ARTICLE IN PRESS

International Journal of Nursing Studies 41 (2004) 119–128

Review
Prison health care: a review of the literature
Roger Watsona,*, Anne Stimpsona, Tony Hostickb
a
School of Nursing, Social Work and Applied Health Studies, University of Hull, Hull HU6 7RX, England, UK
b
Hull & East Riding Community Health Trust, West House, Westwood Hospital, Beverley HU17 8BU, UK
Received 15 February 2003; received in revised form 13 June 2003; accepted 23 June 2003

Abstract

The prison population is increasing and the health problems of prisoners are considerable. Prison is designed with
punishment, correction and rehabilitation to the community in mind and these goals may conflict with the aims of
health care. A literature review showed that the main issues in prison health care are mental health, substance abuse and
communicable diseases. Women prisoners and older prisoners have needs which are distinct from other prisoners.
Health promotion and the health of the community outside prisons are desirable aims of prison health care. The
delivery of effective health care to prisoners is dependent upon partnership between health and prison services and
telemedicine is one possible mode of delivery.
r 2003 Elsevier Ltd. All rights reserved.

Keywords: Prisons; Prisoners; Health; Nursing

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
1.1. The purpose of prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
1.2. Nursing in prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
1.3. Delivery of prison health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
1.4. The present study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
4. Health problems in prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
4.1. Mental health of prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
4.2. Communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
4.3. Substance abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
5. Groups of prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.1. Women prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.2. Older prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

*Corresponding author. Tel.: +44-1482-464699; fax: +44-1482-464587.

E-mail address: [email protected] (R. Watson).

0020-7489/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0020-7489(03)00128-7
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120 R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128

6. Underlying themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

6.1. Health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.2. The health of the community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
7. Delivery of prison health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
7.1. Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
7.2. Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

1. Introduction working in, for example, the UK National Health

Service (NHS) (HMIP, 1996). The prison health service
Health care in prisons is an area of increasing in the UK has tried to resist this negative image but it
international concern with literature from Europe, has been an almost inevitable outcome of their isolation.
North American, Australasia and other regions of the It has been considered, in the UK, since the middle of
world testifying to this (World Health Organisation the last decade that it was time to change the separation
(WHO), 1999). The present study is based in the United of prison health care from the NHS and to move
Kingdom (UK) but will be set in an international towards integration without duplication of services
context. (HMIP, 1996). A recent working group in the UK
The prison population of the world is rising and the proposed several action points to be achieved in the
prison population in the UK, while it has reached a integration of doctors working with prisoners including
plateau, has risen rapidly in recent years (Home Office, a rationalised pay structure, continuing professional
2001). The spectrum of health problems which prisoners development, career structure including appropriate
may bring to prison is wide and in many cases qualifications and the provision of appropriate informa-
prevalence is greater than in the general population. tion technology (DoH/HMPS/National Assembly for
For example, 90% of prisoners have mental health Wales (NAW), 2001a).
problems with many also having a substance abuse
problem, 80% of prisoners smoke; hepatitis B and C 1.2. Nursing in prison
rates of infection are high (men 8%; women 12%) along
with several other problems such as being HIV positive Except in cases where individuals may have to be
and self-harming (Her Majesty’s Prison Service/Depart- restrained under relevant mental health legislation,
ment of Health (HMPS/DoH), 2001). custodial care is not part of the nursing role. There is
conflict within this role in the UK as many health care
1.1. The purpose of prison workers in prisons, who carry out nursing roles, are
custodial officers who have undergone short training
Prison has several purposes. Amongst these are courses in prison health but who are not registered with
separation from society and confinement for the safety the Nursing and Midwifery Council. However, it has
of society, punishment for crime, correction and been described as a specialist role (McCausland and
rehabilitation to the community. Prisons are not, Parrish, 2002) and as multifaceted (Norman and
primarily, concerned with the health of the prison Parrish, 2002). However, nurses working in prisons are
population and, indeed, ‘The need for security and working in custodial environments and this has led to
discipline can cut across the perception of individuals some nurses being confused about the boundaries of
(prisoners) as patients’ (Her Majesty’s Inspector of their role (Royal College of Nursing (RCN), 2001) and
Prisons (HMIP), 1996, p. 1). The prison service in the this is especially the case if they are employed by the
UK has traditionally established its own health care prison service rather than by the health service. It has
facilities for prisoners who become patients, with its own been reported that there is a conflict between the
doctors and nurses employed by the prison service ‘divergent aims’ (Reeder, 1991, p. 41) of correctional
(HMIP, 1996). This has served to reinforce the image of officers and nurses due to different ‘underlying assump-
prisoners who are patients as being separate, even in tions’ of providing health care on the one hand and
terms of health care, from the general population and it correction on the other. In the UK this issue has
has also led to isolation of the professionals: doctors and received the attention of the Royal College of Nursing
nurses, working in the prison service. Consequently, (Dale and Woods, 2002; RCN, 2001) and the UK
they have been accorded a lower status by colleagues government (HMPS/NAW/National Health Service
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R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128 121

Executive (NHSE), 2000). Reports produced by both of reports (HMPS/NHSE, 1999) identified broad models
the above bodies have made recommendations for for the delivery of prison health care currently operating
improved training and education for nurses working in in the UK and these were:
prisons and a specific qualification to be obtained by
nurses working with prisoners. The aim is to provide
* directly employed full time doctors,
better health care in prison for prisoners.
* care provided by NHS GPs,
* primary care contracted out to local GPs,
1.3. Delivery of prison health care
* entire external provision of prison health care,
* clustering of prisons to provide primary care.
Health care is delivered to prisoners by different
models, depending upon location and type of institution From this range of models in the UK the intention is
and some of these models, in the developed world, that the prison services start to pay for primary health
including the UK, involve nurses (HMPS/NAW/NHSE, care from the NHS leaving the secondary care of
2000). Models range from health care delivered by prisoners the same as for the remaining population.
prison service employees to those delivered by local and
NHSs—both primary and secondary care. Nurses are
ideally placed to provide health care to prisoners but the 2. Method
prison environment produces dilemmas and problems
for both prisoners and nurses (HMIP, 1996). Further- The method of the present study was a literature
more, the aims and objectives of prison health care are review the purpose of which was to identify models of
not always clear. However, there are European direc- prison health care from which lessons could be learned
tives relevant to the UK context which point out that for the UK prisons service and the NHS. The systematic
prisoners should have the same access to health care as review was conducted using electronic databases rele-
the population outside prison, that the health care given vant to the areas specified (models of prison health care)
to prisoners should be equivalent to that obtained which were accessed through the Internet gateway
outside prison and that such things as patient consent ATHENS. Papers from management, health, socio-
and confidentiality cannot be overruled in prisons logical and psychological sources were included. Re-
(Council of Europe, 1989). This provides a good starting ports and policy documents were obtained from
point for health care in prisons but there is more to governmental and non-governmental organisations.
prison health care. In addition to solving the immediate Grey literature was accessed through the Commission
health problems of prisoners and the prison population for Health Improvement, the NHS Centre for Reviews
generally, prison health care also provides opportunities and Dissemination and Dissertation Abstracts. The
which may benefit the wider community which prisons search was limited to 1991–2002, including international
serve through returning prisoners to the community literature published in English. The reference lists of
with a more positive attitude to personal health and retrieved papers were checked for other key papers in
better health than they entered prison with. Nurses order to ensure a comprehensive search. Abstracts were
clearly have a crucial role to play in the health care of printed for all relevant articles; the team then reviewed
prisoners but they will only be able to fulfil that role if these and abstracts deemed not relevant were disre-
they understand the special issues relating to the health garded. Full papers were obtained for the remainder.
of prisoners. These issues are considered in this paper. The time window for the retrieval and synthesis of
material from the review was 12 weeks.
1.4. The present study The following databases were searched: Medline,
CINAHL, Cochrane Library, BIDS, Psychlit, Sociological
This paper results directly from a systematic review of Abstracts, OMNI; and or reports and policy documents:
the literature on prison health care which was commis- UK Department of Health, HMPS, World Heath
sioned by a UK regional NHSE in order to inform them Organisation, The Council of Europe, The National
about the establishment of new systems of prison health Institution for Correction/US Federal Bureau of Prisons.
care. The research tender was framed around the fact The search strategy included all aspects of prison
that ‘concerns had been expressed for some years about health: health promotion, mental health, communicable
the health of prisoners and the capacity of the current diseases and palliative care and this was accomplished by
prison health care system’ (NHSE Northern and using broad search terms and the results being checked
Yorkshire, 2001, p. 1). The driving force for reforming to eliminate the possibility of relevant items being
prison health care in the UK is to be found in a series of missed. A free-text strategy was utilised in databases
government reports jointly published by the UK without a well-constructed thesaurus, the free-text terms
Department of Health and the UK prison service (Her being: Prison or prisons or prisoner; health or health
Majesty’s Prison Service—HMPS). The earliest of these care; model/s and any combination of the above.
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122 R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128

Medical subject headings (MeSH) terms were used There was literature specifically related to groups of
when searching Medline and CINAHL. For the other prisoners:
databases the Boolean operators ‘and’ and ‘or’ were * Older prisoners
utilised. The terms were used as follows: ep.prisoner; * Women prisoners
health or health care; model or models. ‘Prisoner’ is an
MeSH term in the Medline thesaurus but ‘health’ is not There were a number of themes underlying the above,
thus the use of the Boolean operator ‘or’. ‘Models’ is an with relevance to more than one area and these included:
MeSH term when attached to another term such as
nursing model or psychological model but not health * Health promotion
care model and the Boollean operator ‘or’ was used. * The health of the community

There were a few papers related to delivery of health

3. Results care in prisons:
* Partnership
The total number of hits was 906 but the majority was * Telemedicine
not relevant to the study or were duplicates. One
hundred and thirty-four abstracts were printed of which
24 were regarded as not being relevant. One hundred The results are presented under the themes identified
and ten items were requested for retrieval but nine were above on the basis of the main topic of the papers. Most
unobtainable. A further nine were rejected resulting in papers fell under the theme of mental health followed by
90 papers and 21 reports or policy documents for review. substance abuse and then communicable diseases but it
Of the reports, 13 were UK, five were North American is recognised that these three theme are inextricably
and three were European (other than UK). linked: mental health problems may lead to substance
Items were retained for review on the basis of abuse and may arise from substance abuse (Munetz
relevance to the study and on the basis of their standing et al., 2001). Communicable diseases may result from
as individual items with letters, editorials and unrefer- substance abuse, especially from intravenous methods of
enced opinion pieces being rejected. Otherwise, a self-administration but mental health problems and
hierarchy of evidence was not applied to the retrieved substance abuse may also lead to high-risk sexual
items because there were no randomised trials and few behaviour with its attendant risk of sexually transmitted
rigorous surveys: most of the items were either scholarly diseases. While the links are obvious these three areas
papers, non-systematic literature reviews or descriptive will initially be considered separately below.
studies and the application of a strict hierarchy of
evidence such as that applied to clinical intervention 4.1. Mental health of prisoners
studies would have left very little material to review.
The entire retrieved literature is not reported here and Forty-seven paper were retrieved which had mental
only key papers will be used to exemplify the themes health as their main topic but, as described above, many
which were identified from the review. A complete of these papers also included material on substance
reference list and annotated bibliography may be abuse, communicable diseases and sexually transmitted
obtained upon request from the corresponding author. diseases. The material was mostly concerned with
screening for mental health problems in general and
not with specific diagnoses.
4. Health problems in prison Mental health problems are more prevalent among
the prison population than the general population and
Prisoners bring a range of health problems to prison this has been established in several studies from different
with them and are also at risk from a range of health countries such as New Zealand (Brinded et al., 2001)
problems while in prison. The nature of the health and North America (Corrado et al., 2000; Diamond
problems of prisoners indicates that there is a link et al., 2001). Europe is also facing an increase in the
between the health problems which prisoners bring with population of prisoners with mental health problems
them to prison and those from which they are at risk. (Blaauw et al., 2000; Joukamaa, 1995; Rasmussen et al.,
The range of health issues for prisoners can be grouped 1999) and a very recent review involving 23,000 prison-
under: ers from 12 countries confirms the view that the mental
health of prisoners is an international problem of
increasing proportions (Fazel and Danesh, 2002).
* Mental health Whether or not being in prison exacerbates the mental
* Substance abuse health problems of prisoners is not known (Gullone
* Communicable diseases et al., 2000) but it is clear that having mental health
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R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128 123

problems is a causative factor in imprisonment (Fujioka, these would include specific training for staff (officers,
2001; Lamberti et al., 2001) and also that prisoners with doctors and nurses) and early assessment of prisoners
mental health problems may pose a greater risk to for mental health problems.
correctional staff and other prisoners than prisoners
without mental health problems (Hilton and Simmons, 4.2. Communicable diseases
2001; Hoptman et al., 1999). However, one study from
Canada found that there was no evidence that people Twenty-one papers were retrieved in which the main
with mental health problems were being ‘warehoused’, topic was communicable diseases amongst prisoners.
in other words kept in prison purely as a result of their The prevalence of sexually transmitted diseases, includ-
mental health problem (Corrado et al., 2000). A UK ing HIV/AIDS, in prisoners is high (20 times greater
study found that severity of mental health problem was than the general population according to one study by
not related to length of custodial sentence nor did time Potts (2000) and they are at great risk in this respect
spent in hospital reflect the gravity of the offence (Huws from a combination of substance abuse and mental
et al., 1997). Clearly, there is a link between mental health problems (WHO, 1999) which may make them
health and suicide, with prisoners who have mental vulnerable to high-risk sexual activity. The problem of
health problems at higher risk; prison is also a high-risk HIV/AIDS in prisons is truly international as demon-
environment for suicide and this has been recognised in strated by studies from Africa (Simooya and Sanjobo,
the World Health Organisation resource document for 2001), Australia (Butler et al., 2001), Canada (Beaupr!e,
prison officers on suicide (WHO, 2000). 1994; Potts, 2000), Ireland (Allwright et al., 2001),
With the high prevalence of mental health problems in Pakistan (Akhtar et al., 2001), Spain (Est!ebanez et al.,
prisons, the results of a recent UK study are a cause for 2002), UK (Bellis et al., 1997; Edwards et al., 2001) and
concern: Reed and Lyne (2000) reported that no prison USA (Okwumabua et al., 2000). Other sexually trans-
doctors in their study had specialist training and less mitted diseases such as syphilis also pose a problem for
than a quarter of nurses had mental health training. prisoners (Wolfe et al., 2001; Okwumabua et al., 2000)
They concluded that the mental health service offered to and hepatitis is also present (Allwright et al., 2000).
prisoners fell below the standard of the NHS. Also, Another communicable disease in prisons with an
given the high incidence of mental health problems international dimension is tuberculosis (TB) and this
among prisoners coming into prison it is a further cause has prompted the attention of the WHO and the
for concern that only a few of these are identified at International Committee of the Red Cross (WHO/
reception into the prison system. ICRC, 2001). Studies from around the world point to
The key to addressing mental health problems in how prisons are conducive to the spread of TB (Reyes
prisoners, therefore, is assessment. In order to avoid and Coninx, 1997), how mortality from TB is high and
duplication of effort, in other words if put on remand or drug resistance is prevalent (Coninx et al., 1999) and
when finally sent to jail, prisoners should be assessed as how TB in prisons poses a threat to the general
soon as they enter the prison system (Birmingham et al., population (Greifinger et al., 1993). There are also
1996). There is also evidence to support the use of reports of how outbreaks of TB have been contained
standardised assessment procedures incorporating vali- (Mohle-Boetani et al., 2002).
dated assessment instruments (Metzner et al., 1994). Two aspects of preventing communicable diseases
However, there was no evidence of the development of were apparent: the health education/health promotion
specific instruments for use in prisons and there may be approach, which will be considered below as a general
issues related to how instruments developed on popula- strategy for prison health care, and the provision of
tion norms are applicable to the prison population. condoms and clean needles whereby safe sex and safe
Modes of delivery of mental health care are not widely drug use—in terms of HIV/AIDS infection—could be
addressed in the literature but telemedicine, considered practised (Potts, 2000; Simooya and Sanjobo, 2000).
separately below, is one such mode. Health promotion, However, the attitudes of correctional officers is key to
with regard to mental health and related aspects such as the success of such strategies as many may have
substance abuse is also relevant and will likewise be understandable misgivings about providing such things
considered below. Two models of partnership in the as condoms and clean needles (Godin et al., 2001).
delivery of mental health services to prisoners involving
a university medical school, the state and other local 4.3. Substance abuse
services has been reported from North America (Apple-
baum et al., 2002; Lamberti et al., 2001). The applic- The use of illegal drugs was recognised as a major
ability of these models outside North America may, category for health promotion amongst prisoners by the
however, be low. Based on the literature reviewed above, WHO (1999) and the National Institute of Corrections
it is possible to point to what may be the essential (National Institute of Corrections, 1991) in the USA
features of any model of prison mental health care and addressed the issue of substance abusing offenders as
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124 R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128

long ago as 1991. Substance abuse is common in prisons designed for men may not be applicable to women as
and very common among those committed to prison. they face different problems in prison.
Clearly, there is a relationship with substance depen- Prostitution, being abused as a child and running
dency and crime and, as mentioned above, this is also away from home were all identified as leading to the
related to mental health problems and communicable imprisonment of women (McClanahan et al., 1999;
diseases as studies from the UK (Hucklesby and Este! banez et al., 2002) add to this list, having illegal
Wilkinson, 2001), USA (Langan and Pelissier, 2001) sources of income, leaving education early and early
and Greece (Koulierakis et al., 2000) demonstrate. drug abuse, especially in relation to HIV/AIDS. Clearly,
There are no definitive data on the success of drug there is a link between mental health, substance abuse
rehabilitation programmes in prison and efforts to and communicable diseases in women, as there is in men
reduce the prevalence of substance abuse are fraught and this is of particular concern in the USA where
with problems. Mandatory drug testing of prisoners has women are the ‘fastest growing population of prison
reduced substance abuse in some circumstances but it inmates’ (Staton et al., 2001, p. 701). In that respect any
also leads to the use of harder drugs, for example, model of health care for prisoners must acknowledge the
opiates as opposed to marijuana. The latter have a greater likelihood of the above problems among women
longer half life (the time taken for the level of a but, in terms of health promotion for women prisoners,
substance to reduce by 50%) in the blood and prisoners it has been recognised that ‘prisons are not therapeutic
may try to avoid failing drug tests by using drugs with environments’ (Hanson and Gray, 1997). While prisons
shorter half lives (Hucklesby and Wilkinson, 2001). may represent an environment where improved health
Clearly, there is every imperative to educate prisoners care with respect to drugs could be achieved, the
about the dangers of substance abuse as most will, punitive environment is particularly problematic for
eventually, return to the community where a reduction women (Malloch, 2000).
in substance abuse may reduce recidivism and reduce the
problem of substance abuse in the general population. 5.2. Older prisoners
In this respect, health promotion is essential and this will
be considered under a separate heading below. Only three papers and an editorial were retrieved on
older prisoners and this does not appear to be a major
concern of government policy documents. Despite the
5. Groups of prisoners fact that the majority of crime is committed by very
young people with only 0.2% of indictable offences
There were two identifiable groups of prisoners: being committed by people over 60 (Tarbuck, 2001), the
women and older prisoners, whose needs are distinct prison population of older people is growing and a
from the rest of the prison population. Younger tendency towards longer custodial sentences means that
offenders are clearly a category of prisoner but were people committed to prison in their younger years are
not specifically covered in the present review. liable to be there when they are older (Corwin, 2001).
Older prisoners have greater health needs than other
5.1. Women prisoners prisoners reflecting the trend in the general population
(Fazel et al., 2001). Multipathology is common with
Clearly, women prisoners are a separate category but 85% of older prisoners having more than one major
in terms of the present review, they appeared to have illness including psychiatric illness. In addition to the
many of the same problems as male prisoners but often health-related aspects of older prisoners, they are also of
to a greater extent. The exception is pregnancy, on criminological interest as they are less likely to offend on
which there was only one paper (Siefert and Pimlott, release (Corwin, 2001) and may be an unnecessary
2001) about improving outcome in prison for pregnant burden on the prison health care system. A Canadian
prisoners in the face of substance abuse and mental study demonstrated that many older prisoners were
health problems. In common with male prisoners, the being incarcerated well beyond their parole dates and
majority of problems are not picked up at reception into called for new policies to address this issue (Gallagher,
prison (Parsons et al., 2001). 2001).
Women appear to have greater problems with mental Related to the care of older prisoners, the subject of
health, substance abuse (Birecree et al., 1994) and hospice care in prisons was represented by two papers.
sexually transmitted diseases (Est!ebanez et al., 2002) This concept seems to be better developed in the USA
and their reasons for incarceration, clearly related to the where there are identified prison hospice workers (US
above problems, display a different pattern. One study Department of Justice, 1998). One such worker presents
identified that women in prison use drugs more experiences in this area and considers issues such as
frequently and that they use harder drugs (Langan and having a hospice unit, admission criteria, ‘do not
Pelissier, 2001) and that drug rehabilitation programmes resuscitate’ orders and pain relief in addition to setting
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R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128 125

a research agenda in this area (Maul, 1998). Recognising interplay in terms of health between prisons and the
the need to provide care for prisoners which is as good communities which they serve.
as for those outside prisons in line with current UK Clearly, there is an interest among prison services in
government policy, Wilford (2001) advocates a link dealing with communicable diseases as these may spread
worker in this area of care. to health care staff and correctional officers and out into
the community, without proper precautions. Despite
this, it has been observed, among health care workers in
6. Underlying themes prison that proper precautions are not always taken
(Gershon et al., 1999).
Running across all of the themes and groups of It was recognised in the literature that prisons, in
prisoners described above, the themes of health promo- addition to being a potential focus for the health
tion and the health of the community were evident. promotion of prisoners, were also a potential focus for
Health promotion is clearly an essential component of improving the health of the community from which the
prison health care in relation to substance abuse and prisoners come (Marquart and Merianos, 1996). In
communicable diseases. If prisoners are to be rehabili- terms of mental health, prison could be the place where
tated and returned to the community then the health of the cycle of jail and homelessness could be broken
prisoners as they return to the community may have (Fujioka, 2001) and where preventative strategies could
consequences for the community to which they return. be implemented to prevent the release of people with
greater mental health problems than when they entered
6.1. Health promotion prison (Lamberti et al., 2001).
There were no explicit theoretical models of prison
Health promotion is considered essential in prisons health care. However, one paper by Roskes and Feld-
and is an integral part of UK government policy in this man (1999) referred to the potential for a ‘value added’
regard (DoH/HMPS/NAW, 2001b). However, with aspect to the health care of prisoners. While there is as
specific respect to prisons, health promotion has been yet little evidence for its efficacy, such a model envisages
described as ‘under-resourced and the concept and improving the health of prisoners while in prison linking
practice poorly understood’ (Carager et al., 2000, p. 5). the delivery of health care to prisoners with a specific
There are problems with the non-therapeutic environ- outcome rather than simply dealing with the health
ment of prisons and one author asked if healthy prisons problems of prisoners as they arise.
were not a contradiction in terms (Smith, 2000). The
lack of standardised assessment instruments and stan-
dard procedures for health screening at entry to the 7. Delivery of prison health care
prison system referred to above must contribute to
difficulties with health promotion: if the health needs The purpose of the review commissioned here was to
and problems of prisoners are not known then how can look for models of health care delivery in prisons which
action be effective? There was an absence of papers from might be applicable to one region of the UK. Evidence
this review on health promotion in relation to chronic of such models was scarce but the general principle of
disease or coping with disability in prison and the use of partnership was evident and one specific move of health
therapeutic approaches to mental health problems. care delivery, namely telemedicine, had received some
One paper on the health care of diabetic prisoners attention in the literature.
reported that they were not allowed to keep their own
equipment for the administration of insulin thus 7.1. Partnerships
reducing their autonomy (Petit et al., 2001). This is a
clear demonstration of the tension between the correc- While partnership is integral to the delivery of prison
tional and health care aspects of being in prison which health care as envisaged in current UK government
have also been referred to above. It is too early in the policy documents, there were few examples in the
history of health promotion in prisons to report on the literature directly applicable to the UK, of where
success or failure of particular schemes but this is an partnerships in prison health care with, for example,
area of considerable importance for the future and secondary services, social work, private health care
which must be integral to any model of health care. providers and other institutions had been successfully
implemented. The models which were presented were all
6.2. The health of the community from the USA and were concerned with partnerships
between prisons and university hospitals and with the
The health problems in prison largely reflect, but private sector (for example, Applebaum et al., 2002).
magnify, the problems present in the communities which This is clearly an area for further research and
the prisons serve. There is, therefore, an inevitable development.
 ARTICLE IN PRESS
126 R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128

7.2. Telemedicine health care (Maeve and Vaughn, 2001). However, with
specific reference to the UK, where prison health care is
It is uncommon to be able to offer all the health care undergoing an element of reform, where there is an
expertise that a prisoner may require in one prison. increasing recognition of the need for health promotion
However, moving prisoners for health care consultations in prisons and with the advanced roles that nurses play
and for minor treatment has implications: it is a security in primary care, this is an area which is ripe for
risk, costly and disruptive (Brecht et al., 1996). For these development both professionally and through research.
reasons telemedicine approaches to consultation and
minor treatment have been tried and, while not an
extensive literature, all the papers retrieved reported
Acknowledgements
favourably upon it. It should be noted that all the papers
were from the USA. An early study by Brecht et al.
Northern and Yorkshire NHSE are thanked for the
(1996) suggested that telemedicine could be cost-
funding and the opportunity to conduct this review.
effective and it has been successfully applied to
Jonathan Parker and Mary Laurenson of the School of
psychiatry and emergency medicine in prisons (Zaylor
Nursing, Social Work and Applied Health Studies at the
et al., 2001; Ellis et al., 2001). It is clear that telemedicine
University of Hull are thanked for their comments in the
may be a potential component of any prison health care
manuscript.
model.
Contributions
Study design: TH, RW; Data collection and analysis:
AS, RW; Manuscript preparation: RW, AS, TH.
8. Conclusion

This review was commissioned to help the local prison

and health services produce a model for partnership in References
the delivery of health care in prisons in line with current
UK government policy. Models include health care Akhtar, S., Luby, S.P., Rahbar, M.H., Azam, I., 2001. HIV/
delivery by employees of the prison services, combined AIDS knowledge, attitudes and beliefs based prediction
models including primary and secondary care divided models for practices in prison inmates, Sindh, Pakistan.
Southeast Asian Journal of Tropical Medicine and Public
between prison services and health services, respectively,
Health 32, 351–361.
and models whereby local and NHSs augment prison Allwright, S., Bradley, F., Long, J., Barry, J., Thornton, L.,
health care through, for example, telemedicine. Parry, J.V., 2000. Prevalence of antibodies to hepatitis B,
In that sense, the review has not uncovered any single hepatitis C, and HIV and risk factors in Irish prisoners:
model which is applicable but there are some vital results of a national cross sectional survey. British Medical
ingredients to any model which must be considered and Journal 321, 78–82.
these include: Applebaum, K.L., Manning, T.D., Noonan, J.D., 2002. A
university–state–corporation partnership for providing cor-
* Health promotion as a unifying concept for health rectional mental health services. Psychiatric Services 53,
care in prisons incorporating health needs assess- 185–189.
ment. Beaupr!e, M., 1994. Confidentiality, HIV/AIDS and prison
* Health screening on arrival in the prison system health care services. Medical Law Review 2, 149–160.
incorporating standardised protocols and validated Bellis, M.A., Wield, A.R., Beeching, N.J., Mutton, K.J., Syed,
Q., 1997. Prevalence of HIV and injecting drug use in
instrument with an emphasis on mental health.
men entering Liverpool prison. British Medical Journal 315,
* Partnership between prison services and the NHS.
30–31.
* Telemedicine as one mode of delivering health care in Birecree, E.A., Bloom, J.D., Leverette, M.D., Williams, M.,
prisons. 1994. Diagnostic efforts regarding women in Oregon’s
* Education of prison staff, including health care staff prison system: a preliminary report. International Journal
about the health needs of prisoners. of Offender Therapy and Comparative Criminology 38,
* Developing a model of prison health care which 215–230.
looks beyond the prison environment to the commu- Birmingham, L., Mason, D., Grubin, D., 1996. Prevalence of
nities which the prison serves. mental disorder in remand prisoners: Consecutive case
study. British Medical Journal 313, 1521–1524.
Blaauw, E., Roesch, R., Kerkhof, A., 2000. Mental disorders in
There was not a great deal of research literature on European prison systems. International Journal of Law and
the role of nurses in the prison service. Two papers from Psychiatry 23, 649–663.
the USA dealt with forensic nursing, one presenting a Brecht, R.M., Gray, C.L., Peterson, C., Youngblood, B., 1996.
theoretical model for forensic nursing (Lynch, 1993) and The University of Texas Medical Branch—Texas Depart-
the other examining the tensions between correction and ment of Criminal Justice Telemedicine Project: findings
 ARTICLE IN PRESS
R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128 127

from the first year of operation. Telemedicine Journal 2, population, worse than younger prisoners. Age and Ageing
25–35. 30, 403–407.
Brinded, P.M.J., Simpson, A.I.F., Laidlaw, T.M., Fairley, N., Fujioka, J., 2001. Helping mentally ill people break the cycle of
Malcolm, F., 2001. Prevalence of psychiatric disorders in jail and homelessness. Psychiatric Services 52, 1380–1383.
New Zealand prisons: A national survey. Australian and Gallagher, E.M., 2001. Elders in prison. Health and well-being
New Zealand Journal of Psychiatry 35, 166–173. of older inmates. International Journal of Law and
Butler, T., Robertson, P., Kaldor, J., Donovan, B., 2001. Psychiatry 24, 325–333.
Syphilis and New South Wales (Autralia) prisons. Interna- Gershon, R.R.M., Karkashian, C.D., Vlahov, D., Kummer, L.,
tional Journal of STD & AIDS 12, 372–379. Kasting, C., Green-McKenzie, J., Escamilla-Cejudo, J.A.,
Carager, M., Dixon, P., Bird, L., Hitchman, C., McGough, H., Kendig, N., Swetz, A., Martin, L., 1999. Compliance with
Carr-Hill, R., 2000. The Range and Quality of Health universal precautions in correctional health care facilities.
Promotion in HM Prisons. King’s Fund and Prison Health Journal of Occupational and Environmental Medicine 41,
Policy Unit, London. 181–189.
Coninx, R., Mathieu, C., Debacker, M., Mirzoev, F., Ismaelov, Godin, G., Gagnon, H., Alary, M., No.el, L., Morissette, M.R.,
A., de Haller, R., Meddings, D.R., 1999. First-line 2001. Correctional officers’ intention of accepting or
tuberculosis therapy and drug-resistant Mycobacterium refusing to make HIV preventive tools accessible to inmates.
tuberculosis in prisons. The Lancet 353, 969–973. AIDS Education and Prevention 13, 462–472.
Corrado, R.R., Cohen, I., Hart, S., Roesch, R., 2000. Greifinger, R.B., Heywood, N.J., Glaser, J.B., 1993. Tubercu-
Comparative examination of the prevalence of mental losis in prison: balancing justice and public health. The
disorders among jailed inmates in Canada and the United Journal of Law, Medicine and Ethics 21, 332–341.
States. International Journal of Law and Psychiatry 23, Hanson, C., Gray, G., 1997. Lessons learned from developing a
633–647. women’s prison haelth promotion program. Journal of
Corwin, P.S., 2001. Senioritis: why elderly federal inmates are Health Education 28, 374–376.
literally dying to get out of prison. Journal of Contempor- Her Majesty’s Inspectorate for Prison for England and Wales,
ary Health Law 17, 687–714. 1996. Patient or Prisoner? Home Office, London.
Council of Europe, 1989. Recommendation R (98) 7 of the Her Majesty’s Prison Service/National Health Service Execu-
Committee of Ministers to member states concerning the tive, 1999. The Future Organisation of Prison Health Care.
ethical and organisational aspects of health care in prison. HMP/NHSE, London.
Council of Europe Committee of Ministers, Strasbourg. Her Majesty’s Prison Service/National Assembly for Wales/
Dale, C., Woods, P., 2002. Caring for Prisoners: RCN Prison National Health Service Executive, 2000. Nursing in
Nurses Forum Roles and Boundaries Project. Royal College Prisons. Department of Health, London.
of Nursing, London. Her Majesty’s Prison Service/Department of Health, 2001.
Department of Health/Her Majesty’s Prison Service/National Prison Health Policy Unit Task Force Annual Report 2000/
Assembly for Wales, 2001a. Report of the working group on 2001. HMD/DoH, London.
doctors working in prisons summary and key recommenda- Hilton, N.Z., Simmons, J.L., 2001. The influence of actuarial
tions plan of action. DoH, London. risk assessment in clinical judgements and tribunal decisions
Department of Health/Her Majesty’s Prison Service/National about mentally disordered offenders in maximum security.
Assembly for Wales, 2001b. Prison Health Handbook. Law and Human Behavior 25, 393–408.
DoH, London. Home Office, 2001. Findings 154. The Prison Population in
Diamond, P.M., Wang, E.W., Holzer, C.E., Thomas, C., 2000: A Statistical Review. Home Office, London.
Cruser, A., 2001. The prevalence of mental illness in Hoptman, M.J., Yates, K.F., Patalinjug, M.B., Wack,
prison. Administration and Policy in Mental Health 29, R.C.m, Convit, A., 1999. Clinical prediction of as-
21–40. saultive behavior among male psychiatric patients are a
Edwards, S., Tenant-Flowers, M., Buggy, J., Horne, P., Hulme, maximum-security forensic facility. Psychiatric Services 50,
N., Easterbrook, P., Taylor, C., 2001. Issues in the 1462–1466.
management of prisoners infected with HIV-1: the King’s Hucklesby, A., Wilkinson, C., 2001. Drug misuse in prisons:
College Hospital HIV prison service retrospective cohort Some comments on the prison service drug strategy. The
study. British Medical Journal 322, 398–399. Howard Journal 40, 347–363.
Ellis, D.G., Mayrose, J., Jehle, D.V., Moscati, R.M., Pierluisi, Huws, R., Longson, D., Reiss, D., Larkin, E., 1997. Prison
G.J., 2001. A telemedicine model for emergency care in a transfers to special hospitals since the introduction of the
short-term correctional facility. Telemedicine Journal and e- Mental Health Act 1983. The Journal of Forensic Psychia-
Health 7, 87–92. try 8, 74–84.
Est!ebanez, P., Zunzuneghui, M.V., Aguilar, M.D., Russel, N., Joukamaa, M., 1995. Psychiatric morbidity among Finnish
Cifuentes, I., Hankins, C., 2002. The role of prisons in the prisoners with special reference to socio-demographic
HIV epidemic among female injecting drug users. AIDS factors: results of the health survey of Finnish prisoners
Care 14, 95–104. (Wattu Project). Forensic Science International 73, 85–91.
Fazel, S., Danesh, J., 2002. Serious mental disorder in 23,000 Koulierakis, G., Gnasdellis, C., Agrafiotis, D., Power, K.G.,
prisoners: a systematic review of 62 surveys. The Lancet 2000. HIV risk behaviour correlates among injecting drug
359, 545–550. user in Greek prisons. Addiction 95, 1207–1307.
Fazel, S., Hope, T., O’Donnell, I., Piper, M., Jacoby, R., 2001. Lamberti, J.S., Weisman, R.L., Schwarzkopf, S.B., Price, N.,
Health of elderly male prisoners: worse than the general Ashton, R.M., Trompeter, J., 2001. The mentally ill in jails
 ARTICLE IN PRESS
128 R. Watson et al. / International Journal of Nursing Studies 41 (2004) 119–128

and prisons: towards an integrated model of prevention. Petit, J.M., Guenfoudit, M.P., Volatier, S., Rudoni, S.,
Psychiatric Quarterly 72, 63–77. Vaillant, G., Hermant, C., Verges, B., Brun, J.M., 2001.
Langan, N.P., Pelissier, B.M.M., 2001. Gender differences Management of diabetes in French prisons: a cross-sectional
among prisoners in drug treatment. Journal of Substance study. Diabetic Medicine 18, 47–50.
Abuse 12, 291–301. Potts, J.R., 2000. HIV/AIDS in federal prisons: Canada’s
Lynch, V.A., 1993. Forensic nursing: diversity in education and national response. HIV Prevalence Plus 2 (2), 1–3.
practice. Journal of Psychosocial Nursing 13 (11), 7–14. Rasmussen, K., Storsaeter, O., Levander, A., 1999. Personality
Maeve, K.M., Vaughn, M.S., 2001. Nursing with prisoners: the disorders, psychopathy, and crime in a Norwegian prison
practice of caring, forensic nursing or penal harm? population. International Journal of Law and Psychiatry
Advances in Nursing Science 24, 47–64. 22, 91–97.
Malloch, M.S., 2000. Caring for drug users? The experiences of Reed, J.L., Lyne, M., 2000. Inpatient care of mentally ill people
women prisoners. The Howard Journal 39, 354–368. in prison: results of a year’s programme of semistructured
Marquart, J.W., Merianos, D.W., 1996. Thinking about the inspections. British Medical Journal 320, 1031–1034.
relationship between health in the free community and the Reeder, D., 1991. Conceptualizing the psychosocial nursing in
prison. Crime & Delinquency 42, 331–361. the jail setting. Journal of Psychosocial Nursing 29, 40–44.
Maul, F.W., 1998. Issues in prison hospice: towards a model for Reyes, H., Coninx, R., 1997. Pitfalls of tuberculosis pro-
the delivery of hospice care in a correctional setting. The grammes in prisons. British Medical Journal 315,
Hospice Journal 13, 57–82. 1447–1450.
McCausland, R., Parrish, A.A., 2002. The context of prison Roskes, E., Feldman, R., 1999. A collaborative community-
nursing. In: Norman, A., Parrish, A. (Eds.), Prison Nursing. based treatment program for offenders with mental illness.
Blackwell, Oxford, pp. 1–13. Psychiatric Services 50, 1614–1619.
McClanahan, S.F., McLelland, G.M., Abram, K.M., Teplin, Royal College of Nursing, 2001. Caring for Prisoners. RCN,
L.A., 1999. Patyhways into prostitution among female jail London.
detainees and their implications for mental health services. Siefert, K., Pimlott, S., 2001. Improving pregnancy outcome
Psychiatric Services 50, 1606–1613. during imprisonment: a model residential care program.
Metzner, J.L., Miller, R.D., Kleinsasser, D., 1994. Mental Social Work 46, 125–134.
health screening and evaluation within prisons. Bulletin of Simooya, O., Sanjobo, N., 2001. ‘In but free’—an HIV/AIDS
the Academy of Psychiatry and Law 22, 451–457. intervention in an African prison. Culture, Health and
Mohle-Boetani, J.C., Miguelino, V., Dewsnup, D.H., Des- Sexuality 3, 241–251.
mond, E., Horowityz, E., Waterman, S.H., Bick, J., 2002. Smith, C., 2000. ‘Healthy prison’: a contradiction in terms? The
Tuberculosis outbreaks in a housing unit for human Howard Journal 39, 339–353.
immunodeficiency virus-infected patients in a correctional Staton, M., Leukfeld, C., Logan, T.K., 2001. Health service
facility: transmission risk factors and effective outbreak utilization and victimization among incarcerated female
control. Clinical Infectious Diseases 34, 668–676. substance users. Substance Use & Misuse 36, 701–716.
Munetz, M.R., Grande, T.P., Chambers, M.R., 2001. The Tarbuck, A., 2001. Health of elderly prisoners. Age and Ageing
incarceration of individuals with severe mental disorders. 30, 369–370.
Community Mental Health Journal 37, 361–372. US Department of Justice, 1998. Hospice and Palliative Care in
National Health Service Executive Northern & Yorkshire Prisons. US Department of Justice, Colorado.
Region, 2001. Invitation to Tender—Prison Health Care. Wilford, T., 2001. Developing effective palliative care within a
NHSE, Durham. prison setting. International Journal of Palliative Nursing 7,
National Institute of Corrections, 1991. Intervening with 528–530.
Substance-Abusing Offenders: A Framework for Action. Wolfe, M.J., Xu, F., Patel, P., O’Cain, M., Schillinger, J.A., St
US Department of Justice, Washington. Louis, M.E., Finelli, L., 2001. An outbreak of syphilis in
Norman, A.E., Parrish, A.A., 2002. The role of the nurse in Alabama prisons: correctional health policy and commu-
prison healthcare. In: Norman, A., Parrish, A. (Eds.), nicable disease control. American Journal of Public Health
Prison Nursing. Blackwell, Oxford, pp. 14–26. 91, 1220–1225.
Okwumabua, J.O., Glover, V., Bolden, D., Edwards, S., 2000. World Health Organization, 1999. Health in Prisons Project.
Perspectives of low-income African Americans on syphilis WHO, Geneva.
and HIV: implications for prevention. Journal of Health World Health Organization, 2000. Preventing Suicide: A
Care for the Poor and Underserved 12, 474–489. Resource for Prison Officers. WHO, Geneva.
Parsons, S., Walker, L., Grubin, D., 2001. Prevalence of mental World Health Organization/International Committee of the
disorder in female remand prisoners. The Journal of Red Cross, 2001. Tuberculosis Control in Prisons: A
Forensic Psychiatry 12, 194–202. Manual for Programme Managers. WHO/ICRC, Geneva.