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

5. Key findings

5.1 What evidence is there on the effectiveness of physical health and wellbeing interventions in the prison setting?

Evidence from the literature demonstrates the following:

• A number of different interventions have been evaluated within particular categories (e.g., sports-based interventions) and a variety of outcomes were measured.
• Qualitative evidence suggests that prison-based physical health and wellbeing interventions can improve a variety of outcomes (e.g., confidence, diet and relationships) for people living in prison.
• Quantitative evidence was mixed for the effectiveness of physical health and wellbeing interventions for improving emotional outcomes (e.g., anxiety and self-esteem).
• Mixed methods evidence largely showed consistency across both quantitative and qualitative outcomes (e.g., improvements in emotional outcomes). However, some studies (e.g., Woods, 2018) reported contradictory evidence across quantitative and qualitative outcomes.

5.2 What are the most effective prison-based physical health and wellbeing interventions?

• There was strong evidence that yoga, meditation, and mindfulness interventions are effective in improving the health and wellbeing outcomes of people who live in prison.
• There was promising evidence for the use of horticultural and art and creative interventions to improve health and wellbeing outcomes. It was acknowledged that the evidence was consistently positive but only included qualitative evaluations and quantitative evidence without control groups, thus they were not evaluated as effective interventions.
• There was mixed evidence for the effectiveness of sports-based and animal-based interventions improving health and wellbeing outcomes. Mixed results were observed across the quantitative evidence for these interventions, while qualitative results reported positive changes in physical health and wellbeing.
• There was inconclusive evidence for the effectiveness of peer-support interventions. This was of particular interest in the current report as peer-support interventions were one of the more commonly delivered prison-based physical health and wellbeing interventions across prisons in Scotland, according to the results of the survey.

5.3 What are the emerging health needs of Scotland's prison population?

The Covid-19 pandemic has thrown into sharp relief the health needs of people in prison and the relationship between the conditions within prisons and the health of the people who live in them (Armstrong & Pickering, 2020; Prison Reform Trust, 2021). Scotland's prisons went into lockdown in March 2020, which resulted in drastic changes to the lives of people in custody. Many aspects of prison life which can contribute positively to health and wellbeing (e.g., access to prison gyms and group activities) were paused and the amount of time people spent confined primarily to their cells rose significantly (Maycock, 2021). The negative consequences of this for the health and wellbeing of people living in Scotland's prisons was expected to be significant, thus it was perhaps not surprising that half of people who live in Scotland's prison who participated in the Scottish Lockdown Survey reported their personal wellbeing had worsened (Armstrong, 2020).

One of the emerging health needs identified by prison management and NHS staff in the survey completed for this report was the need to improve the mental health and wellbeing of people living in Scotland's prisons. As this is what some interventions included in the review aimed to enhance, their delivery across the Scottish prison estate will likely 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 Covid-19 pandemic (Armstrong & Pickering, 2020; HMIPS, 2021a; Maycock, 2021; Prison Reform Trust, 2021).

Reducing the harmful use of substances was identified as another prominent emerging health need in the Scotland's prison population. This was also a priority identified in Scotland's last National Health Needs Assessment in 2007 (Graham, 2007) and in local, health board level health needs assessments (Flanigan et al., 2021; Gillies et al., 2012).

Managing the health needs of older people living in prison was the third most prominent, emerging health need in Scotland's prison population. It is widely understood that this sub-population has increased health needs – e.g. a higher prevalence of chronic conditions (e.g., coronary heart disease) and dementia (Flanigan, 2020). Given the increase in number of older people living in prison in Scotland (Scottish Government, 2020), it is likely that prisons will need to adapt existing support services, including healthcare, to cater for this needs of this subpopulation. Modifying interventions to improve the physical health and wellbeing in prison could be play an important role in this process.

5.4 What physical health and wellbeing interventions are currently being delivered in Scotland's prisons?

It was encouraging to see that the six intervention categories included in the evidence review all appeared to be implemented in Scotland's prisons, albeit to varying degrees. Peer-support and sport-based interventions were the most commonly reported.

Given that improving mental health and wellbeing was a key health need identified in the survey, it was encouraging that interventions which are designed to fulfil this need are active across Scotland's prisons, particularly yoga, meditation, and mindfulness. Based on the evidence reviewed, this category of interventions was classified as effective at promoting physical health and wellbeing. It was promising that this category of intervention was also identified by respondents as one they think would be beneficial to people who live in their establishment.

The interventions included in the evidence review were not primarily designed to reduce substance use. However, some of the interventions were found to be beneficial to individuals who were experiencing issues with substance use. For example, a horticultural intervention delivered to males in a UK prison who reported issues with substance use, reported that the outdoor environment supported recovery in the sense that it provided freedom and purposeful activity (Brown et al., 2016).

Specific to the health needs of older people in prison, the use of a variety of interventions across Scotland's prisons is promising, particularly considering how these could be modified to suit this population. For example, a music-based intervention (i.e., Good Vibrations) was delivered to an older UK adult sample and participants reported improvements in managing their emotions and socialisation. This is relevant to older people in prison as this population report feelings of isolation and loneliness (HMIPS, 2017). These types of interventions may also be particularly beneficial to older adults as they offset some of the barriers to their participation in other physical health and wellbeing interventions, such as mobilisation issues limiting physical activity (Wilkinson & Caulfield, 2017).

5.5 What does the evidence tell us about facilitators and barriers to intervention delivery in Scotland's prisons?

While reviewing the research, it was identified that many factors need to be considered in order to effectively deliver an intervention to people who live in prison (e.g., funding to hire third sector organisations). Potential facilitators and barriers to intervention delivery were therefore included in the survey. The main facilitators to intervention delivery, identified by prison management and NHS staff, were physical resources, staffing and participant engagement. Likewise, the main barriers to intervention delivery identified were physical resources, staffing and scheduling. The barriers identified highlight a possible explanation as to why certain interventions were less common across Scotland's prisons compared to others (e.g., animal-based (n=3) compared to peer-support (n=10)). For example, Paws for Progress will require a third sector organisation, prison staff, scheduling and physical resources in order to be successfully delivered. Alternatively Samaritan's Listener scheme relies more on the people who live in prison to deliver this intervention. Peer-support interventions therefore may be less complicated or resource-intense from a prison management perspective to deliver, as they are more reliant on people who live in prison compared to third sector organisations.

Some NHS staff who work in Scotland's prisons identified physical resources as a barrier to intervention delivery whereas prison management staff viewed them as a facilitator. It is possible that health interventions being delivered in health care centre settings face challenges due to limited physical resources compared to interventions delivered elsewhere within Scotland's prisons (e.g. the prison gym or the prison grounds).

5.6 Community interventions

Interventions being offered in the community which prison management and NHS staff thought would be valuable within their establishment were identified in the survey. Two of the interventions suggested, equine therapy and drama therapy, were similar to others included in the evidence review. Rather than equine therapy, which refers to a certified professional using a horse to help an individual reach therapeutic goals (Wilkie et al., 2016), an equine facilitated learning intervention which aims to teach individuals social and communication skills, has been delivered to young men who live in a UK prison. This intervention reported improvements in confidence and feelings of calm (Hemingway et al., 2015). For drama therapy, a theatre based intervention which was delivered to a female sample in a UK prison reported significant reductions in feelings of hopelessness and improved confidence and self-esteem (Stephenson & Watson, 2018). In addition, theatre productions have been performed by people living in prison in Scotland, for example Polmont Youth Theatre (Glass Productions, n.d.), therefore there is the possibility to deliver and evaluate drama-based interventions in Scotland's prisons. The suggestion of football leagues is also promising as a means of improving the health and wellbeing of people who live in Scotland's prisons. A prison in Wales has a long established prisoner football team that participates in a football league within the local community (Grundy & Meek, 2021). Participation in the football league allowed individuals to participate in training and matches each week and participants reported improvements physically (e.g., fitness) and emotionally (e.g., relieved tension).

Other interventions based within the community which were suggested by prison management and NHS staff also highlighted interventions which have been developed for sub-populations within the prison population, for example, parents and individuals who engage in harmful substance use. These included "Storybook Dads" and recovery cafes. "Storybook Dads" helps parents record bedtime stories and messages for their children as a means to reconnect families separated through imprisonment (Crawford-Smith et al., 2015). It is also designed to engage the men in other processes relating to literacy, for example practising reading and articulation skills by using different character voices in the story and it also provides the opportunity to talk about parenting skills and positive modelling (Crawford-Smith et al., 2015). Recovery cafes offer a substance free space which encourage people in recovery to meet up with peers and engage in positive activities (SPS, 2018). Given that reducing harmful substance use was identified as an emergent health need in the survey and is a longstanding one in Scotland's prisons, as shown across earlier health needs assessments (Gillies et al., 2012; Graham, 2007), the suggestion of introducing recovery cafes to Scotland's prisons would be an innovative method for addressing this health need.

5.7 Intervention modification for women and older adults

A large proportion of the interventions included in the evidence review were delivered to men who live in prison. However, in Scotland the number of older adults (50+) living in prison have risen in recent years (Scottish Government, 2020). Consequently, being able to modify and tailor physical health and wellbeing interventions to meet the needs of this specific population would appear to be an important area of future focus.

As highlighted previously, older people in prison are more likely to experience mobility issues which would likely limit their ability to participate in some types of interventions, such as sports-based interventions, and particularly those included in this review which primarily focussed on rugby and football. An example of a modification to sports-based intervention to account for the needs of older adults in prison was the walking rugby intervention, which was a slower, non-contact version of the sport. This was found to be beneficial emotionally and physically to older people living in prison (Ulster Rugby, 2019). Other sports-based interventions that have been modified and introduced in Scotland's prisons to cater for the needs of this older people in prisons include walking football and carpet bowls (HMIPS, 2021b).

A report from HMIPS (2021b) acknowledged that some older adults reported the distance to travel to activities and fear of falling as barriers to engaging in physical health and wellbeing interventions in Scotland's prisons. Tailoring physical activity interventions for this population could include the introduction of personalised gym sessions focussing on mobility and balance, rather than fitness or weightlifting, with the latter often being a key motivation for attending the gym among younger adults in prison (Baumer & Meek, 2018). Modifications which could permit some activities to be done within cells may also benefit health and wellbeing among older people in prisons. For example, modifications to the in-cell workshops programme (Baumer, 2018), such as introducing chair-based workouts to provide less intense exercise routines, could benefit those with more severe mobility issues.

The health needs of women who live in prison are often different from their male counterparts – for example, they often have higher levels of mental health issues and problems with substance use (Prison Reform Trust, 2019). Historically, prison systems, regimes, and services have mostly been developed for men (Penal Reform International, 2008) and a focus on men who live in prison was reflected in the evidence review, with a large number of the sports-based interventions delivered to this population. However, women who live in prison can also benefit from sport and physical activity as it provides them with a distraction from the stress of prison life, thus it provides a coping mechanism, and boosts their self-esteem and well-being (Meek & Lewis, 2014a). A promising intervention in Canada involved women in prison in the development of a fitness and nutrition programme (Martin et al., 2013). By asking participants about their perceptions of physical fitness and their use of gym equipment, group circuit classes and/or individual fitness programmes were developed to meet their needs. Improvements from participating in the programme were reported for physical and emotional outcomes. The non-competitive nature of this intervention contrasts with most of the male sports-based interventions (e.g., football or rugby). It was also acknowledged that the intervention designed for women used solo-based activities whereas the sports-based interventions for men were team based. These differences highlight the importance of modifying sports-based interventions to suit the needs of women as increasing their participation in physical activity has been found to have a positive effect on their health and wellbeing.