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

1. Introduction

This report provides an international evidence review of physical health and wellbeing interventions delivered in prison settings. These interventions were subsequently classified using an established intervention classification tool. A survey was also developed to identify which of the categories of physical health and wellbeing interventions included in this evidence review are (or were pre-Covid-19)^[2] available in Scotland's prisons. From this report, future considerations for research were suggested.

1.1 Background

At the time of writing this report, 7,562 individuals were in custody in Scotland. Of the total population, 73% were sentenced, 24% were untried and 3% had been convicted and awaiting sentence (SPS data, 24.08.21).^[3] The annual average prison population has fluctuated over the course of the last ten years reflecting the non-static nature of this population. In 2011-12, there was a continuation of a general rising trend in the population. This was then followed by several years of steady reduction. However, between 2017-18 and 2019-20, the average daily prison population rose steeply from around 7,500 in 2017-18 to nearly 8,200 in 2019-20. This rise was found to be amongst adult men only (Scottish Government, 2020).

The majority of people living in prison in Scotland are males aged 21 and over. The average age of individuals being imprisoned has risen from 31.8 years in 2010-11 to 35.9 years in 2019-20, and the proportion of prisoners aged 55 or over has more than doubled in the last decade (Scottish Government, 2020). Between 2000 and 2010, the number of women in prison in Scotland has risen to a daily average of over 400 and has continued around this level for the last decade (Mental Welfare Commission for Scotland, 2021).

It is widely recognised that the health of people entering prison is often poor and disproportionately so when compared to the general population. Examples of poorer levels of health experienced by people in prisons include substance use, mental health and sexual health (Flanigan, 2020; Graham, 2007). Intervening during imprisonment could improve the health of people who experience imprisonment, public health overall, and time spent in prison can be an opportunity to engage people with health services who often do not access them in the community or only do so in an emergency (Shölin et al., 2018). However, prisons can also be detrimental to health with people experiencing a loss of privacy and disconnection from their families (House of Commons, 2018). Efforts to improve the health of people living in prison has implications for public health - due to the high number of people circulating through the prison system, addressing the health of people in prison impacts not only on the individual level, but also at population level through, for example, treatment and prevention of communicable diseases.

The most recent health needs assessment of Scotland's prison population was in 2007 (Graham, 2007), and while many of the same health concerns endure (e.g., high levels of harmful substance use), service provision, data landscapes, and the demographics of the prison population have changed in the years since. The Scottish Government has committed to delivering a refreshed assessment of need of the prison population to reflect these changes and expanded to include social care.

This work is being delivered through 4 sub-projects: social care, mental health, substance, and physical health. The work assessing social care needs, was completed in 2020 with the report published in January 2021.^[4] Each sub-project will feed into a synthesis project which will draw together learning across the programme of research and offer prioritised recommendations.

1.2 Aims

The aim of this report is to review the evidence about physical health and wellbeing interventions being offered to people who live in prison by responding to the following questions:

• What categories of physical health and wellbeing interventions have been delivered to people who live in prison?
• How effective are these categories of physical health and wellbeing interventions?
• What physical health and wellbeing interventions are currently being delivered in Scotland's prisons?
• Based on the above, what are the gaps in the literature for prison-based physical health and wellbeing interventions?

1.3 Methodology

The research for this report was based on two different methods: a rapid evidence review and primary data collection on physical health and wellbeing interventions being delivered in Scotland's prisons.

A range of search terms were developed for the rapid evidence review, which focussed on interventions being delivered to a prison population in order to improve health and wellbeing.^[5] Primary searches were undertaken through the Scottish Government's library databases which included access to Emerald Insight, Science Direct, Cochrane Database of Systematic Reviews, JSTOR journals and British Library eThOs. Grey literature searches were also undertaken.^[6] Peer-reviewed academic literature, evaluations of third sector programmes (either independent or self-evaluated) and unpublished theses were identified and included in this evidence review. An international evidence review was decided to include the UK, Ireland, USA, Canada, Australia and New Zealand. These countries were chosen as their justice systems in developed Western countries are much alike in form, structure, and function. Additional inclusion criteria for the evidence review was:

• publication between 2011-2021;
• the intervention was delivered to people who live in prison;
• participants were aged 15+;
• academic literature and reports written in English and with at least one reported health or wellbeing outcome.

Studies were excluded if the intervention was centred on substance use, blood-borne viruses or was therapeutic in relation to mental health (e.g., cognitive behavioural therapy) because the Scottish Government is publishing separate reports on these health needs. This report is based on a rapid evidence review, rather than a systematic review, due to time constraints. As such, this is an indicative review of the evidence and is should be read as comprehensive.

The search strategy was as follows (see Figure 1 below):

• A total of 3,897 records were identified (3,867 from database searches and 30 from other methods).
• Following the automated removal of duplicates (1,423), 2474 records remained and were screened using their title and abstract.
• This screening resulted in 127 articles remaining and sought for retrieval. One record could not be retrieved, leaving 126 records to be assessed for eligibility.
• Of the 126 articles reviewed, a further 68 were excluded based on the following criteria:
  • 31 did not include a measure of health and/or wellbeing;
  • 11 were outwith the countries of interest;
  • 4 included participants under 15 years of age;
  • 13 were not evaluating an intervention;
  • 4 had an intervention outwith the scope of the evidence review;
  • 4 were not in prison populations;
  • and 1 was a protocol with no results reported.
• This resulted in 58 studies for inclusion in the final analysis.

To identify what physical health and wellbeing interventions are currently being provided in Scotland's prisons, a survey was developed with input from colleagues in the NPrCN, the SPS and an external academic with expertise in prison health research. The survey was shared with relevant prison management and NHS staff across Scotland's 15 prisons. This information was organised and appropriate descriptive analyses were run. The results from the survey were combined with the rapid evidence review to inform Section 5 of this report.

1.4 Definitions

Wellbeing has no fixed definition, with many different terms used to describe it (Dodge et al., 2012). One common characteristic across definitions is that wellbeing is the evaluation of one's quality of life. For the purpose of this report, wellbeing is defined by emotional outcomes (e.g., self-esteem), physical outcomes (e.g., fitness) and social outcomes (e.g., improved relationships).