Inequalities in physical and mental health among people in prison
Authors: Chantal Edge, Andrew Hayward
Journal: The Lancet Public Health (2024)

The Article by Louis Favril and colleagues1Favril L Rich JD Hard J Fazel S Mental and physical health morbidity among people in prisons: an umbrella review.Lancet Public Health. 2024; 9: e250-e260Summary Full Text Full Text PDF Google Scholar seeks to better understand the epidemiology of physical and mental health conditions among people in prison worldwide. This is the first time much of the evidence on the prevalence of these conditions among prisoners has been collected together in an umbrella review of meta-analyses. This is a welcome addition to the published evidence base; summaries of the overall burden of disease among prisoners are rare, with much of the available literature focusing only on one or two aspects of ill health, thereby failing to highlight the wide spectrum of diseases that disproportionately affect this population.2Stürup-Toft S O'Moore E J Plugge E H Looking behind the bars: emerging health issues for people in prison.British Medical Bulletin. 2018; 125: 15-23Crossref PubMed Scopus (53) Google Scholar Data were extracted to estimate the prevalence of key diseases among prisoners and identified levels of disease that were in many cases substantially higher than in the general population, with some clear gender differences. Authors reported high estimates of mental health conditions such as major depression, and a large proportion of people with comorbid mental health and substance misuse disorder. The very high levels of infectious diseases including blood-borne viruses, tuberculosis, and sexually transmitted infections (particularly in women) highlight the important opportunities for improving health and control of infections through systematic programmes to identify and treat infection in groups that might otherwise be hard to access. This Article1Favril L Rich JD Hard J Fazel S Mental and physical health morbidity among people in prisons: an umbrella review.Lancet Public Health. 2024; 9: e250-e260Summary Full Text Full Text PDF Google Scholar clearly highlights the opportunities for better health outcomes and the reduction of inequalities through improving the health of people in prison. At any one time there are an estimated 11·5 million people in penal institutions worldwide;3Fair H Walmsley R World Prison Population List.thirteenth edition. Institute for Crime and Justice Policy Research, London2022Google Scholar however, the true number of people impacted by imprisonment might be higher given the constant turnover of the population. The high burden of different diseases identified demonstrates the need to move away from treatment of disease in silos to holistic care models that consider the extensive comorbidities among prisoners and provide support alongside treatment. The very high proportion of prisoners with mental health problems suggests that strengthening of community mental health services could have a substantial effect on reducing levels of incarceration. However, important complexities and controversies remain such as stigma and exclusion around the most prevalent of these mental health diagnoses, namely anti-social personality disorder, which in some studies was diagnosed in most male prisoners. Interventions such as screening for blood-borne viruses on entry into prison, or diversion of people with mental health conditions to community treatment requirements4NHS EnglandMental Health Treatment Requirements (MHTRs).https://www.england.nhs.uk/commissioning/health-just/mental-health-treatment-requirements/Date: 2022Date accessed: February 19, 2024Google Scholar rather than imprisonment, are examples of services developed specifically for the requirements of prisoners. Despite the opportunity for health improvement that could be used during incarceration, there remain substantial barriers. In many countries, prison health care is underfunded and struggles with recruitment. Distrust, suspicion, and fear of stigma can prevent people from actively seeking support, exacerbated by the justice system's focus on delivering the order of the courts as opposed to the improvement of health.5Edge C Stockley R Swabey L et al.Secondary care clinicians and staff have a key role in delivering equivalence of care for prisoners: a qualitative study of prisoners' experiences.EClinicalMedicine. 2020; 24100416 Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar High turnover and poor integration with community services leads to treatment interruptions and lack of continuity of care. Despite the principle that those in prison should receive equal access to health care, in many countries the so-called Inverse Care Law applies strongly in prison settings. Favril and colleagues1Favril L Rich JD Hard J Fazel S Mental and physical health morbidity among people in prisons: an umbrella review.Lancet Public Health. 2024; 9: e250-e260Summary Full Text Full Text PDF Google Scholar have successfully highlighted the health inequalities faced by the prison population, but there is yet more work to be done. There was a paucity of information in the Article on chronic physical health conditions such as cardiovascular, respiratory, endocrine, renal and liver disease, and cancers. All these conditions are likely to be at least as common and, in many cases, more common than in the general population. Variation by setting is another important but under-researched area. The prevalence of key infections will no doubt vary by demographics and prison churn, as will the ability to effectively support and treat conditions identified. Overall, the review findings provide strong evidence of the importance of prisons as a setting to address health inequalities by providing services to high-risk populations that are often underserved in the community. Despite these challenges, there are numerous international examples of humane, well planned, effective prison health services, such as those in Finland.6Berger R Kriminalomsorgen: a look at the world's most humane prison system in Norway.SSRN. 2016; (published online Dec 11.)https://ssrn.com/abstract=2883512Crossref Google Scholar These need to be expanded and supported to take advantage of the myriad opportunities this setting provides to improve the health of prisoners and of broader society. Continuing to invest in improving the health of people in prison will not only result in better outcomes for this population but will bring community dividends through the reduction in disease reservoirs, earlier treatment of chronic conditions, and an overall improved ability to rehabilitate and reintegrate back into society.7Wallace D Wang X Does in-prison physical and mental health impact recidivism?.SSM Popul Health. 2020; 11100569 PubMed Google Scholar We declare no competing interests. Mental and physical health morbidity among people in prisons: an umbrella reviewPeople 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. Full-Text PDF Open Access