The association between criminal legal attitudes and healthcare utilization among adolescents: differences by gender and race

Adolescents' interactions with the police significantly influence their legal beliefs and behaviors, a process known as legal socialization. Negative experiences or perceptions of injustice within the legal system can lead to legal cynicism and mistrust, potentially extending to other institutions like healthcare. The concept of system avoidance suggests that contact with the criminal legal system may cause individuals to avoid other institutions, particularly those involving formal record-keeping. This study investigates the association between adolescents' negative criminal legal attitudes (legal cynicism and police legitimacy) and their healthcare utilization. Prior research focusing on adults has shown a link between criminal legal contact and reduced healthcare access, but this relationship remains understudied in adolescents. This research uses data from the Future of Families and Child Wellbeing Study (FFCWS) to examine this association, hypothesizing that adolescents with more negative criminal legal attitudes will be less likely to utilize healthcare services due to skepticism and mistrust of the institution.

Existing literature highlights the impact of police contact and negative experiences with the legal system on the development of legal cynicism and mistrust in authority figures. This mistrust can extend beyond the legal system, affecting other social institutions. Studies on adults have demonstrated a link between criminal legal system contact and decreased healthcare utilization, including avoidance of formal healthcare settings and reduced trust in healthcare providers. However, research on adolescents' experiences and attitudes in this context is limited. This study aims to fill this gap by investigating the association between adolescents' self-reported criminal legal attitudes and healthcare utilization, specifically exploring potential gender and racial differences.

This study uses data from Wave 6 of the Future of Families and Child Wellbeing Study (FFCWS), a nationally representative sample of families with non-marital births. The analytic sample includes 3444 adolescents (age 15) with complete data on study variables. Healthcare utilization was measured by caregivers' report of whether the adolescent had a regular check-up in the past 12 months. Criminal legal attitudes were assessed using six items measuring legal cynicism and police legitimacy, averaged into a mean score (higher scores indicate more negative attitudes). Other variables included health insurance status, delinquency (measured by self-reported delinquent acts), sociodemographics (gender, race/ethnicity, age, household income, parental education, marital status), depression (CES-D), and anxiety (modified BSI-18). Logistic regression analyses were conducted in Stata 17 to examine the association between criminal legal attitudes and healthcare utilization, stratified by gender and race, controlling for other relevant variables.

Approximately 89% of adolescents utilized healthcare in the past 12 months, and 96% had health insurance. The mean score for negative criminal legal attitudes was 0.76 (SD = 0.57). The sample was 48% female and 82% non-white. Key findings from the logistic regression analysis revealed a significant association between negative criminal legal attitudes and reduced likelihood of healthcare utilization only among non-white girls (adjusted odds ratio [aOR] = 0.55, 95% CI = 0.35, 0.85). In contrast, among non-white girls, delinquency was associated with an increased likelihood of healthcare utilization (aOR = 1.28, CI = 1.06, 1.55). Having health insurance was significantly associated with increased healthcare utilization across various gender and racial groups. Household income also showed a positive association with healthcare utilization for non-white boys. Sensitivity analyses controlling for prior police contact did not significantly alter the primary finding regarding non-white girls.

The finding that negative criminal legal attitudes were associated with reduced healthcare utilization only among non-white girls is consistent with the concept of system avoidance. This suggests that negative experiences or perceptions of the criminal legal system may generalize to other institutions, leading to avoidance of healthcare services. Non-white girls may be particularly vulnerable due to pre-existing disparities in healthcare access and experiences of marginalization. The unexpected positive association between delinquency and healthcare utilization among non-white girls might be explained by the increased risk of health issues associated with delinquent behaviors, necessitating both emergency and routine care despite potential mistrust in the system. This highlights the need for further investigation into the nature and types of healthcare services utilized by this group. The study's limitations include its cross-sectional design, which prevents causal inferences; the crude measure of healthcare utilization (focused only on check-ups); and the lack of direct measurement of police contact.

This study demonstrates a significant association between negative criminal legal attitudes and reduced healthcare utilization among non-white adolescent girls, supporting the concept of system avoidance. The findings highlight the need for policymakers to consider the broader societal impacts of criminal justice policies, particularly on marginalized communities. Future research should explore this complex relationship further using longitudinal designs and more nuanced measures of healthcare utilization and police contact, focusing on understanding the mechanisms underlying this association and developing strategies to improve healthcare access for vulnerable adolescents.

The cross-sectional nature of the study limits causal inferences. The measure of healthcare utilization was limited to preventive check-ups and did not capture other healthcare interactions. The study did not directly measure police contact, and it relied on self-reported data, which may be subject to bias. The generalizability of the findings may be limited due to the specific sample used.