mood/anxiety disorder given high comorbidity with other health conditions.