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Time out of cell and time in purposeful
activity and adverse mental health
outcomes amongst people in
prison: a literature review
Thomas Stephenson, Jane Leaman, Éamonn O’Moore, Anh Tran and Emma Plugge
Abstract
Purpose –The purpose of this study is to synthesise the availablepeer-reviewed literature on the impact
of time out of cell (TOOC) and time in purposeful activity (TIPA) on adverse mental outcomes amongst
people in prison.
Design/methodology/approach –The outcomes of interest of this literature review were mental health,
suicide, deliberate self-harm (DSH) and violence. Exposures of interest were TOOC, TIPA or a partial or
indirect measure of either. In total, 14 studies were included. An abbreviated review methodology was
used because of time constraints.
Findings –There was consistent evidence of an association between lower TOOC and TIPA and worse
mental health and higher suicide risk. Limited evidence suggests a link between TOOC and DSH. No
evidence was identified regarding the relationship between TOOC/TIPA and violence.
Research limitations/implications –A lack of longitudinal studies prevents conclusions regarding
causality. Significant heterogeneity of mental health outcomes limits the comparability of studies.
Practical implications –These findings highlight the importance of considering the impact of TOOC
and TIPA on adverse mental outcomes for prisoners when designing prison regimes, including during
urgent adaptation of such regimes in response to Covid-19. They are likely to be of interest to
practitioners and policymakers concerned with prison regime design.
Originality/value –This paper is the first to synthesise the existing literature on the impact of TOOC and
TIPA on mental health outcomes.
Keywords Health promoting prison, Mental health, Self-harm, Prison psychiatry, Violence, Suicide
Paper type Literature review
Introduction
Over 10 million people are imprisoned worldwide (Walmsley, 2018) and in England and
Wales alone, there are over 80,000 people in prison (Walmsley, 2018;Ministry of Justice,
2018). Imprisoned people have poorer mental health and higher rates of severe mental
illness than the general population, as well as high rates of suicide, deliberate self-harm
(DSH) and violence (Fazel and Seewald, 2012;Fazel et al., 2006;Fazel et al., 2011;Rivlin
et al., 2013;Fazel et al.,2008;Hawton et al., 2014;Lord Harris Review, 2015;UK Ministry of
Justice, 2017). One in seven people in prison has depression or psychosis, while estimated
standardised mortality ratios for suicide are 3–7 times higher amongst this group (and 20
times higher for women) than in the general population (Fazel et al.,2011;UK Ministry of
Justice, 2017). The documented annual prevalence of self-harm in UK prisons is 5%–6%
amongst men and 20%–24% amongst women (Hawton et al.,2014).
Thomas Stephenson is
based at South London and
Maudsley NHS Foundation
Trust, London, UK and
Institute of Psychiatry,
Psychology and
Neuroscience, King’s
College London, London,
UK. Jane Leaman is based
at National Health and
Justice Team, Public Health
England, London, UK.
E
´amonn O’Moore is based
at National Health and
Justice Team, Public Health
England, London, UK and
is Director at WHO UK
Collaborating Centre for
Health in Prisons
Programme, Public Health
England, London, UK.
Anh Tran is based at the
Department of Research,
Translation and Innovation
Division, Public Health
England, London, UK.
Emma Plugge is based at
WHO UK Collaborating
Centre for Health in Prisons
Programme, Public Health
England, London, UK and
School of Primary Care,
Population Sciences and
Medical Education,
University of Southampton,
Southampton, UK.
Received 3 June 2020
Revised 26 October 2020
Accepted 17 November 2020
Wendy Marsh and Nicola
Pearce-Smith contributed
feedback to a draft version of
this manuscript.
PAGE 54 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jVOL. 17 NO. 1 2021, pp. 54-68, ©Emerald Publishing Limited, ISSN 1744-9200 DOI 10.1108/IJPH-06-2020-0037
While the reasons for these disparities include characteristics of the individual, the prison
environment is also likely to contribute to poor mental health and increased suicide risk,
particularly for vulnerable people (Slotboom et al., 2011;Marzano et al.,2016). Within the
general population, environmental variables such as leisure-time, physical activity and
being in employment have important positive effects on mental health (White et al.,2016;
Modini et al.,2016) and suicidality (Vancampfort et al., 2018;Milner et al.,2013;Milner
et al.,2018
).
Specialist treatment pathways exist for those in prison with identifiable psychiatric
disorders, including diversion from custody or prison to hospital. However, it is also
recognised internationally that the state has a special duty of care for the mental health of all
those incarcerated (UN General Assembly, 2016). This includes the duty to modify prison-
related factors, which adversely affect their mental health (World Health Organisation and
UN Office for Drugs and Crime, 2013). In addition, fostering of a rehabilitative culture in
prisons is a growing interest amongst governmental and non-governmental organisations
within the UK and internationally, with potential mental health benefits for all imprisoned
people (World Health Organisation, 2014;House of Commons Health and Social Care
Committee, 2018;UK Ministry of Justice, Public Health England, UK Department of Health
and Social Care, NHS England, Hm Prison and Probation Service, 2018;UK Ministry of
Justice, 2016;Mann et al.,2018;Smith and Schweitzer, 2012).
TOOC and TIPA represent core features of the prison regime, which shapes the
environment and daily experience of all people in prison. TOOC is defined by Her Majesty’s
Inspectorate of Prisons (HMIP) as “all the occasions when prisoners are unlocked from their
cells” and includes: “the other times when prisoners are out of their cells, for example, to
associate with other prisoners, have exercise or meals, take showers or make telephone
calls”. TIPA is defined more narrowly as time spent in “the formal activities aimed at helping
prisoners to gain skills –for example, through education, training, work and participation in
offending behaviour programmes” (Hm Inspectorate Of Prisons, 2007). They reflect,
respectively, a prisoner’s opportunities for social engagement with family and wider prison
establishment including peers, and for engagement with rehabilitative activities such as
education, training, employment and health programmes (including mental health). In
prisons worldwide, lockdown policies in response to outbreaks of the pandemic novel
coronavirus (Covid-19) have led to a significant and, in many cases, enduring reduction of
TOOC and TIPA (Hewson et al., 2020). However, there has to date been no comprehensive
review of the impact TOOC and TIPA have on mental health or on the incidence of suicide,
DSH and violence in prisons.
The aim of this review was to examine and synthesise the global evidence on the impact of
TOOC and TIPA on mental health and the incidence of suicide, DSH and violence amongst
people in prison.
Methods
Search strategy
We searched the online databases Embase, Medline, PsychInfo and Social Policy and
Practice up to 2 April 2018 (Table 1, for example of search strategy for one database). We
also searched the references and citations of relevant papers for further studies.
Article retrieval and screening
Initial abstract screening was conducted by [AT] using the inclusion and exclusion criteria
(Table 2). [TS] reviewed 187 abstracts and conducted a full-text review of 67 articles, from
which 14 studies were included (Figure 1 for flow diagram).
VOL. 17 NO. 1 2021 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jPAGE 55
Data collection and quality assessment
[EP] and [TS] extracted data from 14 full-text articles on the measured exposures and
outcomes and methodology. They assessed qualitative studies for methodological
quality using the critical appraisal skills programme (CASP) qualitative research
checklist, giving a score from a total of 10. For quantitative research designs, they used
the Newcastle-Ottawa Scale for non-randomised studies, adapted for research in
prisons (Munday et al., 2018), giving a score out of 15. Differences were resolved by
discussion.
Results
In total, 14 studies were included with a total study population of 3,331 (Table 3). Nine were
cross-sectional design (Slotboom et al.,2011;Albertie et al., 2017;Ali et al.,2016;Buckaloo
et al., 2009;Cashin et al., 2008;Cooper and Berwick, 2001;Mannocci et al.,2015;
Mannocci et al., 2017;Togas et al.,2014), two studies used a qualitative approach (Nurse
et al.,2003;Borrill et al.,2005), one used mixed-methods (Marzano et al., 2011a) and two
used ecological designs (Huey and McNulty, 2005;Leese et al., 2006). In total, 9 of the 14
studies were conducted in Europe, with the remainder from Australia, Malaysia, Mexico and
the USA.
Ten studies examined the relationship between TOOC and mental health outcomes (Slotboom
et al.,2011
;Albertie et al., 2017;Ali et al., 2016;Buckaloo et al., 2009;Cashin et al.,2008;
Cooper and Berwick, 2001;Mannocci et al.,2015;Mannocci et al.,2017;Togas et al.,2014;
Nurse et al., 2003). The nine cross-sectional studies used partial measures of TOOC e.g. time
in exercise, availability of visits. Outcomes included depressive and irritability symptom
ratings, hopelessness, life satisfaction and health-related quality of life (Table 2).
Table 1 Example search strategy for Embase
Database: Embase 1974 to 2018 April 2
1 exp prison/
2 (prisonor jailor correctional or detainor remand or penal or offenderor
incarcerat).tw.
3 1 or 2
4 (“time out” or unlock or segregator isolator peeror visitor courseor
educationor trainor libraror workor gardenor exercisor “physical activity” or
employ).tw.
5 exp mental health/
6 exp psychological well-being/
7 exp depression/
8 exp anxiety/
9 (depressor anxiety).tw.
10 exp "quality of life"/
11 ((mental adj (health or disorder)) or well-being or well-being or “quality of life”).tw.
12 5or6or7or8or9or10or11
13 exp suicidal behaviour/
14 exp automutilation/
15 exp violence/
16 (suicor self-harm or viole).tw.
17 13 or 14 or 15 or 16
18 3 and 4 and 12
19 3 and 4 and 17
20 3 and 4
PAGE 56 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jVOL. 17 NO. 1 2021
Three studies examined the relationship between TOOC and suicide. Of these, one
qualitative and one mixed-methods study used near-lethal self-harm as a proxy outcome for
suicide (Borrill et al., 2005;Marzano et al., 2011a,2011b) and an ecological study reported
on an indirect measure of TOOC (prison security level) and completed suicide (Huey and
McNulty, 2005).
Three cross-sectional studies and one qualitative study explored the relationship
between various measures of TIPA and mental health outcomes (Slotboom et al., 2011;
Albertie et al., 2017;Ali et al.,2016). One ecological study examined the relationship
between TIPA (as a binary outcome: high or low) with completed suicide (Leese et al.,
2006). One qualitative study and one mixed-methods study explored the relationship
Table 2 Inclusion and exclusion criteria
Study characteristic Inclusion criteria Exclusion criteria
Participants Sentenced or remand prisoners (or a
subset of either)
Any gender
Any duration of sentence
Any age
Study population were those in
a secure hospital setting or in
prison segregation [1]
Study population were those
with identified mental disorder/
meeting a minimum threshold
on the symptom scale
Outcomes Must include as an outcome variable
one of:
1. Mental health [2]
2. Suicide
3. DSH
4. Violence
Only physical-health-related
quality of life measured
Exposures Must include as an exposure variable
either:
1. Time out of cell
2. Time in purposeful activity
3. An indirect measure of either 1
or 2 e.g. security level of prison;
or a subjective measure such
as prisoners’ perceptions of
activities
4. A partial measure of 1 or 2 e.g.
time spent in peer association,
physical activity/exercise,
visits, phone calls, work and
education programmes
Exercise or other partial
measure related to TOOC/TIPA,
which was only recorded as an
in-cell activity
Other Prevalence studies, cross-sectional
studies, cohort studies, ecological
studies, qualitative studies
Any language
Any publication dates
Any country (high, middle and low
income)
Published and unpublished data.
Discussion papers
Policy papers without original
data
Commentaries
Book chapters
Editorials
Conference abstracts
VOL. 17 NO. 1 2021 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jPAGE 57
between TIPA and near-lethal self-harm (Borrill et al.,2005;Marzano et al., 2011a), as a
proxy outcome for suicide.
One cross-sectional study explored the association between a partial measure of TOOC
and DSH ideation (Slotboom et al.,2011). No studies were identified, which reported on
violence as an outcome.
Mental health
The impact of time out of cell
A lack of TOOC was found to lead to stress, anger and frustration amongst people in a
UK prison and acted as a push factor for increased drug misuse in prison (Nurse et al.,
2003). Cross-sectional studies explored the impact of various aspects of the prison
regime, which form a component of TOOC; a positive perception of the availability and
appropriateness of physical activities predicted life satisfaction amongst people
(n= 465) in a Malaysian prison (Ali et al., 2016). Receiving visits in prison predicted a
lower likelihood of severe depression, lower anxiety and improved health-related quality
of life amongst Mexican, British and Greek prisoners, respectively (Albertie et al., 2017;
Cooper and Berwick, 2001;Togas et al.,2014). Negative perceptions of the availability of
family contact amongst people in Dutch prisons (n= 251) predicted the presence of
depressive symptoms (Slotboom et al.,2011).
Exercise in prison consistently predicts better mental health outcomes amongst those
in prison and was associated with lower depression and stress scores amongst in the
USA (Buckaloo et al., 2009), less hopelessness amongst a stratified sample of those in
Australian prisons (Cashin et al., 2008) and higher mental health-related quality of life in
the pilot (n= 121) and multi-centre (n= 636) studies in Italian prisons (Mannocci et al.,
2015;Mannocci et al., 2017). Amongst a group of youth offenders in UK prisons,
Figure 1 Flow diagram for article retrieval and screening process
Records idenfied through database
searching, aer de-duplicaon (n = 7113)
ScreeningIncluded Eligibility Idenficaon
Addional records idenfied through other
sources (n = 36)
Records screened (n = 7149) Records excluded (n = 7082)
187 required resoluon by 2nd screener
Full-text arcles assessed for
eligibility (n = 67) Full-text arcles excluded (n = 55)
Studies included in qualitave
synthesis (n = 14)
PAGE 58 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jVOL. 17 NO. 1 2021
Table 3 Included studies with study characteristics, exposure and outcome variables and quality assessment
Author Title
Study characteristics
Relevant exposure
variable(s)/themes
Outcome of interest Quality assessment
Study type
Population and sampling/
identification strategy Mental health Suicide DSH
Modified Newcastle-Ottawa score (total 15)/
CASP score (total 10) and comments
Albertie
et al.
(2017),
Mexico
Connectivity, prison
environment and mental
health amongst first-time male
inmates in Mexico City
Quantitative
–cross-
sectional
593 “novice” men in 3
Mexican prisons (excluding
maximum security);
volunteers
TOOC partial measure:
total visits in past week;
conjugal visits (Y/N);
self-reported
TIPA partial measure:
current employment (Y/
N); current activity
participation (Y/N); self-
reported
Severe
depression on
BDI-IA;
substance abuse
(excluding
alcohol) on self-
report
11/15 Sample size not justified for power;
low response rate, no mention of
comparability of responders and non-
responders; exposure assessment is
self-report
Ali et al.
(2016),
Malaysia
The impact of social climate
on life satisfaction of drug-
abuse inmates in Malaysia
prison
Quantitative
–cross-
sectional
465 prisoners in one
Malaysian prison
incarcerated for drug-related
offences; volunteers
TOOC indirect measure:
satisfaction with
exercise activities and
day programmes; self-
reported
TIPA indirect measure:
satisfaction with work,
education, library and
creative activities; self-
reported
Life satisfaction
on adapted
SWLS
9/15 Sample size not justified;
comparability between respondents/
non-respondents unclear; exposure
assessment piloted but only largely
objective; outcome assessment not
validated in prison population; no
confounding factors controlled for
Borrill et al.
(2005),UK
Learning from “near misses”:
Interviews with Women who
Survived an Incident of
Severe Self-Harm in Prison
Qualitative –
focus group
15 women in 6 UK prisons
who had experienced “near
miss” suicide attempt;
approached via register
TOOC direct measure,
self-reported
TIPA direct measure,
self-reported
Near-
lethal
self-
harm
event
7/10 Relationship between researcher and
participants not adequately
considered; some ethical issues
considered but ethics committee
approval not sought; only one author
involved in developing thematic
analysis
Buckaloo
et al.
(2009), USA
Exercise and the low-security
inmate: Changes in
depression, stress and
anxiety
Quantitative
–cross-
sectional
60 male prisoners in low-
security Oklahoma prisons;
volunteers
TOOC partial measure:
exercise (Y/N)
Depressive
symptoms on
BDI-2; Stress and
frustration on LES
and DHS
5/15 Sample size not justified; unclear how
participants were approached;
comparability between respondents
and non-respondents unclear; some
outcome assessment measures not
validated in prison population; no
confounders controlled for; statistical
analysis incomplete (no confidence
intervals)
Cashin et al.
(2008),
Australia
The relationship between
exercise and hopelessness in
prison
Quantitative
–cross-
sectional
914 prisoners in New South
Wales prisons; randomised
stratified sample
TOOC partial measure:
weekly exercise in
minutes; self-reported
Hopelessness on
BHS
9/15 Exposure assessment is by self-
report; outcome assessment not
validated in prison population, no
confounding factors controlled for;
inappropriate statistical analysis
(Linear Regression with only one
independent variable)
(continued)
VOL. 17 NO. 1 2021 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jPAGE 59
Table 3
Author Title
Study characteristics
Relevant exposure
variable(s)/themes
Outcome of interest Quality assessment
Study type
Population and sampling/
identification strategy Mental health Suicide DSH
Modified Newcastle-Ottawa score (total 15)/
CASP score (total 10) and comments
Cooper and
Berwick
(2001),UK
Factors affecting the
psychological well-being of
three groups of suicide-prone
prisoners
Quantitative
–cross-
sectional
171 prisoners in 3 sub-
groups: 60 remand prisoners
in YOI, 59 sentenced
prisoners in YOI and 52 adult
prisoners in Cat B prison;
randomly sampled,
volunteers
TOOC partial measure:
enjoy sport/exercise in
prison (Y/N); number of
visits received per
month, excluding
remand prisoners
TIPA partial measure:
hobbies in cell (Y/N);
Job in prison (Y/N);
education/training/
reading in prison (Y/N),
excluding remand
prisoners
Depressive
symptoms on
GHQ-12 and BDI;
Anxiety
symptoms on
Trait anxiety sub-
scale of STAI
5/15 Sample size not justified; non-random
sampling; strategy; comparability
between respondents and non-
respondents unclear; incomplete
exposure data; exposure assessment
was unclear; outcome data were
incomplete/unclear; outcome
assessment measures largely
objective but not validated in prison
population; some important
confounders not controlled for;
incomplete statistical analysis
Huey and
McNulty
(2005), USA
Institutional conditions and
prison suicide: conditional
effects of deprivation and
overcrowding
Quantitative
–ecological
1,118 prisons in USA (prison
census data from 1990 and
1995)
TIPA indirect measure:
security level of prison
Prisons
with 1
or more
suicide
in 1995
14/15 Potential confounding individual-level
variables not controlled for as not
available from census data
Leese et al.
(2006),UK
An ecological study of factors
associated with rates of self-
inflicted death in prisons in
England and Wales
Quantitative
–ecological
All prisoners in UK prisons
(national database from
2000–2002
TIPA direct measure
(high/low)
11/15 Sample size not justified;
comparability between respondents/
non-respondents unclear, exposure
assessment largely objective,
individual-level confounding factors
not available to control for e.g.
personal psychiatric history
Mannocci
et al.
(2015), Italy
The relationship between
physical activity and quality of
life in prisoners: A pilot study
Quantitative
–cross-
sectional
121 male prisoners in two
Italian prisons; volunteers
TOOC partial measure:
physical activity on
international physical
activity questionnaire
and metabolic
equivalents score; self-
reported
Health-related
QOL on SF-12
11/15 Sample size not justified; sample
somewhat representative; limited
comparability between respondents/
non-respondents; exposure
assessment largely objective; some
important confounding factors not
controlled for
Mannocci
et al.
(2017), Italy
Health-related quality of life
and physical activity in prison:
a multicentre observational
study in Italy
Quantitative
–cross-
sectional
636 male prisoners in eight
Italian prisons; volunteers
TOOC partial measure:
physical activity on
international physical
activity questionnaire
and metabolic
equivalents score; self-
reported
Health-related
QOL on SF-12
10/15 Response rate unsatisfactory and
comparability unclear; incomplete
exposure data; exposure assessment
largely objective
Marzano
et al.
(2011a), UK
Near-lethal self-harm in
women prisoners:
contributing factors and
psychological processes
Mixed
methods
including
semi-
structured
interview
60 female inmates from 10
closed UK prisons with a
history of near-lethal self-
harm; volunteers
TOOC direct measure,
self-reported
TIPA direct measure,
self-reported
Near-
lethal
self-
harm
event
9/10 Relationship between researcher and
participants not fully explored e.g.
examination of potential bias and
influence in formulation of research
questions and in data collection
(continued)
PAGE 60 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jVOL. 17 NO. 1 2021
Table 3
Author Title
Study characteristics
Relevant exposure
variable(s)/themes
Outcome of interest Quality assessment
Study type
Population and sampling/
identification strategy Mental health Suicide DSH
Modified Newcastle-Ottawa score (total 15)/
CASP score (total 10) and comments
Nurse et al.
(2003),UK
Influence of environmental
factors on mental health
within prisons: focus group
study
Qualitative –
focus group
31 category B prisoners (M: F
18:13) and 21 prison staff in
focus groups, from one UK
prison; volunteers
TOOC direct measure,
self-reported
TIPA direct measure,
self-reported
Mental health of
prisoners; self-
report
7/10 Recruitment strategy (advertising
study, awaiting participants to self-
select) not most appropriate to aims of
research. Thematic analysis carried
out chiefly by one author only in
consultation with others
Slotboom
et al.
(2011), The
Netherlands
Psychological well-being of
incarcerated women in The
Netherlands: Importation or
deprivation?
Quantitative
–cross-
sectional
251 female prisoners from
four Dutch female-only
prisons; volunteers
TOOC partial measure:
perceived stress due to
prison environment; self-
reported
TIPA indirect measure:
prisoners’ perceptions
of available activities;
self-reported
Depression and
irritability on
adapted ISWI;
Post-traumatic
stress on IES
Self-
harm on
adapted
ISWI
11/15 Sample size not justified, non-random
sampling used, exposure assessment
not piloted, outcome assessment not
validated in prison population.
Nevertheless, all relevant confounding
factors controlled for
Togas et al.
(2014),
Greece
An assessment of health-
related quality of life in a male
prison population in Greece
Associations with health-
related characteristics and
characteristics of detention
Quantitative
–cross-
sectional
100 male prisoners from one
Greek prison; volunteers
TOOC partial measure:
availability of work (Y/N)
and visits (Y/N); self-
reported
Health-related
QOL on SF-36
and EQ-5D
11/15 Sample size not justified, non-random
sampling used, exposure assessment
not piloted, outcome assessment not
validated in prison population.
Nevertheless, all relevant confounding
factors controlled for
VOL. 17 NO. 1 2021 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jPAGE 61
enjoyment of sport/exercise predicted lower anxiety, while physical exercise within cell
did not (Cooper and Berwick, 2001).
Impact of time in purposeful activity
A lack of TIPA has also been found to lead to stress, anger and frustration amongst people in
prison and acts as a push factor for increased drug misuse in prison. Furthermore, amongst
focus groups, a lack of TOOC and TIPA was rated equally important by people in prison as a
determinant of mental health although staff rated TIPA as more important (Nurse et al., 2003).
Findings from cross-sectional studies generally suggest an association between less TIPA
and poorer mental health. A positive perception of the availability and appropriateness of
purposeful activity predicted greater life satisfaction (Ali et al.,2016) and lower depression
and irritability symptom scores (Slotboom et al.,2011) in Malaysia and The Netherlands and
lower-quality evidence from a British prison suggests that participation in activities such as
education and training predicted lower depression scores (Cooper and Berwick, 2001). In
contrast, participation in such activities was not significantly correlated with lower
depression or substance abuse in Mexican prisons (Albertie et al.,2017).
Cross-sectional studies explored the impact of various aspects of the prison regime, which
form a component of TIPA (partial measures) and reported varied outcomes for employment:
having a job was associated with lower odds of substance abuse and increased health-
related quality of life in Mexican and Greek prisons (Albertie et al.,2017;Togas et al.,2014).
A lower quality study in a British prison found no association (Cooper and Berwick, 2001).
Suicide
The impact of time out of cell
A lack of TOOC contributed, amongst other individual and environmental factors, to “near
miss” severe self-harm (where the person could have died) amongst imprisoned women
(Borrill et al., 2005;Marzano et al., 2011a). A large US ecological study based on prison
census data, using prisons as the base unit of analysis (n= 1,118), reported that varying
levels of security between prisons (an indirect measure of TOOC) predicted the odds of at
least one suicide occurring in a given year. A higher level of security predicted a higher
odds of suicide, though, in low-security settings, this association was minimised by a third
variable, overcrowding (Huey and McNulty, 2005).
The impact of time in purposeful activity
A large ecological study in the UK reported that low TIPA was the only risk factor to
independently predict associated a higher suicide rate; assault rates, overcrowding levels,
cost per prisoner, positive drug tests and availability of behaviour programmes for people in
prison were not associated with suicide (Leese et al., 2006). A lack of TIPA was found to be
a common primary factor contributing to “near miss” severe self-harm amongst women in
prison (Borrill et al., 2005;Marzano et al., 2011a).
Deliberate self-harm
Impact of time out of cell and time in purposeful activity
One cross-sectional study identified that contact with family members not being possible (a
partial measure of TOOC) predicted self-reported DSH ideation, amongst other prison-
related characteristics such as feeling repressed by, and not respected by, staff and
individual characteristics such as prior incarceration and prior treatment for mental health
problems (Slotboom et al., 2011). In contrast, peoples’ perceptions of available activities
(an indirect measure of TIPA) did not predict DSH ideation.
PAGE 62 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jVOL. 17 NO. 1 2021
Discussion
This review has found limited but consistent evidence of an association between lower
TOOC and poorer mental health of people in prison and of an association between lower
TOOC and increased risk of suicide. Limited evidence suggests that lower TOOC increases
the risk of DSH and that lower TIPA is associated with poorer mental health. The evidence
shows a consistent association between lower TIPA and increased risk of suicide. We did
not find evidence to suggest that TIPA affects the risk of DSH and found no evidence on the
impact of TOOC or TIPA on violence in prisons.
Primary studies and systematic reviews consistently conclude that the determinants of poor
mental health, suicide and DSH are multifactorial and include individual- and environment-
related factors (Rivlin et al.,2013;Marzano et al.,2016). The nature of prisoners’ social
networks and perceived social support have also been implicated in cases of near-fatal
self-harm amongst men and women in UK prisons (Rivlin et al.,2013;Marzano et al.,
2011b). However, there is a paucity of evidence on the effects of the prison environment
itself on adverse mental outcomes, except for studies of prison segregation. Meta-analyses
of segregation and mental health amongst people in prison have noted its negative impact
on anxiety and hostility/aggression, though effect sizes were small to moderate (Morgan
et al.,2016
). Our findings on the association between TIPA and suicide diverge from those
of a meta-analysis of risk factors for prison suicide, which concluded that employment in
prison (a factor related to TIPA) was not associated with suicide in prisons (Fazel et al.,
2008). This could be because TIPA, encompassing a broad range of activities including
employment, has a protective effect on suicide risk where single activities do not.
A lack of longitudinal studies has made it difficult to establish the relative contribution of the
prison environment and individual characteristics towards poorer mental health in prisons
(Fazel et al., 2016). Our findings on the association between lower TOOC/TIPA and poorer
mental health amongst imprisoned people are consistent with recommendations in the grey
literature. HMIP explored the nature of UK prison regimes in a 2007 review (Hm
Inspectorate Of Prisons, 2007), noting that TOOC was “crucial to health and mental well-
being of prisoners” and that sufficient TOOC was “particularly important for those poorly
equipped to distract themselves [...] including poor coping skills, those undergoing
detoxification and those unable to read and write”. The World Health Organisation (WHO),
in a joint normative statement with the International Committee of the Red Cross on mental
health in prisons, note that “enforced solitude or conversely, lack of privacy, lack of
meaningful activity” are all important environmental factors, which make prisons “bad for
mental health” (World Health Organisation and International Committee of Red Cross,
2005).
Findings on the impact of TOOC and TIPA on the risk of suicide are consistent with those of
the Harris Review, an independent report on self-inflicted deaths of young men in custody in
England and Wales, which found that a lack of TOOC and TIPA contributed to poorer
mental health, which, in turn, increased risk of suicide (Lord Harris Review, 2015). There
exists only limited indirect evidence on the impact of TOOC and TIPA on the risk of DSH
amongst people in prison. The Criminal Justice Alliance, in a submission to the Harris
review (see above), has argued that a lack of TOOC and TIPA is likely to increase prisoner
vulnerability and the risk of DSH (Criminal Justice Alliance, 2014).
Our review did not identify published evidence related to the relationship between TOOC/
TIPA and levels of violence in prisons. One meta-analysis has documented that
employment in prisons predicts lower levels of all disciplinary infractions, while high-security
levels and the proportion of high-security inmates were associated with higher levels of
infractions (Gonc¸alves et al., 2014).
Major UK bodies have outlined minimum levels of both TOOC and TIPA, highlighting their
importance for mental health. The UK’s Inspectorate for Prisons, HMIP, whose published
VOL. 17 NO. 1 2021 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jPAGE 63
“Expectations” for men’s and women’s prisons are underpinned by a detailed review of
the human rights literature (Hm Inspectorate of Prisons, 2017a), include the requirement
for people in prison to have at least 10 h out of the cell on weekdays and 1 h of
association in the evening every day (Hm Inspectorate of Prisons, 2014;2017b). HMIP’s
expectations have been expanded to incorporate into measurement of TOOC, those
activities that support rehabilitation such as creative activities and physical education
(Hm Inspectorate of Prisons, 2018). Recognising the importance of full and purposeful
prison regimes, the UK Government’s Prison Safety and Reform White Paper has
proposed to include TOOC as one of six indicators in a Prison League Table in future
work (Smith and Schweitzer, 2012).
Major international bodies have outlined their own standards on TOOC and TIPA. The
Committee for the Prevention of Torture 2001 standards hold that:
A satisfactory programme of activities (work, education, sport, etc.) is of crucial importance for
the mental well-being of prisoners [...] one should aim at ensuring that prisoners in remand
establishments are able to spend a reasonable part of the day (8 hours or more) outside their
cells, engaged in purposeful activity of a varied nature. Of course, regimes in establishments for
sentenced prisoners should be even more favourable. (Morgan and Evans, 2001)
The UN’s Standard Minimum Rules (the “Mandela rules”) and Council of Europe’s European
Prison Rules outline minimum levels of exercise (1 h per day) and standards on TOOC and
work programmes in prisons (UN General Assembly, 2016;Council of Europe, 2006).
This review is the first to collect and appraise the evidence in this area, which is viewed as
important by major international organisations working in health in prisons. As such it
provides important evidence to support the assertions and recommendations set out by
major national and international organisations and has the potential to influence positively
the well-being of the many millions of imprisoned people across the world. However, we
acknowledge that the non-systematic design of this review, necessary because of time
constraints, included a search strategy, which was not exhaustive. It is, therefore, possible
that relevant studies were missed.
The lack of longitudinal study designs such as prospective cohort studies, which are
challenging to run in prison settings, prevents conclusions being drawn about the causality
of the relationships established between TOOC or TIPA and mental health or risk of suicide
in prisons. Many studies were of low or very low-quality design, limiting the reliability of
findings.
Moreover, just one study explored a “dose-response” relationship between exposures and
outcomes (Cashin et al., 2008). It is not possible to draw conclusions about whether the
relationship is linear or whether there exists an “optimum” quantity of either TOOC or TIPA.
This relationship is likely to be dependent on the local prison climate and culture, for
example, TOOC in a poorly controlled institution with high violence rates would likely have a
different impact on mental health and suicide risk compared to the same in a safe and
secure one.
The studies included in this review largely examine indirect or partial measures of
TOOC or TIPA, rather than direct measures. Where these exposures have been
quantified, dichotomised measures have often been used. Furthermore, what activities
are considered purposeful can vary qualitatively between institutions. A large amount of
time spent in a menial job in prison might count as a higher “dose” of TIPA but have a
different impact on adverse mental outcomes compared to participation in regular
education.
There was significant heterogeneity in reported mental health outcomes, with only one
outcome, health-related quality of life, used in more than one study. The heterogeneity of
reported outcomes precluded meta-analysis of findings. In qualitative or mixed-methods
PAGE 64 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jVOL. 17 NO. 1 2021
studies interviewing survivors of near-fatal self-harm, suicide-related outcomes were
proxies. While the case for studying such proxies has been laid out by Hawton and
colleagues (Rivlin et al., 2012), it is nonetheless difficult to draw firm conclusions about the
direct relationship between either TOOC or TIPA and completed suicide amongst prisoners.
The findings of this review reveal key areas where evidence is lacking. These include the
association between TOOC and TIPA and violence in prisons, as well as the factors shaping
the relationship between the quantity and quality of TOOC and TIPA and mental health and
suicide, including potential mediators/moderators such as violence and individual prisoner
characteristics. Such questions, if addressed in further research, could, in turn, allow
preliminary work on an explanatory model of prison suicide (Rivlin et al.,2013)tobe
expanded to incorporate the impact of environmental factors.
There are many factors, which are known to shape well-being and risk of suicide, DSH and
violence in prisons (Marzano et al.,2016). These include individual factors such as prior
mental health problems and adverse life events, and other aspects of the prison environment
such as prisoners’ relationships with staff and peers. Our findings must be interpreted in this
context. Nevertheless, there is consistent evidence for a relationship between TOOC and
mental health, and between both TOOC and TIPA and suicide. This makes them notable
aspects of the prison regime for policymakers, commissioners and providers of prison
services seeking to support a rehabilitation culture in prisons. In England and Wales, for
example, the Ministry of Justice and Department of Health and Social Care, alongside their
partner agencies, are currently committed to developing and applying a “whole prison
approach” to health and mental health in prisons (UK Ministry of Justice, 2016;Smith and
Schweitzer, 2012). They have signed a National Partnership Agreement to foster services in
which the “regime, activities and staffing facilitate an environment that promotes good health
and well-being and reduces violence for all people in prison, including those with protected
characteristics” (Mann et al.,2018). This provides important foundations for the development
of prison regimes that effectively promote mental health and decrease the risk of DSH and
suicide. This review is particularly timely given the COVID-19 pandemic and the increased
restrictions on the movements of imprisoned people necessitated by infection control
measures. This has often resulted in reduced TOOC and TIPA. Policymakers and prison
authorities should consider carefully the health impact of prison regimes and the ways in
which these can be modified to minimise the adverse health effects of restrictive regimes.
Addressing such adverse effects across the prison population may also accrue additional
benefits such as reducing suicide deaths on release and reoffending rates.
Notes
1. Prison segregation is also commonly referred to as “supervised confinement” or “isolation” in the
literature. Those housed in segregation were not deemed representative of the general population.
The psychological effects of prison segregation have been examined elsewhere (28).
2. We adopted the definition of mental health used by the WHO: “mental health is defined as a state of
well-being in which every individual realises his or her own potential, can cope with the normal
stresses of life, can work productively and fruitfully and is able to make a contribution to her or his
community” (29).
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Corresponding author
Thomas Stephenson can be contacted at: thomas.stephenson@kcl.ac.uk
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