Challenges in ensuring robust research and reporting of health outcomes in sub-Saharan African prisons
Authors: Rosemary Mhlanga-Gunda, Nthabeleng Motsomi-Moshoeshoe, Emma Plugge, Marie Claire Van Hout
Journal: The Lancet Global Health (2019)

The global prison population has continued to rise, with almost 11 million people in prison despite downward trends in crime.1Penal Reform InternationalGlobal Prison Trends 2018. Penal Reform International, London2018Google Scholar The Standard Minimum Rules for the Treatment of Prisoners mandates the protection of basic human rights for persons deprived of liberty and advocates for the improvement of living conditions and environments of people in prison.2UN General AssemblyUnited Nations Standard Minimum Rules for the treatment of prisoners (the Nelson Mandela Rules) resolution adopted by the General Assembly. United Nations, New York, NY2016Google Scholar Health disparity is evident with imprisoned people likely to be the most marginalised and poorest members of society, with health outcomes further compounded when incarcerated.1Penal Reform InternationalGlobal Prison Trends 2018. Penal Reform International, London2018Google Scholar Tackling health inequalities by addressing the health needs of people in prisons is therefore an essential component of contributing to the achievement of the Sustainable Development Goals specifically to reduce inequality within and among countries and leaving no one behind. Ensuring effective delivery of health care in prisons is an important aspect of life in prison, often challenging given the huge burden of disease in this key population, and is vital in terms of connecting prison health to public health.3WHOMoscow declaration on prison health as part of public health.http://www.euro.who.int/__data/assets/pdf_file/0007/98971/E94242.pdf?ua=1Date: 2003Date accessed: September 16, 2019Google Scholar Imprisoned people are however significantly under-represented in health research, which underpins a lack of evidence-based interventions addressing their complex health needs or informing wider reform of the health service in prisos.4Plugge E Stürup-Toft S O'Moore ÉJ Møller L WEPHREN: a global prison health research network.Int J Prison Health. 2017; 13: 65-67Google Scholar, 5Institute for Criminal Policy ResearchWorld Prison Brief online database. University of London, London2019Google Scholar Whilst a global increase in prison health research has been observed, this rise is uneven and concentrated in high-income countries.4Plugge E Stürup-Toft S O'Moore ÉJ Møller L WEPHREN: a global prison health research network.Int J Prison Health. 2017; 13: 65-67Google Scholar We comment here specifically on the sub-Saharan African region. Although there are over one million people in prison in sub-Saharan African,5Institute for Criminal Policy ResearchWorld Prison Brief online database. University of London, London2019Google Scholar research activity on prison health is historically of low priority and generally confined to the gathering of rapid situational assessment of infectious diseases (HIV, tuberculosis) in selected prisons, documentation of good practices, some qualitative studies, books, academic thesis, and human rights, UN and African Union country missions.6Telisinghe L Charalambous S Topp SM et al.HIV and tuberculosis in prisons in sub-Saharan Africa.Lancet. 2016; 388: 1215-1227Google Scholar, 7Van Hout MC Mhlanga-Gunda R Contemporary women prisoners health experiences, unique prison health care needs and health care outcomes in sub Saharan Africa: a scoping review of extant literature.BMC Int Health Hum Rights. 2018; 18: 31Google Scholar, 8Van Hout MC Mhlanga-Gunda R Mankind owes to the child the best that it has to give': Prison conditions and the health situation and rights of circumstantial children incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 13Google Scholar, 9Van Hout MC Gunda R Prison health situation and rights of juveniles incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 7Google Scholar Detail on prison population, routine gathering of strategic health information on imprisoned people and prison staff, and surveillance of rates of infectious and non-communicable disease6Telisinghe L Charalambous S Topp SM et al.HIV and tuberculosis in prisons in sub-Saharan Africa.Lancet. 2016; 388: 1215-1227Google Scholar, 10Herbert K Plugge E Foster C Doll H Prevalence of risk factors for non-communicable diseases in prison populations worldwide: a systemic review.Lancet. 2012; 379: 1975-1982Google Scholar is poor in part due to high pre-trial detention, the revolving door of re-incarceration, low uptake to testing, and extreme bureaucratic procedures governing access to and conducting of research in prisons. Many sub-Saharan African countries have no published academic research on prison health at all or in some cases very little.6Telisinghe L Charalambous S Topp SM et al.HIV and tuberculosis in prisons in sub-Saharan Africa.Lancet. 2016; 388: 1215-1227Google Scholar, 7Van Hout MC Mhlanga-Gunda R Contemporary women prisoners health experiences, unique prison health care needs and health care outcomes in sub Saharan Africa: a scoping review of extant literature.BMC Int Health Hum Rights. 2018; 18: 31Google Scholar, 8Van Hout MC Mhlanga-Gunda R Mankind owes to the child the best that it has to give': Prison conditions and the health situation and rights of circumstantial children incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 13Google Scholar, 9Van Hout MC Gunda R Prison health situation and rights of juveniles incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 7Google Scholar Reasons for this lack of engagement in routine prison health enquiry and prison health research are unclear, perhaps in part due to societal views on incarceration as punitive rather than restorative, imprisoned people as devalued citizens, and lack of political will to improve resource allocation to prisons, all of which compound barriers to access for outsider research and situational investigation.6Telisinghe L Charalambous S Topp SM et al.HIV and tuberculosis in prisons in sub-Saharan Africa.Lancet. 2016; 388: 1215-1227Google Scholar, 7Van Hout MC Mhlanga-Gunda R Contemporary women prisoners health experiences, unique prison health care needs and health care outcomes in sub Saharan Africa: a scoping review of extant literature.BMC Int Health Hum Rights. 2018; 18: 31Google Scholar, 8Van Hout MC Mhlanga-Gunda R Mankind owes to the child the best that it has to give': Prison conditions and the health situation and rights of circumstantial children incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 13Google Scholar, 9Van Hout MC Gunda R Prison health situation and rights of juveniles incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 7Google Scholar The ethical conduct of health research in sub-Saharan African prisons is therefore an important issue. Little published literature directly addresses the protection of imprisoned people (and prison staff) in sub-Saharan African health research, and a distinct lack of clear prison focused guidance and oversight in line with international standards to ensure ethical and robust prison health research.11Salaam AO Brown J Ethical dilemmas in psychological research with vulnerable groups in Africa.Ethics Behav. 2013; 23: 167-178Google Scholar Substantial ethical concerns exist in terms of prison management influencing research data, structural obstacles to voluntariness, coercion of imprisoned people and prison staff, and embargoing of academic publications by management and government at a country level. Growth of prison health research activity is therefore dependent upon an adequate ethical framework to protect imprisoned people and prison staff as research participants.11Salaam AO Brown J Ethical dilemmas in psychological research with vulnerable groups in Africa.Ethics Behav. 2013; 23: 167-178Google Scholar Promoting and supporting good practice in prison health research and the publication of findings is vital to support continental, regional, and international efforts to monitor prison health situation, and to ensure adequate standards of care for imprisoned people and standards of working environments for prison staff. Continued neglect of prison health research in the sub-Saharan African region has huge implications on mortality, morbidity, and disease prevention, the right to health and a healthy working environment, and overall impact on general population health. The region is characterised by high HIV and tuberculosis co-infection, with the emergence of multidrug-resistant tuberculosis complicating chronic care management, amid rising multi-comorbidity with non-communicable diseases.12Gouda HN Charlson F Sorsdahl K et al.Burden of non-communicable diseases in sub-Saharan Africa, 1990–2017: results from the Global Burden of Disease Study 2017.Lancet Glob Health. 2019; 7: e1375-e1387Google Scholar The high rates of risk behaviours and practices in prisons, exposure to disease (staff and imprisoned people) coupled with high recidivism in sub-Saharan Africa, poses potential threat to the efforts that have been achieved in the HIV and tuberculosis response with populations outside prisons. Imprisoned people are frequently re-incarcerated and released, posing risks to themselves, their immediate families, and the wider community as they become potential carriers of transmissible diseases that can be catastrophic to public health.6Telisinghe L Charalambous S Topp SM et al.HIV and tuberculosis in prisons in sub-Saharan Africa.Lancet. 2016; 388: 1215-1227Google Scholar, 7Van Hout MC Mhlanga-Gunda R Contemporary women prisoners health experiences, unique prison health care needs and health care outcomes in sub Saharan Africa: a scoping review of extant literature.BMC Int Health Hum Rights. 2018; 18: 31Google Scholar, 8Van Hout MC Mhlanga-Gunda R Mankind owes to the child the best that it has to give': Prison conditions and the health situation and rights of circumstantial children incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 13Google Scholar, 9Van Hout MC Gunda R Prison health situation and rights of juveniles incarcerated in Sub Saharan African prisons.BMC Int Health Hum Rights. 2019; 19: 7Google Scholar A strategic approach spanning public health and human rights, and connecting research, surveillance, and evidence-based health care in prisons to that in the community is warranted not only for the millions who pass through the prison system each year in sub-Saharan African countries and those who work in these prisons, but also to entire populations. The work was funded by the Medical Research Council Grant Ref: MC_PC_MR/R024278/1 as part of the Arts and Humanities Research Council—Medical Research Council Global Public Health Partnership grant entitled 'Promoting positive sexual and reproductive health and accessible HIV Prevention, Treatment, Care and Support (PTC&S) services for women prisoners in Zimbabwe and Malawi'. The funder was not involved in the design of the scoping review protocol, data collection, and analysis, interpretation of the data, or writing of the Comment. The views of NM-M are her own and not that of UN Office on Drugs and Crime Regional Office for Southern Africa.