Prisons are important public-health settings: housing an estimated 11.5 million people worldwide (Fair & Walmsley, 2024). The health needs of people in prison differ markedly from those in the general population, including higher prevalence of mental disorders (Fazel et al., 2016), communicable diseases (such as HIV and hepatitis) (Dolan et al., 2016), non-communicable diseases (such as cancer and diabetes) (Mundey et al., 2019) and lower life expectancy (Patterson, 2013). The incarceration experience can be even more detrimental to prisoners’ health outcomes, and length of incarceration has a direct correlation with decreased survival (Patterson, 2013).
Despite the disproportionate burden of disease on people in prison, health care provision is inadequate. Prison can provide a place of stability that provides the same access and quality of health care provision that people in the community receive. To do this, policy makers and service leaders need clear and comparable data to allocate resources and deliver interventions. This recent comprehensive review (review of meta-analyses) may help by summarizing the breadth of evidence across different conditions (Faverill et al, 2024).
People in prison are disproportionately affected by health conditions, this comprehensive review summarizes the health status of prisoners around the world
methods
Favrill and colleagues conducted a comprehensive review of meta-analyses reporting the prevalence or incidence of mental and physical health conditions among the general prison population worldwide. They searched five databases through October 2023. To enhance their search, they used forward citation chains, manually searched the reference lists of relevant papers, and searched gray literature.
The authors selected the one best meta-analysis per condition, and pooled prevalence estimates, heterogeneity (I²), and indicators of publication bias (small-study effect and extrapolated significance).
Quality was assessed using the ROBIS (Risk of Bias in Systematic Reviews) tool, and an overall quality assessment was assigned to each health condition ranging from 0 (low quality) to 4 (high quality). The authors summarized the evidentiary strength of each position in psychiatric, infectious, and noncommunicable diseases. Analyzes were descriptive and where possible stratified by sex, age and national income level.
Result
mental health conditions
- Five meta-analyses were identified reporting on eight mental health conditions.
- The overall prevalence of mental health conditions ranged from 3.7% (95% CI 3.2 to 4.1) for psychotic illness to 40.4% (31.8 to 49.0) for antisocial personality disorder.
- One in ten people was estimated to be affected by major depression (11.4% (95% CI 9.9 to 12.8)) or PTSD (9.8% (6.8 to 13.2)).
- When people were admitted to prison, 23.8% (95% CI 21.0 to 26.7) met criteria for an alcohol use disorder and 38.9% met criteria for a drug use disorder (95% CI 31.5 to 46.2).
- Among women, 22.7% (95% CI 17.8 to 27.7) were affected by borderline personality disorder.
- Mental illnesses and major depression were more prevalent in low-income and middle-income countries than in high-income countries, while PTSD was more prevalent in high-income countries.
physical health conditions
- Seven meta-analyses were found reporting on ten physical health conditions.
- Prevalence ranged from 0.6% (95% CI 0.3 to 0.8) for epilepsy to 17.7% (95% CI 15.0 to 20.7) for hepatitis C virus.
- The prevalence of other blood-borne diseases was low. The prevalence of hepatitis B was 5.2% (95% CI 2.2 to 9.3) and that for HIV was 3.4% (95% CI 3.2 to 3.6).
- The prevalence of bacterial sexually transmitted infections was 8.9% (95% CI 8.2 to 9.7) for chlamydia, 3·3% for gonorrhea (95% CI 2·9 to 3.8), and 2·9% (95% CI 2·6 to 3·2) for syphilis.
age and gender difference
- Women in prison displayed higher rates of PTSD and substance use disorder, while men were more likely to have antisocial personality disorder
- Noncommunicable diseases were more prevalent among older prisoners (aged ≥50 years).
quality assessment
- Robis Criteria:
- 33% of studies were rated as low risk of bias.
- 25% of studies were rated as moderate risk of bias.
- 42% of studies were rated as high risk of bias.
- The three most common reasons for lack of bias were the absence of a pre-registered study protocol, no risk-of-bias assessment, and inadequate examination of heterogeneity.
- Heterogeneity was found to be high in 94% of the studies.
- Small-study effects were found in 89% of the studies.
- Overall quality rating was low (0.9 rating out of 4):
- 6 (out of 4) for physical health conditions.
- 4 (out of 4) for mental health conditions.
Antisocial personality disorder and hepatitis C were the most prevalent mental health and physical health conditions among prisoners worldwide.
conclusion
The findings confirm that incarcerated people suffer a disproportionate burden of mental and physical health conditions. The authors correctly highlight that prevalence estimates should be interpreted with caution due to small study effects and high heterogeneity in the selected studies.
Given that the majority of incarcerated individuals return to the community, prisons represent important sites for the screening, treatment, and prevention of treatable mental and physical health conditions that impact population health beyond prison walls.
Prisons represent important sites for the screening, treatment, and prevention of treatable mental and physical health conditions that impact population health beyond prison walls.
Strengths and limitations
Strength
- This study brings awareness to people whose health needs are often ignored and highlights where service provision is needed.
- Five suitable databases were included, and gray literature was searched. Additionally, the authors enhanced their literature search using forward citation chains and reference lists of relevant reviews.
- The authors were very transparent with their inclusion criteria which makes replication and comparison much easier.
- Multiple quality assessments for selected studies included prevalence estimates with confidence intervals, heterogeneity, small-study effects, risk of bias (assessed by the ROBIS tool), and overall quality assessment.
- Health conditions were included only in clinical investigations, for example biological markers or diagnostic tests. This helps reduce false-positivity and is a more rigorous tool than using screening tools or patient notes. However, clinical testing in prisons can be difficult due to demand, staff shortages, and high prison populations. So I would not be surprised if the true prevalence of health conditions is higher than reported in this review.
boundaries
- The disadvantage of including studies across different countries is that it may reduce the ability of policy makers to make specific changes to national prison systems.
- The list of countries included in the analysis was not reported. It is therefore not possible to understand whether the pooled prevalence is being influenced by countries that generally conduct more research. Without understanding the proportions of countries used to calculate prevalence, it is not possible to understand how representative these prevalences are of the global burden.
- Analysis based on gender, age and country’s income level was proposed, but results are likely to be limited due to the studies selected.
- Data gaps are evident for many disorders (e.g., anxiety, bipolar disorder, neurodevelopmental conditions).
This review was conducted to a high standard; But further analysis is needed for specific recommendations.
Implications for practice
- This comprehensive review applied a rigorous methodological process to analyze data from meta-analyses researching the global burden of physical and mental health conditions in prisons. Despite the heterogeneity in the selected studies (a common limitation of research in prisons), this review appears to accurately represent physical and mental health conditions in prisons. It brings much-needed awareness to the pressures on prisons and their health care staff.
- Prisons present a unique opportunity to provide physical and mental health care support to populations experiencing health disparities. With adequate provision of resources based on such reviews, prisons can implement effective screening, tailored treatment and community follow-up for highlighted conditions.
- These findings highlighted some differences in need between male and female prisons, as well as differences between countries’ income levels. Further research and stratigraphic analysis in this area may yield insights that will further inform resource acquisition. This review highlighted that substance use disorder was more prevalent in the female population and acknowledged the co-morbidity that is often seen with PTSD. Policy makers can therefore use these results to provide provision for trauma therapy and substance use, as well as ensure that staff feel skilled in managing the interplay of PTSD and substance use.
Prisons provide an opportunity for those who have been unfairly denied access to assistance with their health care.
Statement of Interests
Ross Ndoma declares that there is no conflict of interest.
Editor
Edited by Laura Hemming
Link
primary paper
Louis Favril, Josiah Rich, Jake Hardt, Seena Fazal (2024). Mental and physical health morbidity among people in prisons: a comprehensive review.. Lancet Public Health, 9(4), E250-E260.
Other references
Dolan, K., Wirtz, A. L., Mozen, B., Ndefo-Mbah, M., Galvani, A., Kinnear, S. A., Courtney, R., McKee, M., Amon, J. J., Maher, L., Hellard, M., Beyrer, C., and Altice, F. L. (2016). Global burden of HIV, viral hepatitis and tuberculosis among prisoners and detainees. The Lancet, 388(10049), 1089-1102. https://doi.org/10.1016/S0140-6736(16)30466-4
Fair, H., and Walmsley, R. (2024). World Prison Population List. fourteenth edition. 1-18.
Fazal, S., Hayes, A.J., Bartels, K., Clerici, M., and Trestman, R. (2016). Prisoners’ mental health: Prevalence, adverse outcomes, and interventions. Lancet Psychiatry, 3(9), 871-881. https://doi.org/10.1016/S2215-0366(16)30142-0
Munday, D., Leaman, J., O’Moore, E., and Plug, E. (2019). Prevalence of noncommunicable disease among older people in prison: a systematic review and meta-analysis.. age and old age, 48(2), 204-212. https://doi.org/10.1093/aging/afy186
Patterson, EJ (2013). Dose-response of time spent in prison on mortality: New York State, 1989–2003.. American Journal of Public Health, 103(3), 523-528. https://doi.org/10.2105/AJPH.2012.301148
