Prison-based health and wellbeing interventions: evidence review and survey of provision

Executive Summary

Research Aims and Overview

This report contains a rapid evidence review of prison-based physical health and wellbeing interventions and a survey to identify the scale and scope of these kinds of interventions are currently (or were pre-Covid-19) active across Scotland's prisons. This report was undertaken to support a larger programme research, commissioned by the Scottish Government, to deliver a health and social care needs assessment of Scotland's prison population.

This report focuses on six physical health and wellbeing intervention categories: sports-based; horticultural; yoga, meditation, and mindfulness; art and creative; animal-based; and peer-support. This report is intended to provide information about the effectiveness associated with each of these intervention categories and the extent to which these kinds of interventions are active across Scotland's prisons.

The evidence summarised within this rapid review is predominantly drawn from the UK and the USA. There were few physical health and wellbeing interventions which have been evaluated across Scotland's prisons. The findings from the rapid review and survey have been combined to inform a series of key findings. Conclusions and gaps in the evidence regarding prison-based physical health and wellbeing interventions are also provided.

Rapid evidence review

Given the time constraints for this project, a rapid evidence review was undertaken as opposed to a systematic review. As such, this is an indicative review of the evidence about prison-based physical health and wellbeing interventions and is not intended to be comprehensive. An initial scoping search strategy was undertaken to identify potential prison-based physical health and wellbeing interventions. The following categories were identified: sports-based; horticultural; yoga, meditation, and mindfulness; art and creative; animal-based; and peer-support.

A total of 58 studies were identified as suitable for inclusion. These were individually evaluated based on: the relevance of the evidence; what the evidence says about the effectiveness of the intervention; and the strength of the evidence presented. These pieces of information were used in conjunction with a specific decision-making tool, which had been used in a previous Scottish Government study on What Works to Prevent Violence Against Women: A Summary of the Evidence, to assign an effectiveness rating to each category. The categories used in this report are as follows:

• Effective (Green)
• Promising (Amber)
• Mixed (Amber)
• No effect (Red)
• Negative effect/potentially harmful (Red)
• Inconclusive (Grey)

The decision-making tools were used together to appropriately classify the interventions. The effectiveness of decision-making tree was used to evaluate the evidence for each physical health and wellbeing intervention category as a whole. This led to a classification being provided which were as follows:

• Effective: Yoga, meditation, and mindfulness
• Promising: Art and creative; Horticultural
• Mixed: Animal-based; Sports-based
• Inconclusive: Peer-support

Primary research

As a lack of studies identified in the rapid evidence review were conducted in Scotland's prisons, primary research was undertaken to increase knowledge about which physical health and wellbeing interventions are being provided in Scotland's prisons. The survey was developed, with grateful assistance from colleagues in the National Prison Care Network (NPrCN), the Scottish Prison Service (SPS) and an external academic with expertise in prison health research. The survey was shared with relevant prison management and NHS staff across the Scotland's 15 prisons. The survey collected information about:

• What prison and NHS staff perceived to be the emerging or most pressing health needs of Scotland's prison population
• The types of physical health and wellbeing interventions delivered (or were pre-Covid-19) in the prison setting
• The uptake of those interventions by people who live in prison
• The main facilitators and barriers to intervention delivery
• Other interventions prison and NHS staff were aware of in other prisons in Scotland or in the community which they would like to see introduced in their establishment

A total of 12 of Scotland's 15 prisons had prison and/or NHS staff respond to the survey.

According to respondents, the top three emerging or most pressing health needs of Scotland's prison population were: reducing the harmful use of substances, improving mental health and wellbeing and managing the health needs of older people living in prison.

Sports-based and peer-support interventions were the most commonly delivered across Scotland's prisons. Animal-based and horticultural interventions were the least common.

The uptake of physical health and wellbeing interventions by those who live in prison was encouraging for the majority of the intervention categories. There were various facilitators and barriers to intervention delivery in Scotland's prisons. Staffing, physical resources and engagement with interventions were identified as both facilitators and barriers. Suggestions for future prison-based physical health and wellbeing interventions made by respondents of the survey included:

• "equine therapy"
• "storybook dads"
• "walking groups"

Key findings

It was identified that several different interventions have been evaluated across each category with a variety of outcomes measured. The qualitative evidence reviewed was largely positive regarding the effects of interventions on the physical health and wellbeing of people who live in prison. Quantitative evidence was more mixed with some studies reporting improvements while others reported no change.

Yoga, meditation and mindfulness was classified as an "effective" intervention in the rapid evidence review. However, this was only found to be active in 5 of the 12 prisons that responded to the survey. Peer-support interventions were classified as "inconclusive" yet were the most common intervention identified.

Improving mental health and wellbeing was identified as one of the emerging health needs of Scotland's prison population according to the results of the survey. This finding may be particularly important given the current Covid-19 pandemic which is expected to have negative consequences for the health and wellbeing of people living in Scotland's prisons. The survey identified that all of the physical health and wellbeing intervention categories included in the evidence review were active across Scotland's prisons to varying degrees. The delivery of these kinds of interventions may have an important role to play in supporting people in prison to recover from the negative effects on mental health and wellbeing which have arisen due to the effects of Covid-19 on their lives of people in prison.

The rapid evidence review identified that a large number of physical health and wellbeing interventions were evaluated in young and adult men. Given that the proportion of older adults living in Scotland's prisons has risen in recent years (Scottish Government, 2020), and the distinct healthcare needs of women in prison, , there is potential for considering how interventions could be modified to suit these particular sub-populations. For example, the introduction of walking sports for older adults. Additionally, the identification of other types of interventions by prison and NHS staff that have been delivered in the community suggests that there is scope to expand the current interventions being offered within Scotland's prisons.

Finally, the facilitators and barriers to intervention delivery in Scotland's prisons provided insight as to why some physical health and wellbeing interventions are more active across Scotland's prisons compared to others. For example, some types of interventions, such as animal-based interventions, are more resource intensive when compared to other categories of interventions, such as peer support.

Conclusions

This report highlighted that more evaluative research of prison-based physical health and wellbeing interventions internationally and in Scotland would be beneficial. Few studies used a randomised controlled design, for example, to evaluate an intervention, which is regarded as one of the more robust approaches to determining intervention effectiveness. However, given some of the potential complexities associated with utilising a randomised controlled design within the prison setting, such as the potential additional burden placed on prison resources and logistical difficulties (e.g. following research participants through transfers and post-release) (Kouyoumdjian et al, 2015), the use of contribution analysis and utilising a mix of quantitative and qualitative approaches, when available and appropriate, is encouraged in future research.

It was outwith the scope of this report to identify the costs and cost-effectiveness of delivering prison-based physical health and wellbeing interventions. Research in this area could assist prison and healthcare service staff when making decisions about which kinds of physical health and wellbeing interventions could be delivered to the people who live in their establishment.

The evidence review showed that many of the prison-based physical health and wellbeing interventions were delivered to men, particularly sports-based interventions. Modifying and evaluating these interventions for sub-populations, such as women and older adults, could be beneficial.