Evidence based practice through the process of research study

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This paper will address the issues of evidence based practice through the process of a proposed research study that will focus on an aspect of health care. It will explore the peer reviewed literature available that relates to a chosen topic and identify common themes within that area in order to highlight areas for further research. The methodology of the research process will then be discussed taking into account the boundaries and ethical issues in undertaking a research study. I certify that confidentiality has been maintained by the use of pseudonyms and all identifying information has been removed.

The World Health Organisation (WHO) Health in Prisons Project (HIPP) was established in partnership with the UK Government in 1995, because of the recognition that there was a gap between health services for the public and prison health, and the Prison Service was failing to address the public health needs of prisoners. It acknowledged that

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prison populations in general suffered from worse health, but realised that prisons offered an opportunity for improving health and tackling inequality (WHO, 2010:1). HM Prison Service (2010) identifies the prison population of the UK to be 85,159 in October 2010 and identifies that a large amount of this population come from lower social class backgrounds with limited educational achievements. This collaborates in the idea outlined by WHO 2010 that prisoners suffer from poorer health of the general population through the phenomenon of inverse health law i.e. that people from lower social class backgrounds experience higher incidences of poor health compared to those in higher social classes (Tudor Hart, 1971). This in turn indicates that when people enter the prison system they may already be experiencing poor health or living lifestyles that maybe detrimental to their health.

HM Prison Service (2003) explicitly states that prisoners should expect to have access to healthcare services that are broadly equivalent to those the general public receives from the NHS and that there should be clear management and provision made for health promotion in the prison service. This approach is designed to improve the general health of the prison population and educate them on the importance of healthy lifestyles as well as ultimately cutting costs incurred by the prisoner accessing healthcare services on release by identifying their specific health needs.

On reviewing the literature related to the health needs of prisoners a majority found related to the prison population as a whole, and is based on research is focused mainly on young white male inmates. The data from the Office of Population Censuses and Surveys (Bridgwood & Malbon 1995) provided the first national survey of the physical health and health-related behaviour of over 1000 prisoners in England and Wales, but was restricted to sentenced male prisoners. The above study has been used extensively to inform planning and healthcare needs of all prisoners (Marshal et al. 2000), although findings may be limiting when addressing the needs of other prisoner groups, such as women, older prisoners, young offenders and

those from minority ethnic groups. A second extensive survey by the Office for National

Statistics, which explored the psychiatric morbidity of prisoners (Singleton et al. 1998), researched a more diverse prisoner population covering remand and sentenced prisoners (n = 3142). This survey included women and young offenders, and considered ethnicity in some aspects of the findings. It contributed substantial evidence of the differences amongst groups of prisoners. In particular, it showed that women prisoners and young offenders, although having many of the same problems as male prisoners, have them to a significantly greater degree (Singleton et al. 1998). Findings from the Office of Population Censuses and Surveys/Office for National Statistics surveys (Bridgwood & Malbon 1995, Singleton et al. 1998) remain the main sources of information on the health needs of prisoners for England and Wales. More recently, studies by Borrill et al. (2003a), Fazel et al. (2001a) and Coid et al. (2002a) have shown a conscious move towards researching the needs of specific groups of prisoners.

Health needs of women in prison Women comprise approximately 6% of the total prison population, but the rate is increasing rapidly; 10 years ago, the average female prison population was under 2000 (Prison Reform Trust 2005), and is now currently

4392 (National Offender Management Service 2006).They are mainly a 'young' population with 62% of women in prison under 30 years of age (Marshall et al. 2000).

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Women tend to commit non-violent crimes and serve shorter sentences compared to men, with nearly two thirds f women in 2003 being sentenced to custody for 6 months or less (Prison Reform Trust 2005). Questions challenging this system of punishment have been raised, not least because of the impact on the children of incarcerated

women (Prison Reform Trust 2005). The short sentences and rapid turnover of female prisoners also creates problems for the prison healthcare since there is little time in which to address women's healthcare needs. Social exclusion of women in prison

Women in prison experience greater adverse social conditions prior to imprisonment than men. A disproportionate number of women in prison have no qualifications

(71%) compared to 15% of women in the general population and 52% of the male prison population (Social Exclusion Unit 2002). O'Brien et al. (2001), exploring data from the Office for National Statistics survey, found that one in four women interviewed had come

from a background of local authority care, and as many as one in three had experienced sexual abuse (Singleton et al. 1998).

There is no national data regarding the numbers of pregnant women in prison or those giving birth during the time of imprisonment; however, Imprisoned Women and Mothers

(Home Office 1997) reported that, of the then entire female prison population, 61% were mothers of children aged 18 years or younger and/or were pregnant. During a 5-year period between 1990 and 1995, 269 babies were born to women in prison (HM Inspectorate of Prisons for England and Wales 1997a). Mothers in prison continue

to experience social disadvantage; issues such as separation and making arrangements for children following imprisonment can have an impact upon mental and physical health. Although there was no health focus to the survey, the majority of mothers reported concerns about their children, depression, loneliness and problems coping with prison (Home Office 1997). Risky behaviour of women in prison Prisoners' health problems are compounded by a greater incidence of 'risky' behaviour including smoking,

drinking, drugs and unsafe sex compared to the general population (Bridgwood & Malbon 1995, Social Exclusion Unit 2002). The evidence suggests that there are

high levels of drug misuse and alcohol consumption amongst women in prison. Fifty-five per cent of female sentenced prisoners have a history of problematic drug use compared to 8% of women in the general population (Social Exclusion Unit 2002). Although fewer women than men in prison report hazardous drinking habits, over twice as many female sentenced prisoners admitted to hazardous drinking in the year prior to imprisonment than women in the general population (Social Exclusion Unit 2002). Women prisoners are more likely than their male counterparts to be heavy smokers (females, 82%; males, 77%) and considerably more likely to smoke than women in the general population (27%) (Marshall et al. 2000). The review found no studies which explored the sexual behaviour or prevalence of sexually transmitted infections of female prisoners, although research exploring the sexual behaviour of male prisoners suggests

they are generally more sexually active than a general population-based sample in terms of lifetime number of partners (Green et al. 2003). Although few papers in the review from the early 1990s specifically addressed the health needs or health

behaviour of women prisoners, evidence and opinions emerging towards the end of the decade suggested that women's health needs were not being met. The Prison Service recognised that, without effective interventions, the vast majority of women prisoners would, on release, return to their risky lifestyles (HM Inspectorate of Prisons for England and Wales 1997a). A raft of recommendations was set out in response to the findings of

the review in order to meet the specific needs of women in prison more appropriately. Recommendations included the implementation of a developed healthcare service

for women, and the need to regularly audit women's healthcare screening methods in order to assess the efficacy of the service (HM Inspectorate of Prisons for England and Wales 1997a). Physical and mental health needs of women in prison

There is no national data of the physical health and health-related behaviour of female prisoners as exists for the male prison population in the Office of Population Censuses and Surveys survey (Bridgwood & Malbon 1995). The limited evidence from the psychiatric morbidity survey suggests that women have greater physical health needs than men. Approximately 40% of female prisoners reported long-standing physical

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problems compared to 33% of the male prisoners (Singleton et al. 1998).

Two studies concerning cervical cancer amongst female prisoners were retrieved (Downey et al. 1994,Plugge & Fitzpatrick 2004). Risk of cervical cancer is

much higher amongst women in prison; abnormal cervical smears in the prison population have been put at double that of the general practice population (Downey

et al. 1994). This could be explained by women in prison being less likely to have gone for regular smear tests (Plugge & Fitzpatrick 2004). Women suffer higher levels of mental health problems compared to male prisoners, and in terms of primary mental health needs, female prisoners report significantly higher numbers of neurotic symptoms than male prisoners. Of those prisoners held on remand, 81% of women compared to 67% of men reported sleep problems (O'Brien et al. 2001). Much of the literature regarding the mental health of women prisoners considers the concerns about high levels of psychotropic drugs prescribed to women in prisons (HM Inspectorate of

Prisons for England and Wales 1997a, Prison Reform Trust 2000, O'Brien et al

. 2001, Kesteven 2002, Rickford 2003). The psychiatric morbidity survey uncovered

evidence that many more women were being put on prescription drugs acting on the central nervous system than had been receiving prescriptions for such drugs

before entering prison (O'Brien et al. 2001). The combining of antidepressants, major tranquillisers and night sedation are also causing concern since the practice may put women at even greater risk of increasing their addictions (Rickford 2003). These findings have implications for the management of mental health needs for women in prison; in 2000, the Prison Reform Trust and the National Health Service called for an

audit of patterns of drug prescribing for prisons in order to establish the extent of the problem. As yet, then audit is still to be carried out (Prison Reform Trust 2000). Despite a wealth of literature about attempted suicide and self-harm amongst the prison population, there was comparatively little that focused on these problems in the female prison population. However, there are concerns about the high and rising levels of suicide attempts and self-harm amongst the female prison population (Dockley 2001, Prison Reform Trust 2005). Over one-quarter of the female remand respondents in the

psychiatric morbidity survey had tried to commit suicide in the previous year, twice the proportion of male remand prisoners (Singleton et al. 1998). Selfharm is also much more common among female than male prisoners, and despite representing only 6% of the prison population, women make up nearly half of all reported incidents of self-harm (Prison Reform Trust 2005). The Prison Service use a single strategy for any prisoners

assessed as being at risk of self-harm or suicide, but this is thought by some to be counterproductive for women who deliberately and persistently self-harm (Dockley 2001). However, a follow-up review to Women in Prison presented evidence that measures are being addressed by the Suicide Awareness and Support Unit in order to manage such specific problems encountered in women's prisons (HM Inspectorate of Prisons for England and Wales 2001).

HM Prison Service (2010) 'Publications and Documents' Resource Centre http://www.hmprisonservice.gov.uk [accessed 31st October 2010]

Tudor Hart, J (1971) ' The inverse car law today' The Lancet.360 (9328) pp.252-254

World Health Organisation. (2010) 'Activities' Prisons and Health http://www.euro.who.int [accessed 31st October 2010]