Changes in health-related quality of life following imprisonment in 92 women in England: a three month follow-up study

There are approximately 85,000 prisoners in England and Wales and a small but increasing proportion of them are women; women prisoners number about 4,300 [1]. Prisoners in the United Kingdom (UK) are a socially excluded group. Compared with the general population, prisoners are 13 times as likely to have been in care as a child, 13 times as likely to be unemployed and 10 times as likely to have been a regular truant. Their basic skills are very likely to be poor; 80 per cent have the writing skills, 65 per cent the numeracy skills and 50 per cent the reading skills at or below the level of an 11-year-old child [2]. Women prisoners are particularly disadvantaged in a system designed for men by men [3]. They are not imprisoned for violent crime but for acquisitive crime; much of this is drug related, committed either by drug users to fund their habit (theft and handling, burglary or robbery) or by women involved in the trafficking and sale of drugs (drug offences) [4]. It is therefore not surprising that substance use is a considerable health problem for imprisoned women [5].

There is also evidence indicating a number of other important health issues for women prisoners: mental health problems [6], blood borne virus infections [7, 8], sexually transmitted infections [9], cervical dysplasia [10, 11] and pregnancy complications [12, 13]. Even though there is this apparent high level of need, women prisoners are more likely to experience reduced access to health services in the community [2].

Despite the increasing amount of evidence on imprisoned women's health and the considerable changes in the provision of health care to prisoners in the UK which have resulted in the transfer of health services from the Prison Service to the National Health Service [14], there is little published literature that attempts to examine broader aspects of health and the impact of imprisonment on this. This is surprising given that one of the main drivers behind the changes was the recognised need for improvements in the quality of care [14]. Examining changes in health outcomes should be an important part of monitoring the progress of these service changes. However, the current research tends to focus on disease specific areas rather than using quality of life measures to gain a fuller picture of these women's health. Furthermore, most of the studies are cross sectional or case-control in design and thus take only a snapshot of women's health at one point during imprisonment. There are however instruments that are able not only capture broader aspects of well-being but are also sensitive to change over time. The short form 36 (SF-36) is such an instrument which not only is well validated [15] but has demonstrated its usefulness in a female prison population in England [16]. The SF-36 therefore, as a health outcome measure, has the potential to contribute to the monitoring of health service changes with prisons.

The overall aim of this study was to examine changes in the health related quality of life of women prisoners during a period of three months imprisonment.

This study presents unique longitudinal data on the health-related quality of life of women prisoners in England. The results highlight the poor physical, psychological and social health of women prisoners but also show that their mental well-being improved over the three months of imprisonment. Physical health as measured by the PCS did not improve significantly and remained lower than that of the general population.

The design and conduct of the study had several advantages. The researchers met with the women on more than one occasion and this is likely to have contributed to good data quality by helping them gain the confidence and trust of the participants. The study achieved good response rates with 82% of women agreeing to participate initially, and 93% of those still imprisoned participating three months later. However, we acknowledge that 92 women comprise a small sample of the total female prison population. Analysis of specific demographic information on participants suggested that this sample did differ from the general population of women prisoners in England. Although similar in age, this sample was less likely to be white and more likely to have stayed in education beyond the age of 16 years. However, it may be that this sample was similar to women who stay in prison for at least three months but no data was available from HM Prison Service to explore this. A further issue regarding the generalizability of the findings is that these women were only followed up for three months and it is therefore not possible to know how they differed from women who were imprisoned for longer or whether the changes would be sustained. It would be important for future research studies to follow up women for a longer period.

The SF-36 was an appropriate instrument to measure health-related quality of life in this population. It provides information on a number of aspects of well-being: physical, mental, psychological and social. It is sensitive to change over the short period of three months and suitable in a general, not solely a patient, population [21]. As noted, previous research has also demonstrated its usefulness in a female prison population in England [16]. However, it has not been widely used with prison populations and this is the first study to have used the SF-36 to monitor women prisoners' health status over time.

On entry into prison, women prisoners had lower summary scores compared to than those in the general population. The mean MCS was 35.5; only 14.3% of the general female population have a score of 36 or less [22]. The mean PCS was 44.3; only 22.8% of females have a score of 45 or less [22]. A small number of published studies have reported the SF-36 dimension and summary scores for prisoners. These studies report that scores for several dimensions were significantly lower than for the general population [16, 23‐25]. The UK study found that the dimensions of social functioning, mental health, energy/vitality, pain and general health perception were all significantly lower than scores for the general population [16]. An Australian study looking at prisoners infected with hepatitis C found that they had lower scores in four of the eight domains: social functioning, role emotional, mental health and general health [23].

The mental well-being of these women, as measured by the SF-36, improved over the three months of imprisonment. The reasons for the improvement in mental well-being are unclear. For those who have visited prison and experienced the unique environment - restrictive, lacking comfort or the presence of loved ones- it is difficult to see why there should be any improvement in health. For many people, this could only damage their health. However, it is perhaps an indictment of the lives women prisoners lead in community that such an environment is experienced as health promoting; for women who are homeless in the community perhaps enforced containment is preferable, and for those who live in fear of violence, a locked cell door provides security. Furthermore women may benefit from the shelter, regular meals and reduction in alcohol and/or drug consumption that prison affords. Improved access to health services may be another reason for the change; women may be able to access addiction and mental health services in prison which they have been unable to do in the community. Of course the change may not be attributable to any positive effect of imprisonment, it might simply be because these women are adapting to life in prison in the way that people adapt to other stressors such as bereavement or the diagnosis of a life threatening illness [26, 27]. Future qualitative research would be important in exploring this area in more depth.

These findings contrast with an Australian study which examined change in psychological health in women prisoners using the 12 item General Health Questionnaire [28]. The investigators followed women up after four months of imprisonment and found no statistically significant change in GHQ-12 score. However, this may in part be attributable to the fact that the study design used a cross section of all those in prison at a given time. It is likely that many would have been in prison some time and therefore any initial changes on prison entry would not have been captured. The difference in findings may also be related to the differences in prison regimes in the two countries which have different impacts on women's mental health.

These findings highlight the scale of the challenge faced by those providing health care to prisoners and underline the need to address the health problems of women prisoners. The results also draw attention to the major health disadvantages of women offenders compared to women in general that were likely to exist prior to imprisonment. While recent reforms may improve health services for prisoners, broader inequalities in the health of women are a larger and more complex challenge.