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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

Authors:
  • UK Health Security Agency

Abstract and Figures

Purpose The purpose of this study is to synthesise the available peer-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.
Content may be subject to copyright.
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 OMoore, 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 37 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 idenfied through database
searching, aer de-duplicaon (n = 7113)
ScreeningIncluded Eligibility Idenficaon
Addional records idenfied through other
sources (n = 36)
Records screened (n = 7149) Records excluded (n = 7082)
187 required resoluon by 2nd screener
Full-text arcles assessed for
eligibility (n = 67) Full-text arcles excluded (n = 55)
Studies included in qualitave
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
20002002
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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... Physical distancing is difficult in congregate settings, and people residing in carceral facilities may experience inadequate access to personal protective equipment (PPE), sanitation, and medical care (4)(5)(6)(7)(8). Furthermore, restrictive strategies for infection control in carceral settings such as facility lockdowns and suspension of visitation and programming may be especially harmful to well-being in an already isolated population with high rates of pre-existing mental illnesses and medical conditions (4,(9)(10)(11)(12)(13)(14). ...
... Relatedly, there has been little research on the perceptions of incarcerated individuals or staff toward COVID-19 policies, or on the unintended impacts of such policies, both of which can influence acceptability and effectiveness (45,46). For instance, medical isolation and quarantine may be damaging for mental health in a carceral setting and may stoke fears that disincentivize testing uptake (11,43,46,47). ...
... Accordingly, incarcerated members of our CAB cited widespread fears that a positive COVID-19 test would effectively lead to solitary confinement. Considered in conjunction with evidence on the health harms of restrictive housing (11)(12)(13), these findings strongly caution against over-reliance on isolation and quarantine in place of comprehensive implementation of other preventive measures such as masking, testing, and vaccination for residents and staff. When medical isolation is necessary, jail administrators and staff should undertake exhaustive efforts to distinguish its conditions from solitary confinement, which could critically reduce barriers to reporting of illness. ...
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Background Carceral facilities are high-risk settings for COVID-19 transmission. Little is known about the hidden burden of infection or practical barriers to infection control in these settings, especially in jails. There is also limited research on the mental health impacts of the pandemic among people living and working in carceral facilities. Methods Between July 8, 2020 and April 30, 2021, we performed SARS-CoV-2 rapid antibody testing and administered a questionnaire among residents and staff of four Northern California jails. We utilized multivariable logistic regression, adjusting for demographic and carceral characteristics, to analyze factors associated with prior infection, including perceived likelihood of prior infection and access to new masks. We additionally assessed the implementation of, perceptions toward, and impacts of COVID-19 policies in practice. We engaged stakeholder representatives, including incarcerated individuals, to guide study design, procedures, and results interpretation. Results We enrolled 788 jail residents and 380 jail staff. Nearly half of residents and two-thirds of staff who were antibody-positive had not previously tested positive for COVID-19. Among residents without a prior COVID-19 diagnosis, antibody positivity was significantly associated with perceived likelihood of prior infection (adjusted OR = 8.9; 95% CI, 3.6–22.0). Residents who had flu-like illness in jail cited inadequate responses to reported illness and deterrents to symptom reporting, including fears of medical isolation and perceptions of medical neglect. Residents also disclosed deficient access to face masks, which was associated with antibody positivity (adjusted OR = 13.8, 95% CI, 1.8–107.0). Worsened mental health was pervasive among residents, attributed not only to fear of COVID-19 and unsanitary jail conditions but also to intensified isolation and deprivation due to pandemic restrictions on in-person visitation, programs, and recreation time. Conclusion Carceral settings present significant challenges to maintaining infection control and human rights. Custody officials should work diligently to transform the conditions of medical isolation, which could mitigate deterrents to symptom reporting. Furthermore, they should minimize use of restrictive measures like lockdowns and suspension of visitation that exacerbate the mental health harms of incarceration. Instead, custody officials should ensure comprehensive implementation of other preventive strategies like masking, testing, and vaccination, in conjunction with multisector efforts to advance decarceration.
... Recent work reviewing the available evidence has suggested that prison regime characteristics, namely lower time out of cell and lower time in purposeful activity, may influence self-harm and suicide risk in prisons [8]. In addition, qualitative and cross-sectional research implicates a broader range of potential prison environmental factors for self-harm such as lower staffing levels, difficulties in relationships between prisoners and staff, high staff turnover, high prisoner turnover and overcrowding [9][10][11][12][13]. ...
... The current study was part of the wider Self-Harm And Prison Environment Pilot (SHAPE-P) mixed methods project which included a qualitative study using interviews of self-harming prisoners and focus groups of prison staff to explore the relationship between aspects of the prison environment and self-harm. Putative environmental risk factors for the current study were identified by scoping the findings of two recent literature reviews [4,8], and from preliminary findings of the parallel qualitative study which suggested that ...
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Introduction Self-harm is a major public health issue in the imprisoned population. Limited high-quality evidence exists for the potential impact of prison environmental factors such as solitary confinement. This exploratory pilot prospective cohort study in a large male remand prison in England sought to estimate effect sizes for a comprehensive range of prison environmental factors in relation to self-harming behaviours. Methods A random sample of all prisoners (N = 149) starting a period of imprisonment at the study prison took part in a clinical research interview, which assessed a range of known risk factors for self-harm in prison. Information concerning environmental factors, including staff numbers, cell placement and movements, and engagement in work and activities were collected from prison records. Incidents of self-harm behaviour in the 3 months after entering prison were measured using medical records and self-report at end of follow-up. Multivariable logistic regression models were calculated individually for each predictor. Results 55.7% of participants completed follow-up (83/149). Single cell placement (OR 4.31, 95% CI 1.06–18.24, p = 0.041) and more frequent changes of cellmate (OR 1.52, CI 1.14–2.17, p = 0.009) and cell (OR 1.83, 95% CI 1.28–2.86, p = 0.003) were associated with an increased risk of self-harming behaviour. Time spent in areas with a higher number of prisoners per member of prison staff was significantly associated with reduced self-harm behaviour in adjusted models (OR 0.89, CI 0.78–0.99, p = 0.039). Following sensitivity analyses, the associations between frequent cell changes and self-harm behaviour, and between single cell placement and self-harm ideation, remained statistically significant. Discussion This exploratory pilot study provides prospective longitudinal data regarding relationships between prison environmental factors and self-harm behaviour. Findings regarding single cell accommodation and frequent cell changes are consistent with the prior evidence base largely derived from case-control study data. The finding regarding frequent cellmate changes predicting self-harm is novel. Findings regarding prisoner-staff ratio and self-harm most likely reflect a reverse causal relationship. Replication in larger cohort studies is required to address the limitations of this pilot study.
... A livable prison environment should ensure safety, hygiene, and access to healthcare, while also promoting positive social interactions, meaningful activities, and opportunities for personal growth. Research has shown that factors such as overcrowding, access to green spaces, and leisure facilities significantly impact inmates' well-being and rehabilitation outcomes (Baggio et al., 2019;Moran et al., 2022;Skar et al., 2019;Stephenson et al., 2021;Walker et al., 2014). Changes in perceptions of liveability can also be reflected in measures of prison climate (Green et al., 2023). ...
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This study aimed to adapt the Measuring the Quality of Prison Life (MQPL) survey for the Serbian language and culture, considering cultural variations in the quality of prison life. Following established guidelines, the researchers employed two approaches to assess content validity: a panel of prison research experts and focus groups with prisoners. Content validity indexes were calculated at both the item and scale levels. Terminology, phrasing, and sentence structure were adjusted, including changes from passive to active voice, to better reflect the realities of Serbian prisons. The final version achieved conceptual, semantic, idiomatic, and experiential equivalence with the original MQPL. Initial findings indicate that the adapted survey effectively captures prison-specific issues relevant to the contemporary Serbian context. The cultural adaption process reveals both similarities and differences between the Serbian penal system and those of more developed nations, influencing prisoners’ perceptions of their quality of life. Further validation with larger samples is needed to evaluate its psychometric properties.
... 69 Furthermore, environmental conditions of confinement such as overcrowding, lack of sanitation and hygiene, and poor ventilation are conducive to the spread of infectious diseases, with COVID-19 being a topical example. 70 Wider social and organisational issues related to the prison regime, including isolation and limited opportunities for purposeful activity, 71 are known to negatively affect mental health. 72 By contrast, incarceration might also confer a temporary health benefit to some individuals by decreasing exposure to behavioural and social risk factors (eg, substance misuse and victimisation) and providing access to health care. ...
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Background: People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide. Methods: In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827. Findings: Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9–12·8) for major depression, 9·8% (6·8–13·2) for post-traumatic stress disorder, and 3·7% (3·2–4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0–26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5–46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0–20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects. Interpretation: People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health. Funding: Research Foundation–Flanders, Wellcome Trust, National Institutes of Health.
... In prisons, correlational data suggests that prisoner engagement in structured activity, and work in particular, is associated with reductions in problem behavior (Duwe & McNeeley, 2020;Huebner, 2003;Steiner & Wooldredge, 2009;Vuk & Doležal, 2020). Further, research suggests that purposeful activity can have much broader benefits, including positive impacts on prisoner mental health and reducing the risk of suicide and self-harm (Borrill et al., 2005;Cooper & Berwick, 2001;Leese et al., 2006;Marzano et al., 2011;Stephenson et al., 2021). Other studies have found positive associations between the availability of physical activity and quality of life (Ali et al., 2016;Mannocci et al., 2015). ...
Article
Criminologists have long claimed that states of deprivation engendered by restrictive prison environments account for much of the problematic behavior that occurs there. It is logical to assume that any efforts to provide greater access to meaningful and appropriate activities may therefore serve to reduce such behavior by altering motivating operations for misconduct and occasioning reinforcement for other types of behaviors. Given the higher rates of trauma exposure and other mental health issues in prison populations, considering trauma-informed practices in intervention design is prudent. The current study evaluated the effects of environmental enrichment via prisoner-selected, peer-led activities conducted during association times. We used direct observation to assess engagement, existing facility data collection to detect changes in problematic behavior, and prisoner and staff surveys to assess perceptions of the overall acceptability and effects of the intervention. Prisoners engaged with and led a range of activities, with the majority reporting positive effects on behavior, social relationships, and general well-being; staff responses were generally positive but more tempered. Institutional behavior records did not appear sensitive enough to detect treatment effects. We discuss the results in terms of integrating trauma-informed care into prison interventions and the need to develop more robust measures of behavior change.
... Mandatory social isolation meant that there were no educational and occupational workshops, no group leisure activities, and prison medical services and personnel were restricted to the extent that healthcare provision was inadequate. This may also have had an influence on the results obtained, since research has shown that spending time on purposeful activities outside the cell has a positive effect on mental health and reduces the risk of suicide 15 . ...
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Obtectives: A descriptive study was carried out to establish the levels of psychological distress amongst female inmates at a high-security prison in Lima in November 2020, after the first wave of COVID-19. Material and method: The Brief Symptoms Inventory-18 (BSI-18) was applied to a representative sample of 314 female inmates who agreed to participate in the study. Results: Results showed that 34.6% of the inmates could be considered as cases of psychological distress. Moreover, the depression subscale had the highest score, followed by the anxiety and the somatisation subscales. The most prevalent symptom was "feeling blue". Discussion: The prevalence of distress symptoms was analyzed, taking into account the effects of the first wave of COVID-19, the suspension of family visits, the restriction of treatment and leisure activities, etc. Gender aspects were also taken into consideration.
... 15 The second deprivation approach argues that the experience of deprivation in prison acts as a stressor, which may trigger inmate suicide. This approach underscores the contribution of environmental factors that are related to prison conditions, such as the level of occupancy of cells and overcrowding (e.g., Huey and McNulty, 2005), turnover of the prison population (e.g., van Ginneken et al., 2017), and bullying and assault (e.g., Blaauw et al., 2001); and to prison regimes and practices, such as high security levels provoking social isolation, time spent out vs. time spent in cell (Stephenson et al., 2021), forced idleness, the absence of purposeful activities-education, work, antibullying initiatives-, the limited access to rehabilitation programs (e.g., Leese et al., 2006), solitary confinement or accommodation in a single cell (e.g., Frottier et al., 2007), absence of family and social visits, and lack of social links with the outside world (e.g., Duthe et al., 2013). 16 When considering the correlation between suicides and prison conditions, the extant literature finds mixed results. ...
Article
Sleep is a key factor in health and well-being outcomes, but its issues and opportunities are underexplored in institutions. The prevalence of poor sleep quality and insomnia is higher in institutionalised populations than in the general population, stimulating adverse mental and physical health and well-being outcomes, including violence. With supporting evidence from an ethnographic study in an adult male prison, this policy-oriented commentary discusses the relationship between sleep and behaviour, the lived experience of sleeping in institutions, and the opportunities to improve behavioural outcomes. It concludes that sleep deprivation contributes to a downward spiral and proposes three areas of intervention to promote a more person-centred sleeping environment for health and safety.
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Prison has been described as the ultimate form of time-punishment - a place where time is no longer a commodity for individuals to spend, but is ordered by a system which symbolises its power through the control of segments of people's lives. As such, a prison sentence epitomises the experience of waiting. Yet anticipating release is not the only form of waiting within carceral life; waiting for healthcare in its various forms also shapes people's temporal experience. Drawing on interviews with 21 people who have lived in prison, this article describes how experiences of waiting for healthcare are mediated by expectation or hope, perceptions of the relationship between behaviour and healthcare access, and the consequences of waiting for care. Constraints on the autonomy of people in prison mean that waiting for healthcare differs in important ways from waiting for healthcare in the community, and can be perceived as an additional form of punishment. The experience of waiting for prison healthcare can affect physical and psychological well-being, and can in itself be understood as a pain of imprisonment.
Chapter
This chapter marks my turn to the final phase of this pastoral enquiry: Acting Compassionately. My attention turns away from the more contextual and theoretical aspects I have been considering towards specific pastoral practices and principles that embody deep humane regard in carceral space. Such penal pastoral attentiveness is exercised within the paradox of care and custody. The application of ‘polarity thinking’ helps penal practitioners move away from simple ‘or’ thinking (this or that) towards also employing an ’and’ mentality (both). Prisons are places of custody requiring stringent safety and security principles and practices. These often over dominate and hinder or stifle more human-centred ways of being with people in custody. In this chapter I describe ‘custodial compassion’ which honours bother the custodial factors of incarceration and the compassionate principles and practices that can be transformative in the lives of incarcerated life-wounded souls. Drawing on African notions of sawubona and ubuntu I argue that custodial compassion involves pastoral presence and attentiveness to the prevalence of trauma and adverse childhood experiences (ACEs).Keywords Sawubona Ubuntu ParadoxCustodial compassionTraumaAdverse Childhood Experiences (ACEs)
Data
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Some 11.5 million people are held in penal institutions throughout the world, according to the latest edition of the World Prison Population List (WPPL), researched and compiled by Helen Fair and Roy Walmsley and published on 1 December 2021 by the Institute for Crime & Justice Policy Research (ICPR), at Birkbeck, University of London.
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Background: Inmates have a poorer health status than the general population. The physical activity is well know that improve the wellness of the people. This multicentric cross-sectional study aimed to assess the relationship between Quality of Life (QoL) and physical activity levels among Italian prisoners. Methods: Inmates from eight prisons compiled a questionnaire. The Metabolic Equivalent of Task (MET) was used to measure inmates' weekly physical activity levels (MATwk). Their QoL was measured using two components of Short Form with 12 items (SF12): MCS (mental score) and PCS (physical score). Results: A total of 636 questionnaires were compiled. High level of MET was significantly (P <0.05) associated with both PCS (OR = 1.02) and MCS (OR = 1.03). The correlations between PCS, MCS vs. METwk scores were respectively significant: r = 0.17 and r = 0.10, P < 0.05. The number of years of detention was associated to higher MET (OR = 1.04 P < 0.05). The presence of Physical Exercise Areas (PEAs) within Jails did not improve the QoL level. Conclusions: Jails may not seem like the ideal place to fight sedentary behavior, but, in any case, health promotion can occur within its walls. The heterogeneity of Italian jails, and particularly relative PEAs therein (areas had different characteristics between jails), suggests that such spaces should be regulated or well defined. Furthermore, the implement of training schedules could be done in a standardized way. Despite this heterogeneity both the physical and mental components of inmates' quality of life were associated to a high level of physical activity.
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Context: The mental health benefits of physical activity are well established. However, less is known about whether the relationship between physical activity and mental health is consistent across different life domains. It is important to understand how context may influence the relationship between physical activity and mental health so that interventions and policy guidelines can be tailored to maximize positive effects. Evidence acquisition: In 2015, systematic searches of four databases identified 13,435 records, of which 98 studies met the inclusion criteria. Evidence synthesis: Included studies were published between 1988 and 2015 and had a combined sample size of 648,726. Of the 98 included studies, 93 examined leisure-time physical activity, 14 examined work-related physical activity, 15 examined transport physical activity, 16 examined household physical activity, three examined school sport, and three examined physical education. Multi-level meta-analyses showed that leisure-time physical activity (r =0.13) and transport physical activity (r =0.13) both had a positive association with mental health. Leisure-time physical activity (r = -0.11) and school sport (r = -0.09) both had an inverse association with mental ill-health. However, physical activity was not consistently associated with lower mental ill-health across domains, as work-related physical activity was positively associated with mental ill-health (r =0.09). Household physical activity and participation in physical education had no relationship with mental health or mental ill-health. Conclusions: The domain in which physical activity occurs influences the relationship between physical activity and mental health and should, therefore, be considered when developing interventions, treatment programs, and policy guidelines.
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There is a widely held belief that the use of administrative segregation (AS) produces debilitating psychological effects; however, there are also those who assert that AS is an effective strategy for reducing prison antisocial behavior and prison violence. Given these conflicting opinions it is not surprising that the use of segregation in corrections has become a hotly debated and litigated issue. To clarify the competing perspectives, two independent meta-analytic reviews, in an unplanned systematic replication, were undertaken to determine what effect AS has on inmate’s physical and mental health functioning, as well as behavioral outcomes (e.g., recidivism). Collectively, the findings from these two meta-analytic reviews indicated that the adverse effects resulting from AS on overlapping outcomes ranged from d = 0.06 – 0.55 (i.e., small to moderate) for the time periods observed by the included studies. Moderator analyses from both investigations further reveal considerably smaller effect sizes among studies with stronger research designs compared to those with weaker designs. These results do not support the popular contention that AS is responsible for producing lasting emotional damage, nor do they indicate that AS is an effective suppressor of unwanted antisocial or criminal behavior. Rather, these findings tentatively suggest that AS may not produce any more of an iatrogenic effect than routine incarceration. Coding for these meta-analyses also revealed serious methodological gaps in the current literature. Recommendations for future research that will provide a much better understanding of the effects of AS are offered.
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More than 10 million people are imprisoned worldwide, and the prevalence of all investigated mental disorders is higher in prisoners than in the general population. Although the extent to which prison increases the incidence of mental disorders is uncertain, considerable evidence suggests low rates of identification and treatment of psychiatric disorders. Prisoners are also at increased risk of all-cause mortality, suicide, self-harm, violence, and victimisation, and research has outlined some modifiable risk factors. Few high quality treatment trials have been done on psychiatric disorders in prisoners. Despite this lack of evidence, trial data have shown that opiate substitution treatments reduce substance misuse relapse and possibly reoffending. The mental health needs of women and older adults in prison are distinct, and national policies should be developed to meet these. In this Review, we present clinical, research, and policy recommendations to improve mental health care in prisons. National attempts to meet these recommendations should be annually surveyed.
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Background: Worldwide, prisoners are at high risk of suicide. Research on near-lethal suicide attempts can provide important insights into risk and protective factors, and inform suicide prevention initiatives in prison. Aims: To synthesize findings of research on near-lethal attempts in prisons, and consider their implications for suicide prevention policies and practice, in the context of other research in custody and other settings. Method: We searched two bibliographic indexes for studies in any language on near-lethal and severe self-harm in prisoners, supplemented by targeted searches over the period 2000-2014. We extracted information on risk factors descriptively. Data were not meta-analyzed owing to heterogeneity of samples and methods. Results: We identified eight studies reporting associations between prisoner near-lethal attempts and specific factors. The latter included historical, prison-related, and clinical factors, including psychiatric morbidity and comorbidity, trauma, social isolation, and bullying. These factors were also identified as important in prisoners' own accounts of what may have contributed to their attempts (presented in four studies). Conclusion: Factors associated with prisoners' severe suicide attempts include a range of potentially modifiable clinical, psychosocial, and environmental factors. We make recommendations to address these factors in order to improve detection, management, and prevention of suicide risk in prisoners.
Book
Prisoners are a uniquely vulnerable social group and protecting them from oppressive states has given rise to a complex web of standards generated by a variety of international mechanisms and processes. Protecting Prisoners examines the most detailed and far-reaching set of custodial standards yet devised--those of the European Committee for the Prevention of Torture (CPT)---and relates them to those of other European and United Nations bodies. The book also examines the reaction of selected Council of Europe member states---Belgium, France, Hungary, the Netherlands, Turkey, and the United Kingdom---to the application of those standards in CPT reports. This dual perspective provides a critical insight into the degree to which the development of international human rights law is having a practical impact on the situation of prisoners.
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Background: people in prison often experience poor health. Those aged 50 and over are the fastest growing age-group in prison and present particular challenges to criminal justice systems around the world. Non-communicable diseases (NCDs) account for two-thirds of deaths globally and no estimate of the prevalence of NCDs in this vulnerable population exists. Methods: we searched PubMed, Medline, CINAHL, EMBASE and Global Health databases to identify original research papers that met our pre-defined inclusion criteria. No date or language restrictions were applied. Two authors undertook full-text screening as well as quality assessment and data extraction for all included studies. A random effects model was used to calculate pooled prevalence of any disease that was reported in two or more articles. Results: the initial search identified 2,712 articles. 119 underwent full-text screening with 26 meeting the inclusion criteria. This provided prevalence data on 28 NCDs in 93,862 individuals from prisons in 11 countries. Pooled prevalence for the most significant NCDs was a follows; cancer 8% (95% CI 6-10%), cardiovascular disease 38% (95% CI 33-42%), hypertension 39% (95% CI 32-47%), diabetes 14% (95% CI 12-16%), COPD prevalence estimates ranged from 4% to 18%. Heterogeneity across studies was high. Conclusions: those in prison over 50 years of age experience a high burden of NCDs which is often higher than younger prison and age-matched community peers. This health inequality is influenced by lifestyle, environmental and societal factors. Prison services should be adapted to serve the needs of this growing population.
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Objectives Job stressors are known determinants of common mental disorders. Over the past 10 years, there has been evidence that job stressors may also be risk factors for suicidality. The current paper sought to examine this topic through the first comprehensive systematic review and meta-analysis of the literature to date. Methods We used a three-tier search strategy of seven electronic databases. Studies were included if they reported on a job stressor or job-related stress as an exposure and suicide ideation, self-harm, suicide attempt or suicide as an outcome. Two researchers independently screened articles. All extracted effect estimates were converted to log-transformed ORs. Results There were 22 studies that were included in meta-analysis. Overall, exposure to job stressors was associated with elevated risk of suicide ideation and behaviours. The OR for suicide ideation (14 studies) ranged from 1.29 (95% CI 1.15 to 1.44) for poor supervisor and colleague support to 1.96 (95% CI 1.33 to 2.90) for job insecurity. For suicide (six studies), exposure to lower supervisor and collegial support produced an OR of 1.19 (95% CI 1.00 to 1.42), while low job control resulted in an OR of 1.30 (95% CI 1.10 to 1.53). There were only two studies that examined suicide attempt, both of which suggested an adverse effect of exposure to job stressors. Conclusions This study provides some evidence that job stressors may be related to suicidal outcomes. However, as most studies in the area were cross-sectional and obsThe current gold standard for asseservational in design, there is a need for longitudinal research to assess the robustness of observed associations.