Prisons: a global imperative to promote good health

With an estimated 11 million people globally, prisons are a key setting in which to promote opportunities to ensure good health and wellbeing, and address health inequalities where mental ill health and substance misuse and comorbidity are highly prevalent and affecting around half of the global prison population (WHO 2023). Prison is, however, a unique environment that has particular challenges when it comes to promoting health. It is an environment where levels of violence, enforced solitude, a lack of privacy, isolation from social networks, substance use, a lack of meaningful activity and overcrowding greatly impact the mental health and wellbeing of both the people with which this is home and those for whom it is a workplace. The wellbeing of staff in this context cannot be ignored as they experience high levels of stress, prisoner violence, and trauma linked to their roles in supporting people in crisis many of whom self-harm.

People in prison tend to come from marginalised and socio-economically disadvantaged sections of society, are mostly male (with a small percentage of women and girls) and exhibit a disproportionately high incidence of ill health often linked to social exclusion and multiple complex health and social care needs when compared to the general population. Compared to the wider community, people in prison tend to have a higher prevalence of infections such as HIV, hepatitis B, hepatitis C, other sexually transmitted infections, and tuberculosis; with Non-Communicable Diseases (NCDs) and their risk factors also of growing concern and linked to an increasing older population in this setting. Women in prison present different and distinct challenges. As highlighted by the Prison Reform Trust (n.d.) and Penal Reform International (n.d.) they are more often victims of serious crimes than those they have been accused of and linked with histories of abuse, have dependent children – an estimated 17,000 children are affected by maternal imprisonment every year – and are held in prisons that have been designed by men for men that in addition to the architecture, includes security procedures and health care provision. Women’s prisons in the UK are geographically far from their hometowns and families. Globally, incarcerated women experience additional stigma relating to cultural expectations and gendered roles.

It is widely recognised that health is determined by economic and social conditions, which are shaped and influenced by socioeconomic and political factors, including education, employment, occupation and income (WHO 2023). Yet many people in prison have had little or no prior experience of work and are assessed on arrival as having poor educational status. Being engaged in education in prison, learning new skills or employing existing skills and expertise, by working in prison increases the chances of reducing reoffending. In conjunction with having a job, the single most important factor for release is having stable accommodation. Yet significantly high numbers of people are being released homeless or with short-term temporary and unstable accommodation.

However, while notwithstanding the challenges, prisons can provide opportunities: having access to education, primary health and allied care, and drug and alcohol professionals from provider organisations who provide assessment, and tailored interventions with aligned support; and prison-wide support to identify the most vulnerable people ensuring that through specific tailored interventions including key work, engagement with potential employers, housing support and recovery workers, their experience of prison can be improved as they may become more engaged in regime activities that positively impact on the likelihood of successful resettlement.

Beyond this, good prison health concerns the whole of society as people in prison come from and generally return to the wider community. It therefore makes good sense to intervene in a place where health needs are greatest. By doing so this will also achieve the United Nations Sustainable Development Goals (WHO 2019), meet the United Nations Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules) in terms of access to standards of health and health services that are equitable to those in the wider community (UNDOC, 2015), contribute to the United Nations Rules for the Treatment of Women Prisoners – the ‘Bangkok Rules’ - adopted by the UN General Assembly (2010) to meet the specific needs of women in prison and as part of the Helsinki Conclusions (2019) recognise health care delivered to people in prison as part of a pathway to and from community, health and recovery services. Thus, a prime opportunity to address the disproportionate health and social circumstances of people in prison, offering a way of tackling health inequalities through promoting health, reducing reoffending and facilitating community integration is by intervening in prison settings.

Disclosure statement

No potential conflict of interest was reported by the author(s).