Prison population: physical health care needs

Scotland's Prisons and the Physical Health Care Needs of Scotland's Prison Population

Overview

This chapter serves two main functions: 1) it describes Scotland's prison population; and 2) it provides an insight into the physical health care needs of Scotland's prison population. The chapter focuses on the 17 areas of physical health need, selected in consultation with the Scottish Government and relevant stakeholders, that present the greatest health burden to people in prison and to health care services. Data pertaining to Scotland's prison population were drawn from a range of sources to provide prevalence estimates. These were compared with prevalence estimates for Scotland's general population and other national and international prison populations (where relevant and available).

Methods

The findings reported in this Chapter draw on data relating to 3 populations: 1) Scotland's prison population; 2) national and international prison populations beyond Scotland; and 3) Scotland's general (non-prison) population. A variety of sources were utilised, as described below.

Scotland's prison population

Prevalence estimates for Scotland's prison population were drawn from 2 sources:

1) Public Health Scotland Prisons Covid Linkage Study

The Public Health Scotland Prisons Covid Linkage Study (PHS-PCLS) is an ongoing study examining vaccination rates and risk of Covid-19 disease amongst Scotland's prison population, which has linked data held on the Scottish Prison Service Prisoner Records (PR2) system with a range of public health datasets held by Public Health Scotland (PHS)^[7]. This study has collected estimates of the prevalence of a range of conditions shown to confer heightened risk of severe or fatal Covid-19 infection, some of which correspond to the physical health conditions of interest in the current study. The project lead for PHS-PCLS obtained permission to share aggregate, anonymised prevalence estimates for their cohort as a whole, as well as figures disaggregated by gender (male/female), age (18-49/50+) and ethnicity (White/Non-White).

2) Published/publically-available research and reports

Data from relevant published literature was utilised, as identified during the literature review (see Chapter 2 for further details).

Two further data sources were considered, but rejected due to concerns regarding the quality of data stored on these systems. The PR2 system was considered, as it records a range of risk markers, some of which relate to the 17 physical health conditions of interest in this study. Relevant markers were identified and a percentage prevalence for each PR2 marker calculated across the whole prison population in Scotland in 2019. Also, data from the Vision system were considered, which holds health care records for people living in prison in Scotland. On the advice of the Scottish Government, permission was obtained to access anonymised, aggregate data from one health board in Scotland that represented core groups within Scotland's prison population (males, females, adults and young persons). These figures were then extrapolated to the wider prison population in Scotland, accounting for the age and sex composition of the wider prison population in Scotland.

Very low prevalence figures were observed when utilising Vision and PR2 data, which raised doubts regarding the reliability of these data. For example, PR2 data indicated that 0.04% of people living in Scotland's prisons are receiving blood borne virus treatment and there were no records of any Genito-Urinary Medicine (GUM) notes, which may indicate sexually transmitted infection (STI). Furthermore, there were no records within the Vision data of people living in Scotland's prisons who had hepatitis B or C, Chlamydia, Syphillis or Gonoccal infections. Such low prevalence figures seem questionable in light of existing evidence demonstrating much higher rates of blood borne viruses (e.g. hepatitis C) and STI in UK prison populations (e.g. Falla et al., 2014; PHE, 2014; Taylor et al., 2013). The decision was, therefore, taken to exclude prevalence estimates derived from Vision and PR2 in this report. Given the comprehensive data linkage employed in the PHS-PCLS, these data were considered more reliable. This does, however, mean that prevalence estimates are not available for some conditions based on the data available for this project. The issue of data reliability is further discussed in Chapter 5, including recommendations for how health care datasets can be better utilised in the future.

National and international prison populations beyond Scotland

To facilitate comparison with other national/international prison populations, relevant published literature was searched (see Chapter 2 for further details). When selecting national and international prison comparisons, the aim was to select comparison sources that maximise methodological quality and the extent to which the prevalence estimates could be directly compared to those available for Scotland's prison population. Sources from UK prison populations were prioritised over international sources.

Scotland's general population

Comparative data relating to Scotland's general population was drawn from a range of published/publically-available research, reports and datasets (e.g. published by PHS and Scottish Government). Data were also drawn from the Scottish Household Survey 2019^[8].

Scotland's prison population

This section of the report provides a brief description of the prison estate as a whole, describes the different prison types and categories of person served across the estate, briefly describes relevant demographic characteristics of the current prison population in Scotland, and examines how Scotland's prison population has changed over time (since the most recent national health needs assessment of Scotland's prison population; Graham, 2007).

A brief description of Scotland's prison population

As at 06/01/2022, Scotland's prison population was comprised of 7548 individuals. The majority were male (96.48%), White (94.75%), aged 32-36 (19.32%) and sentenced compared to being on remand (70.14%). See Table 1 for further details.

Table 1: Demographic Information on Scotland's Prison Population

Population subgroup		Number of People	Percentage of Total Prison Population
Gender	Male	7282	96.48%
	Female	266	3.52%
Age	16-21	293	3.88%
	22-26	905	11.99%
	27-31	1285	17.02%
	32-36	1458	19.32%
	37-41	1173	15.54%
	42-46	749	9.92%
	47-51	612	8.11%
	52-56	448	5.94%
	57-61	283	3.75%
	62-66	145	1.92%
	67-71	90	1.19%
	72-76	66	0.87%
	77+	41	0.54%
Ethnicity	White	7152	94.75%
	Asian, Asian Scottish or Asian British	136	1.80%
	African, Caribbean or Black	135	1.79%
	Mixed or Multiple	33	0.44%
	Other Ethnic Group	92	1.22%
Status	Sentenced	5294	70.14%
	Remand	2081	29.86%

Note: Data provided by SPS.

Trends in Scotland's prison population^[9]

From 2006/07 to 2019/20, Scotland's prison population rose 14%. Although, it should be noted that much of this increase had disappeared by 06/01/2022, with only a 5% increase noted when comparing the average daily population in 2006/07 with the population at 06/01/2022.

From 2006/07 to 2019/20, the number of males and females living in Scotland's prisons increased by 14%. Although, when considering the population at 06/01/2022, the number of males living in Scotland's prisons has only increased by 7% and the number of females has actually decresed by 25%.

From 2006/07 to 2019/20, the number of people living in Scotland's prisons aged under 21 years decreased by 68%, whereas the number of people aged 21 years and over has increased by 27%. When considering the population at 06/01/2022, the number of people aged under 21 years has decresed by 71% and the number of people aged 21 and over has only increased 17%.

The ethnic composition of the prison population in Scotland has remained stable from 2010/11 to 2019/20, with the predominant self-reported ethnic category White (remaining stable at 96%), followed by Asian, Asian Scottish or Asian British (stable at 2%), then African, Caribbean or Black (stable at 1%), and Mixed or Multiple and Other Ethnic Group (both stable at < 0.5%)^[10].

The number of unique individuals arriving to and departing from prisons in Scotland has decreased from 2010/11 to 2019/20, with the number of arrivals decreasing by 26% and the number of departures decreasing by 24%.

Rate of incarceration and international comparisons^[11]

As at December 2021, the rate of incarceration in Scotland was 136 people in prison per 100,000 of the general population, which is 20^th highest in Europe out of 57 countries. This compares to 132 per 100,000 in England and Wales and 81 per 100,000 in Northern Ireland.

The physical health care needs of Scotland's prison population

This section of the report provides prevalence estimates relating to 17 areas of physical health that present the greatest health burden to people in prison and to health care services. Where possible, prevalence estimates are provided for Scotland's prison population (including comparisons based on demographic characteristics- age, gender and ethnicity), with these estimates compared to relevant baseline data (e.g. prevalence estimates for Scotland's general population and other national and international prison populations). Table 2 provides a summary of these prevalence estimates and key details regarding the sources from which the estimates were derived.

Table 2: A Summary of Prevalence for the 17 Areas of Physical Health and Key Demographic and Methodological Detail

Condition	Population	Study/Dataset	Prevalence	N	Gender	Mean Age	SD Age	Age Range	Ethnicity	Study Methodology
Ischaemic (Coronary) Heart Disease (CHD) and Other Heart Disease (OHD)	Scotland's Prison Population	PHS-PCLSa	CHD: 1.95% OHD: 3.91%	13585	94.1% Male 5.9% Female	35.7	11.3	18-87	94.8% White 5.2% Other	Data linkage study linking PR2 and various PHS datasets
	England's Prison Population	Packham et al. (2020)	Cardiovascular disease: 5.55%	1648	100% Male	43.8	7.6	35-74	White 79.6 %, Black 5.4 %, Asian (S & E) 5.4%, Mixed/other 9.6%	Observational cross-sectional survey based on questions from the NHS Health Check Programme in prison settings
	Scotland's General Population	PHS Scottish heart disease statistics and GP disease prevalence data	CHD: 3.45-3.93%	Scottish heart disease statistics are drawn from the Scottish Morbidity Record (SMR01). The age-sex standardized rate was calculated using the direct method, standardized to the 2013 European Standard Population (ESP2013) GP disease prevalence data are extracted from GP practices in Scotland through the Quality Outcomes Framework (QOF) Calculator
Musculoskeletal Disorders		The only data relating to musculoskeletal disorders in Scotland's prison population that was available for this project comes from the Vision and PR2 systems. It is, therefore, not possible to give reliable prevelance estimates for this group of conditions.
Diabetes	Scotland's Prison Population	Arora et al. (2020)	Type I and II: 3%	353	74.8% Male 25.2% Female	32.1	Unavailable	16-83	Caucasian 93.8%, Black 1.7%, Mixed race 1.4%, Asian 0.8%, Chinese 0.6%, Lithuanian 0.3%, Middle Eastern 0.3%, Romanian 0.3%, Vietnamese 0.3%	The 2019 Oral Health and Psychosocial Needs of the Scottish Prisoners and Young Offenders self-report survey and oral health examination
	Scotland's Prison Population	PHS-PCLS	Type I: 0.66% Type II: 1.21%	13585	94.1% Male 5.9% Female	35.7	11.3	18-87	94.8% White 5.2% Other	Data linkage study linking PR2 and various PHS datasets
	England's Prison Population	Public Health England (2015)	Type I and II: 4.41%	9442	96.7% Male 3.3% Female	Most common age group (34.7%) 21-29 years	Unavailable	Unavailable	White 71%, 11% Black or Black British, 10% Asian or Asian British	A collation of findings from 9 HNAs conducted in prisons in the West Midlands, which drew on a range of data (focus groups, questionnaires and data from health records)
	Scotland's General Population	NHS Scotland (2019)	Type I and II: 5.74% Type I: 0.62% Type II: 5.05%	Data extracted from the Scottish Care Information-Diabetes (SCI-Diabetes) database, which records individuals who are alive and registered with a Scottish General Practitioner across all 14 of Scotland's NHS Health Boards
Epilepsy	Scotland's Prison Population	Arora et al. (2020)	3%	353	74.8% Male 25.2% Female	32.1	Unavailable	16-83	Caucasian 93.8%, Black 1.7%, Mixed race 1.4%, Asian 0.8%, Chinese 0.6%, Lithuanian 0.3%, Middle Eastern 0.3%, Romanian 0.3%, Vietnamese 0.3%	The 2019 Oral Health and Psychosocial Needs of the Scottish Prisoners and Young Offenders self-report survey and oral health examination
	England's Prison Population	Public Health England (2015)	2.79%	9442	96.7% Male 3.3% Female	Most common age group (34.7%) 21-29 years	Unavailable	Unavailable	White 71%, 11% Black or Black British, 10% Asian or Asian British	A collation of findings from 9 HNAs conducted in prisons in the West Midlands, which drew on a range of data (focus groups, questionnaires and data from health records)
	Scotland's General Population	Scottish Health Survey 2019	1%	6451 addresses	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Self-report survey
	Scotland's General Population	Scottish Household Survey 2019	1%	18836	47.7% Male 52.2% Female 0.05% Other	50.3	19.0	16-98	White 93.4%, Mixed 0.1%, Asian 2.3%, African 0.6%, Caribbean or Black 0.06%, Other 0.3%, Don't Know/Refused 0.07%	Self-report survey
Asthma and Chronic Obstructive Pulmonary Disease (COPD)	Scotland's Prison Population	Arora et al. (2020)	Asthma/COPD: 16%	353	74.8% Male 25.2% Female	32.1	Unavailable	16-83	Caucasian 93.8%, Black 1.7%, Mixed race 1.4%, Asian 0.8%, Chinese 0.6%, Lithuanian 0.3%, Middle Eastern 0.3%, Romanian 0.3%, Vietnamese 0.3%	The 2019 Oral Health and Psychosocial Needs of the Scottish Prisoners and Young Offenders self-report survey and oral health examination
	Scotland's Prison Population	PHS-PCLS	Asthma or Chronic Airway Disease: 7.97%	13585	94.1% Male 5.9% Female	35.7	11.3	18-87	94.8% White 5.2% Other	Data linkage study linking PR2 and various PHS datasets
	England's Prison Population	Public Health England (2015)	Asthma: 10.16%	9442	96.7% Male 3.3% Female	Most common age group (34.7%) 21-29 years	Unavailable	Unavailable	White 71%, 11% Black or Black British, 10% Asian or Asian British	A collation of findings from 9 HNAs conducted in prisons in the West Midlands, which drew on a range of data (focus groups, questionnaires and data from health records)
	Greece's Prison Population	Bania et al. (2016)	COPD: 6%	552	91.3% Male 8.7% Female	43 (median)	Unavailable	35-53	Greek 79.2%, others 20.8%	Cross sectional epidemiological study drawing on from a range of sources, including health care records, physical examination, participant interviews and questionnaires
	US' Prison Population	Trotter et al. (2018)	COPD: 6%	199	78.9% Male 21.1% Female	Unavailable	Unavailable	Unavailable	American Indian/Alaska Native 58.8%, White 27.6%, Other 15.6%	Cross sectional self-report survey
	Scotland's General Population	GP disease prevalence data	Asthma: 6.39% COPD: 2.46%	GP disease prevalence data are extracted from GP practices in Scotland through the Quality Outcomes Framework (QOF) Calculator
Blood Borne Viruses (BBV) and Sexually Transmitted Infections (STI)	Scotland's Prison Population	PHS-PCLS	Conditions causing immune deficiency or suppression: 0.26%	13585	94.1% Male 5.9% Female	35.7	11.3	18-87	94.8% White 5.2% Other	Data linkage study linking PR2 and various PHS datasets
	Scotland's Prison Population	Taylor et al. (2013)	Hepatitis C: 19%	5076	95% Male 5% Female	32.4	10.9	Unavailable	Unavailable	Cross sectional sero-behavioural survey and dried blood spot testing
	UK's Prison Population	Falla et al. (2018)	Hepatitis C: 8.0-17.39%	5450	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Systematic literature review. The figures reported relate to the pooled estimates from studies published in the UK from 2010-2013
	England's Prison Population	Public Health England (2014)	HIV: 0.6%	2834	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Data drawn from PHE Sentinel Surveillance of blood-borne virus testing in England
	Scotland's General Population	Health Protection Scotland (2017)	Hepatitis C: 0.64% HIV: 0.11%	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable
Oral Health	Scotland's Prison Population	Arora et al. (2020)	Mean number of decayed, missing and filled teeth: 13.70 Mean number of decayed teeth into dentine: 2.93 Mean number of filled teeth: 4.09 Mean number of missing teeth: 6.68	353	74.8% Male 25.2% Female	32.1	Unavailable	16-83	Caucasian 93.8%, Black 1.7%, Mixed race 1.4%, Asian 0.8%, Chinese 0.6%, Lithuanian 0.3%, Middle Eastern 0.3%, Romanian 0.3%, Vietnamese 0.3%	The 2019 Oral Health and Psychosocial Needs of the Scottish Prisoners and Young Offenders self-report survey and oral health examination
	England's Prison Population	Heidari et al. (2007)	Mean number of decayed, missing and filled teeth: 14.2 Mean number of decayed teeth into dentine: 3.5 Mean number of filled teeth: 4.5 Mean number of missing teeth: 6.2	78	100% Male	37.7	9.6	Unavailable	Black 38.4%, White 34.6%, South Asian 6.5%, Chinese 5.2%, Other 10.2%, Declined to say 5.2%	Structured interview and oral examination
	Scotland's General Population	NHS National Services Scotland (2019)	Mean number of decayed teeth: 0.5 Mean number of filled teeth: 10.6	3114	44.8% Male 55.2% Female	Most common age group (32.0%) 45-54 years	Unavailable	Unavailable	White Scottish 73%, Other 22%, Not answered 4%	Scottish Adult Oral Health Survey 2016-2018. Oral examination.
Cancer	Scotland's Prison Population	PHS-PCLS	1.51%	13585	94.1% Male 5.9% Female	35.7	11.3	18-87	White 94.8% Other 5.2%	Data linkage study linking PR2 and various PHS datasets
	US' Jail and Prison Populations	Maruschak et al. (2016)	3.5-3.6%	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Data drawn from the 2011-12 National Inmate Survey (NIS-3), which is a self-report survey
	Australia's Prison Population	Field et al. (2020)	6.60%	566	65.4% Male 34.6% Female	Unavailable	Unavailable	Unavailable	Australian 69.4%, Other 30.6%	Cross sectional self-report survey
	Scotland's General Population	PHS (2019)	2.67-6.25%	Scottish heart disease statistics are drawn from the Scottish Cancer Registry (SMR06).
Cerebrovascular Disease (Stroke)	Scotland's Prison Population	PHS-PCLS	Other circulatory disease: 5.36%	13585	94.1% Male 5.9% Female	35.7	11.3	18-87	White 94.8% Other 5.2%	Data linkage study linking PR2 and various PHS datasets
	US' Jail and Prison Populations	Maruschak et al. (2016)	Stroke-related problems: 1.8-2.3%	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Data drawn from the 2011-12 National Inmate Survey (NIS-3), which is a self-report survey
	Australia's Prison Population	Field et al. (2020)	2.30%	566	65.4% Male 34.6% Female	Unavailable	Unavailable	Unavailable	Australian 69.4%, Other 30.6%	Cross sectional self-report survey
	Scotland's General Population	PHS Scottish stroke statistics and GP disease prevalence data	2.28-2.49%	Scottish stroke statistics are drawn from the Scottish Morbidity Record (SMR01). The age-sex standardized rate was calculated using the direct method, standardized to the 2013 European Standard Population (ESP2013) GP disease prevalence data are extracted from GP practices in Scotland through the Quality Outcomes Framework (QOF) Calculator
Digestive Conditions: Chronic Liver Disease (CLD), Chronic Kidney Disease (CKD) and Disorders of the Oesophagus, Stomach and Duodenum (DOSD)	Scotland's Prison Population	PHS-PCLS	CLD: 0.80% CKD: 0.04% DOSD: 4.24%	13585	94.1% Male 5.9% Female	35.7	11.3	18-87	White 94.8% Other 5.2%	Data linkage study linking PR2 and various PHS datasets
	US' Jail and Prison Populations	Maruschak et al. (2016)	Kidney-related problems: 6.1-6.7% Cirrhosis of the liver: 1.7-1.8%	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Unavailable	Data drawn from the 2011-12 National Inmate Survey (NIS-3), which is a self-report survey
	Australia's Prison Population	Field et al. (2020)	CKD: 3.30% Liver disease: 4.10%	566	65.4% Male 34.6% Female	Unavailable	Unavailable	Unavailable	Australian 69.4%, Other 30.6%	Cross sectional self-report survey
	Scotland's General Population	Scottish Household Survey 2019	Severe stomach, kidney, liver or digestive problems: 1.90%	18836	47.7% Male 52.2% Female 0.05% Other	50.3	19.0	16-98	White 93.4%, Mixed 0.1%, Asian 2.3%, African 0.6%, Caribbean or Black 0.06%, Other 0.3%, Don't Know/Refused 0.07%	Self-report survey
Respiratory Tract Infection (RTI)		The only data relating to RTI in Scotland's prison population that was available for this project comes from the Vision system. It is, therefore, not possible to give reliable prevelance estimates for RTI.
Covid-19	Scotland's Prison Population	WHO (2022)	May 2020-September 2021: 1520 confirmed cases of Covid-19 (20.77% of the population), 56 (0.77%) of which resulted in transfer to hospital and 6 (0.08%) resulted in death), 13068 instances of people living in prison being isolated or quarantined, including the confirmed cases of Covid-19, and 8754 instances of people isolated as a precautionary measureb
	England's and Wales' Prison Populations	Ministry of Justice and HMPPS Covid-19 Statistics	May 2020-September 2021, 18576 prison residents have tested positive for Covid-19 (23.11% of the population) and 116 residents (0.14%) are suspected to have died from Covid-19
	Scotland's General Population	PHS Covid-19 Statistics	May 2020-September 2021, 559063 individuals have tested positive for Covid-19 (10.23% of the total population)
Dementia	Scotland's Prison Population	PHS-PCLS	Dementia and Neurological Conditions (excl. epilepsy) in residents aged 50+: 2.28%	1667	95.9% Male 4.1% Female	57.6	7.2	50-87	White 96.9%, Other 3.1%	Data linkage study linking PR2 and various PHS datasets
	England's and Wales' Prison Populations	Forsyth et al. (2020)	Dementia: 6.8%	869	68.5% Male 31.5% Female	Unavailable	Unavailable	Unavailable	Unavailable	Data drawn from prison health care records and from various psychometric tests assessing cognitive function
	Scotland's General Population	Dementia Benchmarking Toolkit	Dementia: 4.24%	Data in the Dementia Benchmarking Toolkit are drawn from the Scottish Morbidity Record (SMR01 and SMR04)
Pregnancy, Maternal Health and Post-Natal Care		No reliable data were available for this project
Acquired Brain Injury	Scotland's Prison Population	McMillan et al. (2019)	Hospitalised head injury: 24.69%	4374	94.3% Male 5.7% Female	Most common age group (64.9%%) 26-35 years	Unavailable	16-35	Unavailable	Case-control design, data linkage study linking prison-based health records and the Scottish Morbidity Record (SMR01)
	Scotland's Prison Population	Young et al. (2018)	Traumatic brain injury: 43.3%	390	100% Male	30.3	8.3	Unavailable	Caucasian British 99%, Other 1%	Self-report questionnaires and various psychometric tests
	England's and Wales' Prison Populations	Williams et al. (2010)	Moderate-Severe traumatic brain injury: 15.82%	196	100% Male	Unavailable	Unavailable	18-54	Unavailable	Self-report survey
	Scotland's General Population	McMillan et al. (2019)	Hospitalised head injury: 18.2%	13122	94.3% Male 5.7% Female	Most common age group (64.9%%) 26-35 years	Unavailable	16-35	Unavailable	Case-control design, data linkage study linking prison-based health records and the Scottish Morbidity Record (SMR01)

^a PHS-PCLS = Public Health Scotland Prisons Covid Linkage Study

^b These figures may contain individuals who were infected, isolated or transferred to hospital multiple times

Ischaemic (Coronary) Heart Disease (CHD) and Other Heart Disease (OHD)

The prevalence of CHD amongst Scotland's prison population is estimated to be 1.95% and OHD 3.91% (PHS-PCLS). This compares to an estimated prevalence of 5.55% for cardiovascular disease in English prison populations (Packham et al., 2020) and 3.45-3.93% for CHD in the general Scottish population^[12].

It is important to note that Packham et al. (2020) sampled prison residents aged 35-74, which represents an older sample than the Scottish sample studied by the PHS-PCLS. Moreover, Packham et al. only report figures for cardiovascular disease in general, rather than separate figures for CHD, OHD and other heart-related conditions. Together, these methodological differences might explain the higher prevalence rates in prison samples from England compared to Scotland.

Within Scotland's prison population, CHD is more prevalent amongst males than females (2.03% vs. 0.62%); it is more prevalent amongst those aged 50+ than under 50 (10.68% vs. 0.73%); and is more prevalent amongst White people in prisons in Scotland than those from other ethnic groups (2.02% vs. 0.70%). OHD is more prevalent amongst females than males (4.97% vs. 3.84%); it is more prevalent amongst those aged 50+ than under 50 (12.84% vs. 2.66%); and is more prevalent amongst White people in prisons in Scotland than those from other ethnic groups (4.04% vs. 1.55%).

Musculoskeletal disorders

The only data relating to musculoskeletal disorders in Scotland's prison population that was available for this project comes from the Vision and PR2 systems. It is, therefore, not possible to give reliable prevelance estimates for this group of conditions.

Diabetes

Arora et al. (2020) estimate a 3% prevalence for diabetes (type 1 and 2 combined) and PHS-PCLS estimate a 0.66% prevalence of type 1 diabetes and 1.21% of type 2 diabetes. This compares to an estimated prevalence of 4.41% for diabetes in English prison populations (Public Health England, 2015)^[13] and 5.74% for diabetes in the general Scottish population (Type 1 = 0.62%, Type 2 = 5.05%) (NHS Scotland, 2019).

Within Scotland's prison population (PHS-PCLS), type 1 diabetes is prevalent at a similar rate amongst males (0.66%) and females (0.62%) and it is more prevalent amongst those aged 50+ than under 50 (1.08% vs. 0.60%)^[14]. Type 2 diabetes is prevalent at a similar rate amongst males (1.21%) and females (1.24%); it is more prevalent amongst those aged 50+ than under 50 (5.70% vs. 0.59%); and is more prevalent amongst White people living in Scotland's prisons than those from other ethnic groups (1.24% vs. 0.84%).

Epilepsy

The prevalence of Epilepsy amongst Scotland's prison population is estimated to be 3% (Arora et al., 2020). This compares to an estimated prevalence of 2.79% for Epilepsy in English prison populations (Public Health England, 2015) and 1% for Epilepsy in the general Scottish population^[15].

Asthma and Chronic Obstructive Pulmonary Disease (COPD)

Estimates of the prevalence of asthma and COPD amongst Scotland's prison population vary: PHS-PCLS estimate the prevalence of asthma or Chronic Airway Disease to be 7.97% and Arora et al. (2020) estimate the prevalence of asthma/COPD to be 16%. This compares to an estimated prevalence of 10.16% for asthma in English prison populations (Public Health England, 2015) and 6.39% for asthma in the general Scottish population^[16], and 6% for COPD in US and Greek prison populations (Bania et al., 2016; Trotter et al., 2018) and 2.46% for COPD in the general Scottish population^[17].

Within Scotland's prison population (PHS-PCLS), asthma or Chronic Airway Disease is more prevalent amongst females than males (14.91% vs. 7.54%); it is more prevalent amongst those aged 50+ than under 50 (14.52% vs. 7.06%); and is more prevalent amongst White people living in Scotland's prisons than those from other ethnic groups (8.30% vs. 2.11%).

Blood Borne Viruses (BBV) and Sexually Transmitted Infections (STI)

PHS-PCLS estimate the prevalence of people living in Scotland's prisons with conditions causing immune deficiency or suppression to be 0.26% (male = 0.23%; female = 0.87%; 18-49 = 0.23%; 50+ = 0.48%)^[18]. Taylor et al. (2013) report a 19% prevalence of hepatitis C amongst Scotland's prison population, with the prevalence unsurprisingly much higher amongst individuals with an injecting history than those without (53% vs. 3%). Estimates in UK prison populations indicate the prevalence of hepatitis C to be 8.0-17.39% and HIV 0.6% (Falla et al., 2018; PHE, 2014). In the general Scottish population, the estimated prevalence of hepatitis C is 0.64% and HIV is 0.11%^[19].

Oral health

Arora et al. (2020) report a range of findings relating to the oral health of prison residents in Scotland. In their sample of 353 residents from 10 of Scotland's prisons, the mean number of decayed, missing and filled teeth (DMFT) was 13.70, the mean number of decayed teeth into dentine was 2.93, the mean number of filled teeth was 4.09 and the mean number of missing teeth was 6.68. In Scotland's general population, the mean number of decayed teeth is 0.5 and filled teeth is 10.6^[20]. In English prison residents, the mean number of DMFT was 14.2, the mean number of decayed teeth into dentine was 3.5, the mean number of filled teeth was 4.5 and the mean number of missing teeth was 6.2 (Heidari et al., 2007).

When Arora et al. (2020) compared different groups of prison residents it was found that residents in YOIs had significantly fewer missing and filled teeth than residents in adult prisons (p < .001); female residents had significantly more missing and filled teeth than male residents (p < .001); residents with greater experience of remands (≥3 remands) and shorter length of current imprisonment had a significantly higher number of decayed teeth (p < .05); and residents with longer prison sentences had significantly more filled teeth (p < .05).

Cancer

The prevalence of Cancer (malignant neoplasms) amongst Scotland's prison population is estimated to be 1.51% (PHS-PCLS). This compares to an estimated prevalence of 3.5% for Cancer in persons living in US state and federal prisons and 3.6% in persons living in US jails (Maruschak et al., 2016) and 6.60% in Australian prisons (Field et al., 2020). The prevalence of Cancer is 2.67-6.25% in the general Scottish population^[21].

Within Scotland's prison population, Cancer is more prevalent amongst females than males (1.99% vs. 1.48%) and is more prevalent amongst those aged 50+ than under 50 (6.18% vs. 0.86%), but is prevalent at a similar rate amongst White people living in Scotland's prisons (1.51%) and persons from other ethnic groups (1.41%).

Cerebrovascular disease (stroke)

PHS-PCLS provide data regarding the prevalence of 'other circulatory disease' in Scotland's prison population (5.36%), which may include stroke, but it is important to note that these figures may also include other conditions. This compares to an estimated prevalence of 1.8% for stroke-related problems in persons living in US state and federal prisons and 2.3% in US jails (Maruschak et al., 2016) and 2.30% in Australian prisons (Field et al., 2020). The prevalence of stroke is 2.28-2.49% in the general Scottish population^[22].

Within Scotland's prison population, other circulatory disease is more prevalent amongst females than males (12.42% vs. 4.91%); is more prevalent amongst those aged 50+ than under 50 (10.32% vs. 4.67%); and is more prevalent amongst White persons than persons from other ethnic groups (5.58% vs. 1.41%).

Digestive conditions: Chronic Liver Disease (CLD), Chronic Kidney Disease (CKD) and Disorders of the Oesophagus, Stomach and Duodenum (DOSD)

The prevalence of CLD amongst Scotland's prison population is estimated to be 0.80%, CKD 0.04%, and DOSD 4.24% (PHS-PCLS). This compares to an estimated prevalence of 6.1% for kidney-related problems and 1.8% for cirrhosis of the liver in US state and federal prisons and 6.7% for kidney-related problems and 1.7% for cirrhosis of the liver in US jails (Maruschak et al., 2016). It also compares to a self-reported prevalence of 3.30% for CKD and 4.10% for liver disease in Australian prisons (Field et al., 2020). In the general Scottish population, severe stomach, kidney, liver or digestive problems are prevalent at a rate of 1.90%^[23].

Within Scotland's prison population, CLD is prevalent at a similar rate amongst males (0.81%) and females (0.62%), but is more prevalent amongst those aged 50+ than under 50 (1.92% vs. 0.65%). DOSD is more prevalent amongst females than males (5.09% vs. 4.19%); it is more prevalent amongst those aged 50+ than under 50 (7.86% vs. 3.73%); and is more prevalent amongst White persons than those from other ethnic groups (4.40% vs. 1.41%)^[24].

Respiratory Tract Infection (RTI)

The only data relating to RTI in Scotland's prison population that was available for this project comes from the Vision system. It is, therefore, not possible to give reliable prevelance estimates for RTI.

Covid-19

The date of the first suspected case of Covid-19 within a Scottish prison occurred on 13 March 2020. As described by WHO (2022), from May 2020 to September 2021 there were 1520 confirmed cases of Covid-19 in people living in prison in Scotland (20.77% of the population), 56 (0.77%) of which resulted in transfer to hospital and 6 (0.08%) resulted in death (note: these figures may contain individuals who were infected or transferred to hospital multiple times). There were 13068 instances of people living in prison being isolated or quarantined, including the confirmed cases of Covid-19, and 8754 instances of people isolated as a precautionary measure (note: some people may have been isolated on multiple occasions). In prisons in England and Wales from May 2020 – September 2021, 18576 prison residents have tested positive for Covid-19 (23.11% of the population) and 116 residents (0.14%) are suspected to have died from Covid-19 (note: these figures may contain individuals who tested positive for Covid-19 multiple times). Amongst the general Scottish public from May 2020 – September 2021, 559063 individuals have tested positive for Covid-19 (10.23% of the total population).

Dementia

The prevalence of dementia and neurological conditions (excluding epilepsy) amongst Scotland's prison population is estimated to be 1.13% (PHS-PCLS). However, given that dementia is a condition that affects older populations, it is arguably better to focus on the prevalence of dementia in prison residents aged 50+ years, which is 2.28% amongst Scotland's prison population (PHS-PCLS). This compares to an estimated prevalence of 6.8% for dementia in English and Welsh prison residents aged 50+ (Forsyth et al., 2020)^[25] and 4.24% for dementia in members of the general Scottish population aged 65+^[26].

Within Scotland's prison population, dementia and neurological conditions (excluding epilepsy) are more prevalent amongst females than males (2.36% vs. 1.06%) and more prevalent amongst those aged 50+ than under 50 (2.28% vs. 0.97%)^[27].

Pregnancy, maternal health and post-natal care

Very little data were available regarding pregnancy, maternal health and post-natal care amongst prison residents in Scotland, as such data are not held on Vision and no relevant published research could be found in Scotland. PR2 contains a risk marker indicating prison residents who are pregnant, but these data are not reported here due to the aforementioned concerns regarding data reliability. No data were available relating to other indicators of maternal health and post-natal care, such as low birth weight, stillbirth, pre-term delivery etc. (see Bard et al., 2016, for a systematic review of such factors in international prison populations).

Acquired brain injury

McMillan et al.'s (2019) study found a 24.69% prevalence of hospitalised head injury (HHI) in their sample of 4374 persons living in prison in Scotland aged 35 years or younger, which was significantly higher than the 18.2% prevalence in the matched general population comparison group. Persons living in prison were found to be admitted to hospital for a head injury more frequently, for longer durations and experienced more severe head injury than the general population. HHI was found to be more common amongst male than female persons living in prison (25.1% vs. 18.5%) and was more common amongst those aged 26-35 than 16-25 (27.4% vs. 19.8%), but there was no difference in the prevalence of HHI as a function of deprivation (as measured by the Structured Index of Multiple Deprivation, SIMD). In Young et al.'s (2018) sample of 390 adult males living in HMP Inverness, 43.3% were considered to have experienced Traumatic Brain Injury (TBI, defined by Young and colleagues as loss of consciousness or hospital treatment). According to Williams et al. (2010), 15.82% of persons living in prison in England and Wales are estimated to have experienced moderate-severe traumatic brain injury (defined as loss of consciousness for 10+ minutes) and 49.49% experienced mild traumatic brain injury (loss of consciousness for less than 10 minutes).

Conclusion

There was difficulty developing prevalence estimates to describe the physical health care needs of Scotland's prison population due to a lack of available data, questionable reliability of existing data sources and challenges identifying directly comparable baselines for national/international prison populations and the general Scottish population. Where comparisons were possible, the data suggest that persons living in prison in Scotland experience greater prevalence of some (but not all) physical health conditions examined in this study (particularly: epilepsy, asthma, COPD, hepatitis C, oral health and Covid-19). In general, worse physical health was observed amongst White persons living in prison in Scotland, females and individuals aged 50+.