Mental Health of Staff at Correctional Facilities in the United States During the COVID-19 Pandemic
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ORIGINAL RESEARCH
published: 25 January 2022
doi: 10.3389/fpsyt.2021.767385
Mental Health of Staff at Correctional
Facilities in the United States During
the COVID-19 Pandemic
M. Haroon Burhanullah 1 , Pamela Rollings-Mazza 2 , Jeffrey Galecki 1 , Michael Van Wert 1 ,
Thomas Weber 2 and Mansoor Malik 1*
1
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD,
United States, 2 PrimeCare Medical, Inc., Harrisburg, PA, United States
Background: Although United States (US) correctional workers (correctional officers and
health care workers at correctional institutions) have experienced unprecedented stress
during the COVID-19 pandemic, to date, there are no systematic data on the mental
health impact of COVID-19 on correctional workers.
Objective: To determine the perceived mental health burden of the COVID-19 pandemic
Edited by: on correctional workers and to explore the relationship between workers’ mental health,
Owen Price,
The University of Manchester,
social demographics, and environmental/work factors. In particular, the study sought to
United Kingdom examine if occupational role (correctional officers vs. health care workers) or sex were
Reviewed by: associated with mental health status.
Elizabeth Barley,
University of Surrey, United Kingdom Methods: This cross-sectional survey was conducted in 78 correctional sites in
Laoise Jean Renwick, Pennsylvania, Maryland, West Virginia and New York from November 1 to December
The University of Manchester,
United Kingdom
1, 2020. There were 589 participants, including 103 correctional officers and 486 health
*Correspondence:
care workers employed at the correctional facilities. Measurements included the Patient
Mansoor Malik Health Questionnaire-9, Generalized Anxiety Disorder-7, Adult PROMIS Short Form
mmalik4@jhmi.edu; v.1.0—Sleep Disturbance, Impact of Event Scale-Revised, Maslach Burnout Inventory
mburhan1@jhmi.edu
2-item, and Connor-Davidson Resilience Scale 2-item.
Specialty section: Results: Approximately 48% of healthcare workers and 32% of correctional
This article was submitted to
Forensic Psychiatry,
officers reported mild to severe depressive symptoms, 37% reported mild to severe
a section of the journal anxiety symptoms, 47% of healthcare workers and 57% of correctional officers
Frontiers in Psychiatry
reported symptoms of burnout, and 50% of healthcare workers and 45% of
Received: 30 August 2021 correctional officers reported post-traumatic stress symptoms. Approximately 18%
Accepted: 24 November 2021
Published: 25 January 2022 of healthcare workers and 11% of correctional officers reports mild to moderate
Citation: sleep disturbance. Health care workers had significantly higher depression and sleep
Burhanullah MH, Rollings-Mazza P, disturbance scores than did correctional officers, while correctional officers had
Galecki J, Van Wert M, Weber T and
Malik M (2022) Mental Health of Staff
significantly higher burnout scores. Female correctional workers scored significantly
at Correctional Facilities in the higher on anxiety than their male counterparts. Increased workload, workplace
United States During the COVID-19 conflict, younger age of employees, trust in institutional isolation practices, and
Pandemic.
Front. Psychiatry 12:767385. lower work position were associated with increased burnout. Despite experiencing
doi: 10.3389/fpsyt.2021.767385 high mental health burden, correctional workers showed high resilience (60%).
Frontiers in Psychiatry | www.frontiersin.org 1 January 2022 | Volume 12 | Article 767385Burhanullah et al. COVID-19 and Correctional Health Workers
Conclusion: We found a high level of psychological symptoms among health care
workers in correctional settings, and this population may experience unique challenges,
risks and protective factors relative to other health care workers outside of correctional
settings. Understanding these factors is essential for developing effective interventions
for correctional workers.
Keywords: correctional health, correctional officers, resilience, burnout, mental health
INTRODUCTION the COVID-19 pandemic and examine whether the mental
health of correctional health care workers differed from that
The United States (US) prison system, which holds almost of correctional officers. Although both correctional officers
2.3 million prisoners (1), and employs more than 500,000 and correctional healthcare workers work together in the
correctional workers (includes correctional officers and health challenging environments with persons who have complex needs,
care workers) (2), is chronically understaffed and under- their duties and mandate in the correctional setting differ.
resourced (3). Added to these significant challenges is the impact Correctional officers have primarily security function while
of the COVID-19 pandemic, which has significantly increased the healthcare workers are primarily responsible for well-being of
work demands for correctional workers (4). imprisoned populations. Correctional officers are more likely
One in every five state and federal prisoners in the to be exposed to potentially psychologically traumatic events
United States has tested positive for COVID-19, a rate more such as inmate violence. There are also variable and sometimes
than four times higher than the general population1 . Prisons contradictory levels of organizational and peer support for
have a high prevalence of chronic diseases and mental illness these two groups. Many mental health nurses reported that
and house an increasingly aging population that is vulnerable to they were often or always supported regarding the emotional
viral illness (5). Furthermore, poor personal hygiene contributing demands of their job and consulted on changes at work, yet
to virus spread, is exacerbated by such prison conditions as most correctional officers reported little or no support or
overcrowding, poor ventilation, close habitation, and strict consultation (18). We hypothesized that officers would report
control of everyday items such as soap, cleaning supplies, and higher rates of symptoms of mental disorders, including PTSD,
hand sanitizers. Risks and vulnerabilities are borne not only by depression and anxiety disorders as compared to correctional
the prisoners, but also by the correctional workers, who share all health workers. The study also examined whether social factors,
the risks of the physical environment and the additional risks of such as sex, and environmental/work factors, such as worker rank
inmate violence, gang activity, and uncontrolled physical contact in their occupational hierarchy, presence of workplace conflict,
as they move prisoners or intervene in altercations, and when and working in units with COVID-19-infected people, were
performing physical examinations and medical procedures (6). associated with perceived mental health burden.
Moreover, prisoners unable or unwilling to maintain personal
hygiene may intentionally expose staff to body fluids (7).
Working in correctional facilities has been associated with METHODS AND MATERIALS
high levels of stress and burnout (8–12). For example, Study Design
correctional officers have suicide rates that are 40–100% higher This cross-sectional study was conducted at 78 correctional sites
than those of police officers outside of prison (3). Yet despite in the US. Health care workers were included from 78 sites in
the enormous burden of COVID-19 on the prison system, there New York, Pennsylvania, Maryland, and West Virginia. These
are no US studies examining the mental health of correctional sites had different capacities, ranging from one to 25 health care
workers during the COVID-19 pandemic. workers. Only five of the 78 sites showed interest in surveying
We note with concern, that during the pandemic, health their correctional officers, as correctional administration was
care workers in general hospital settings have increased rates of concerned about overburdening the officers due to the pandemic.
depression, anxiety, and PTSD (13–17), and we hypothesized this Two of the sites declined later and therefore correctional officers
also to be true in the correctional community. Studying the health were ultimately surveyed at the remaining three sites. The survey
of correctional officers and prison health care workers during was administered between November 1, 2020, and December 1,
COVID-19 in a systematic way is urgently needed, to identify 2020, at the beginning of the third peak of COVID-19 in the US,
both the unique risk factors in vulnerable staff and to allocate with new daily cases averaging in excess of 200,000 per day on
scarce resources in correctional settings. November 212 .
Our present study is the first to survey US correctional Approval to conduct this survey was obtained from an
officers and health care workers during the COVID-19 pandemic. independent IRB (Solutions IRB) and the Department of
The primary aim of this exploratory study was to evaluate Corrections Research Review Committee, in accordance with the
the perceived mental health of correctional workers during principles in the Declaration of Helsinki and the Common Rule.
Informed consent was provided by all survey participants prior
1 https://www.themarshallproject.org/2020/12/18/1-in-5-prisoners-in-the-us-
has-had-covid-19 2 https://coronavirus.jhu.edu/map.html
Frontiers in Psychiatry | www.frontiersin.org 2 January 2022 | Volume 12 | Article 767385Burhanullah et al. COVID-19 and Correctional Health Workers
to their enrollment. Participants accessed the survey using an MBI-2: low burnout: not answering once a week or more on
anonymous email link via Qualtrics. No personal identification either question vs. high burnout: answering once a week or more
information was collected. Participants could terminate the on either question.
survey at any time they desired. The survey was anonymous, and CD-RISC-2: lower resiliency: < 6 vs. higher resiliency: 656 years), living situation (lives alone or not), and presence
survey and 486 completed it. or absence of a chronic medical condition.
Statistical Analysis
Main Outcome Measures IBM SPSS 27.0.1.0 (Corp., 2020) was used for all data preparation
For all participants, we assessed mood, anxiety, sleep, trauma, and analysis. Significance was assessed at the 0.05 level unless
burnout, and resilience using validated measurement tools as otherwise noted. To examine the differences between health care
follows: (i) depression, nine-item Patient Health Questionnaire workers and correctional officers on each of the nine mental
(20) (PHQ-9, range 0–29); (ii) anxiety, seven-item Generalized health outcome measures, independent-samples t-tests and a
Anxiety Disorder (21) scale (GAD-7, range 0–21); (iii) sleep Mann Whitney U-test were conducted. Using the Bonferroni
disturbance, four-item PROMIS Sleep Disturbance Index short adjustment (30) to aid in controlling the family-wise error rate
form (22–24) (PSDI, range 32–73); and (iv) post-traumatic from multiple comparisons, an alpha of 0.05 divided by the nine
stress, 22-item Impact of Event Scale–Revised (25) (IES-R, comparisons resulted in an adjusted alpha of 0.005 (e.g., 0.05/9
range 0–88). To measure burnout, and resilience, we used = 0.005) as the threshold for significance. The Mann Whitney
modified versions of the Maslach Burnout Inventory (MBI-2) U effect size was calculated based on Rosenthal’s (31) method
(26, 27) and the Connor-Davidson Resilience Scale (CD-RISC-2) for converting a z-score to an effect size estimate (e.g., dividing
(28), respectively. z by the square root of N) (31). Cohen’s d was calculated for each
The total scores of these measurement tools were interpreted independent samples t-test with the suggestion by Cohen (32)
as follows: that d = 0.20 is a small effect, d = 0.50 is a medium effect, and
PHQ-9: mild (5–9), moderate (10–14), moderately severe d = 0.80 is a large effect (32).
(15–19), and severe (20–27) depression. A series of multiple linear regressions were conducted with
GAD-7: normal (0–4), mild (5–9), moderate (10–14), and predictor variables on each of the mental health outcome
severe (15–21) anxiety. measures. The assumption of normally distributed errors was
Adult PROMIS Sleep Disturbance: raw scores are converted examined by visual inspection of residuals histograms and plots
to t-scores which range from 32 to 73.3: 32–54: within (33, 34). To assess autocorrelation the Durban-Watson statistic
normal limits, 55–60: mild, 61–70: moderate, 71–73.3: severe was calculated with values 3 indicating departure
sleep disturbance. from this assumption (35). Multicollinearity was assessed by
IES-R: normal (0–8), mild (9–25), moderate (26–43), and examining the correlation matrix for predictor variables that
severe (44–88) distress. correlate very highly which is problematic in the interpretation
Frontiers in Psychiatry | www.frontiersin.org 3 January 2022 | Volume 12 | Article 767385Burhanullah et al. COVID-19 and Correctional Health Workers
TABLE 1 | Demographic characteristics of participants (N = 589). TABLE 2 | Categorized scores on mental health measures for health care workers
and correctional officers.
Characteristic N %
Scale Healthcare workers Correctional officers
Age at time of survey N = 483 N = 103
18–24 34 5.9
25–34 173 30.0 PHQ-9
35–49 231 40.0 None (0–4) 249 (51.55) 70 (67.96)
50–56 139 24.1 Mild (5–9) 131 (27.12) 24 (23.30)
Sex Moderate (10–14) 69 (14.29) 6 (5.82)
Female 447 76.3 Moderately severe (15–19) 28 (6.80) 3 (2.91)
Male 139 23.7 Severe (20–27) 6 (1.24) 0 (0.00)
Race GAD-7
White or Caucasian 509 86.4 Minimal anxiety (0–4) 228 (47.20) 57 (55.34)
Black or African American 42 7.1 Mild anxiety (5–9) 125 (25.88) 29 (28.15)
Hispanic or Latino 13 2.2 Moderate anxiety (10–14) 62 (12.84) 10 (9.70)
Asian or Asian American 4 0.7 Severe anxiety (15–21) 0 (0.00) 0 (0.00)
American Indian or Alaska Native 2 0.3 MBI-2
Worker position
Low 254 (52.58) 43 (41.75)
Health care workers 486 82.5
High 228 (47.20) 59 (57.28)
Correctional officers 103 17.5
PROMIS sleep
Living status
Normal (32–54) 394 (81.57) 89 (86.41)
Not alone 540 91.7
Mild (55–60) 84 (17.39) 11 (10.68)
Alone 49 8.3
Moderate (61–70) 1 (0.02) 1 (0.97)
Chronic medical conditions
Severe (71–73) 0 (0.00) 0 (0.0)
No 381 64.7
IES-R total
Yes 199 33.8
Normal (0–8) 209 (43.27) 46 (44.66)
Mild (9–28) 140 (28.99) 28 (27.18)
Moderate (26–43) 60 (12.42) 14 (13.59)
of the models (36) and by examining the variance inflation factor
Severe (44–88) 38 (7.87) 5 (4.85)
(VIF) and tolerance (the reciprocal of VIF) where VIF > 10,
or an average VIF markedly larger than 1 (37), or tolerance CD-RISC-2
below 0.2 being a cause for concern. These regression models Low (6) 269 (55.69) 65 (63.11)
(36). Unstandardized coefficients (B) indicated the amount Numbers in parenthesis are percentages.
that a mental health outcome measure score changed as a
given predictor variable changed by one unit, keeping all other
predictor variables constant. To facilitate the comparison of
respondents (82.5%) were healthcare workers and only 17.5%
coefficient sizes across outcome measure scores with different
were correctional officers.
scales, the standardized coefficients (β) converted scores to
The survey was emailed to 1,700 correctional workers, and out
standard deviations. For instance, a β value of 2.15 indicates that
of these, 900 opened their email (60%). Of those 900, 589 (486
a change of one standard deviation in a predictor corresponds
health care workers and 103 correctional officers) completed the
to an increase of 2.15 standard deviations in the outcome
survey (65%). Descriptive statistics comparing health care worker
measure scores.
and correctional officer mental health are presented in Table 2.
For multiple linear regression analyses, the following variables
were coded as 0 = No and 1 = Yes: COVID-19 fear, increased
workload, work conflict, COVID-19-unit infection, quarantined, Comparison of Health Care Worker and
self-isolation, chronic medical (condition), and lives alone. Sex Correctional Officer Mental Health
was coded as 0 = Male and 1 = Female, and work position as Independent sample t-tests were conducted on the eight
0 = health care worker and 1 = correctional officer. Age and continuous measures. These t-tests indicated statistically
isolation practices were coded along an ordinal scale but treated significant differences (adjusted 0.005 level) between health
as continuous for analysis. care workers and correctional officers (see Table 3). Specifically,
health care worker mean PHQ-9 depression score (M = 5.74, SD
= 5.15) was higher than that of correctional officers (M = 3.96,
RESULTS SD = 3.86) [t (182.70) = 3.94, p < 0.001]. Health care worker mean
GAD-7 anxiety score (M = 6.24, SD = 5.91) was also higher
Respondent demographic characteristics are presented in than that of correctional officers (M = 4.66, SD = 4.48) [t (185.56)
Table 1. Most of the respondents were female (76.3%), ages = 3.05, p = 0.003]. Finally, health care worker mean PROMIS
25–50 (70%) and white/Caucasian (86.4%). Most of the sleep disturbance score (M = 10.98 SD = 1.81) was higher than
Frontiers in Psychiatry | www.frontiersin.org 4 January 2022 | Volume 12 | Article 767385Burhanullah et al. COVID-19 and Correctional Health Workers
TABLE 3 | Differences in mental health measures between health care workers and correctional officers.
Health care workers Correctional officers
Measure N Mean SD N Mean SD df t p 95% Confidence interval of the difference Cohen’s d
PHQ-9 472 5.74 5.15 100 3.96 3.86 182.70 3.94Burhanullah et al. COVID-19 and Correctional Health Workers TABLE 4 | Multiple linear regression analysis for worker variables predicting PHQ-9 depression score. Variable B SE B 95% CI β t p Constant 1.91 1.07 [−0.20, 4.01] 1.78 0.08 Isolation practicesa 0.60 0.15 [0.30, 0.89] 0.17 3.98
Burhanullah et al. COVID-19 and Correctional Health Workers TABLE 6 | Multiple linear regression analysis for worker variables predicting MBI-2 burnout score. Variable B SE B 95% CI β t p Constant 0.75 0.61 [−0.44, 1.94] 1.24 0.22 Isolation practicesa 0.53 0.08 [0.36, 0.70] 0.25 6.28
Burhanullah et al. COVID-19 and Correctional Health Workers TABLE 8 | Multiple linear regression analysis for worker variables predicting IES-R posttraumatic stress total score. Variable B SE B 95% CI β t p Constant 1.18 3.48 [−5.65, 8.01] 0.34 0.74 Isolation practicesa 1.44 0.49 [0.48, 2.40] 0.13 2.96 0.003 COVID-19 fearb 6.37 1.37 [3.68, 9.07] 0.20 4.65
Burhanullah et al. COVID-19 and Correctional Health Workers TABLE 10 | Multiple linear regression analysis for worker variables predicting IES-R posttraumatic stress—hyperarousal score. Variable B SE B 95% CI β t p Constant 0.10 1.03 [−1.93, 2.13] 0.10 0.92 Isolation practicesa 0.38 0.14 [0.08, 0.66] 0.11 2.64 0.009 COVID-19 fearb 1.90 0.41 [1.09, 2.70] 0.19 4.65
Burhanullah et al. COVID-19 and Correctional Health Workers TABLE 12 | Multiple linear regression analysis for worker variables predicting CD-RISC-2 resilience score. Variable B SE B 95% CI β t p Constant 7.50 0.36 [6.80, 8.20] 20.98
Burhanullah et al. COVID-19 and Correctional Health Workers
care workers and correctional officers (55 and 64%, respectively). correctional facilities an important focus of public health
This is an encouraging finding, since fostering resilience has been interventions. The well-being of correctional workers is a key
shown to be associated with a reduction in stress and improved factor in such interventions. Correctional populations and staff
job performance in many occupational groups (44). Our data have a much lower rate of COVID-19 vaccination3 and high
also support the hypothesis that psychological distress is inversely flow into and out of correctional facilities will continue to
correlated with resilience. threaten those imprisoned, the staff, and the larger community
Contrary to the previous studies on healthcare workers during (44–46). Further research and resources are required for long
the pandemic, working in COVID-19-unit was not found to term planning and crisis response during pandemics to mitigate
have a statistically significant relations in any of the regression the stress and psychological impact on correctional workers (47).
models. However, it should be noted that none of the previous
studies were carried out in correctional settings. This suggests AUTHOR’S NOTE
that in the present sample, correctional workers’ perceptions of
risk were perhaps a more important driver of perceived mental PrimeCare medical provides comprehensive health care services
health burden than actual work conditions. Also, in our sample to county jails, prisons and juvenile detention centers throughout
correctional staff provided cross coverage and were rotated the Northeastern United States.
throughout the prison or jail. They did not stay at any specific
unit for more than few days and this may be the reason why we DATA AVAILABILITY STATEMENT
did not find any correlation with working in COVID-19-unit.
To our knowledge, this is the first study surveying the The original contributions presented in the study are included
mental health of correctional workers during the COVID-19 in the article/Supplementary Material, further inquiries can be
pandemic. Our findings suggest that correctional workers face directed to the corresponding author/s.
high psychological morbidity amid unique challenges in the
correctional environment. Nevertheless, this study has several ETHICS STATEMENT
limitations of a cross-sectional design. Although our study had
a relatively high response rate, response bias may still exist The studies involving human participants were reviewed and
if the non-respondents were either too stressed to respond or approved by Solutions IRB. The patients/participants provided
not interested as they were not stressed, about 80% of the their written informed consent to participate in this study.
participants were health care workers. This was likely due to
the fact the correctional officers are government employees AUTHOR CONTRIBUTIONS
and needed departmental permission to participate in research,
while health care workers were contracted employees through All authors listed have made a substantial, direct, and intellectual
a 3rd party called PrimeCare medical, Inc. (which provides contribution to the work and approved it for publication.
healthcare services to county jails, prisons, and juvenile detention
centers throughout the Northeastern United States) and did not SUPPLEMENTARY MATERIAL
require such permission. This differential response may have
biased the results, as the correctional officers who were able The Supplementary Material for this article can be found
to get departmental clearance may have been more motivated online at: https://www.frontiersin.org/articles/10.3389/fpsyt.
to participate. 2021.767385/full#supplementary-material
Correctional facilities can become pandemic hotspots and
3 https://www.prisonpolicy.org/blog/2021/04/22/vaccinerefusal/
drive transmission in surrounding communities, thereby making
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