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The Relationships of Prison Climate to Health Service in Correctional

Environments: Inmate Health Care Measurement, Satisfaction and Access in
Prisons

Article  in  The Howard Journal of Crime and Justice · July 2011

DOI: 10.1111/j.1468-2311.2011.00658.x

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The Howard Journal
of Criminal Justice

The Howard Journal Vol ]]] No ]]. ]]] 2011 DOI: 10.1111/j.1468-2311.2011.00658.x
ISSN 0265-5527, pp. 1–13

The Relationships of Prison Climate

to Health Service in Correctional
Environments: Inmate Health Care
Measurement, Satisfaction and Access
in Prisons

MICHAEL W. ROSS, ALISON LIEBLING and SARAH TAIT

Michael W. Ross is Professor of Public Health, University of Texas, USA;
Alison Liebling is Professor of Criminology, University of Cambridge;
Sarah Tait is Visiting Scholar, University of Cambridge

Abstract: Correctional institutions which are characterised by authoritarian organisation

may control access to health care services through filtering requests through correctional
staff, or conversely by using staff to identify and facilitate inmate medical care. We
investigated the relationship between inmate-assessed prison social climate and
satisfaction with health care in over 4,800 male and female inmates in 49 English/
Welsh correctional institutions (ranging from high to low security). A single eleven-item
dimension of health care satisfaction was identified in the Measuring the Quality of
Prison Life (MQPL) instrument. Multiple regression of the dimensions of prison climate
as measured by the MQPL on health care satisfaction indicated that the scales
‘Relationships with staff ’, ‘Safety’, ‘Feedback and care’, ‘Fairness’ and ‘Care for
vulnerable’, predicted 30% of variance in health care satisfaction. Qualitative data on
health care issues from a parallel study of twelve English/Welsh local prisons were used to
explicate the quantitative findings. Data suggest that positive prison climates facilitated
interactions between correctional and health care staff and prisoners, while in negative
climates correctional staff acted as a filter or barrier between inmates and health services.
Further, data suggested that health care staff themselves may be influenced by prison
climate. These findings implicate health care provision and access as an integral part of
prison climate, and suggest that inmates’ judgments on access to, and satisfaction with,
prison health services are significantly associated with general, non-health related prison
climate measures.

Keywords: prison; health care; measurement; access; satisfaction; prison

climate; England

Health-related behaviours and health-seeking behaviours in correctional

environments are of considerable importance. First, inmate populations
are typically disadvantaged and often from the underclass in society, and,
as such, are likely to have poorer health and in some health systems, poorer

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or limited access to health care services. Second, the correctional

environment may potentially exacerbate health issues by facilitating or
exposing to infectious disease transmission, mental health problems
including risk of self-destructive behaviours, and injury from other
inmates. Third, the correctional environment may also provide an
opportunity to make available interventions to inmates to screen for
disease, improve health, avoid risk behaviours, and treat physical and
mental health problems.
Prison or jail (the latter the US term for county prisons holding remand
prisoners or relatively short-term sentenced inmates) health services may
be run by a dedicated prison health service, be contracted to a local health
service agency, be provided by a local authority, or be provided by a
national health scheme. Where it is provided by a prison health service, it
may incorporate the ethos and climate of the prison service. Where it is
usually provided (or contracted) by a national health scheme, as has been
occurring in the UK since 2006, it is assumed that the influence of prison
climate will be less, but see Liebling et al. (2005a). Private correctional
settings, immigration detention centres, and other facilities may also
incorporate institutional rather than national correctional climates.
Thus, depending on the health service available, correctional health
may cover the range of comprehensiveness from provision only of basic
care to the obviously ill, through to preventive health services and attention
to more minor ailments. Some institutions will include their own (24-hour)
hospital facilities, while others will refer out serious cases requiring
hospitalisation.
However, Sim (2002) has noted that historically, prison medicine was
often ‘more concerned with caring for the order of the prison than
ordering care for the prisoners’ (p.301). He argues that the power
dynamics of the prison setting frequently limit health care to the narrowest
of definitions and that it is simply an extension of the prison’s formal and
informal power networks. There are at least two mechanisms by which
prison climate may influence health care. Where the health service is
deeply embedded within the institution and reflects the prison culture, a
suspicion that inmates seek care as malingerers, to obtain better conditions,
or in the hope of being prescribed psychoactive medications, may colour
the judgment of health care workers. This should be a less salient
consideration where health staff attend the institution as part of a
community-wide health service, but this is by no means always the case.
Second, even given no index of suspicion of malingering on the part of the
health care worker, the wing staff may act as a filter for requests for medical
and other health care, and only facilitate requests to see health personnel if
they (the prison staff) feel that the request is regarding something
sufficiently serious. In more extreme cases (US: see, for example, Khanna
2008), prison staff may deny access to health care as a form of punishment,
and actively impede treatment through disrupting it or ensuring that
medication is not taken on time or as directed. In the latter case, for
example, where HIV antiretroviral medication must be taken at appro-
priate times and with appropriate nutritional accompaniments, the

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implications for development of drug resistant viruses for the individual

and for the community are serious, as is a similar impact for development
of antibiotic-resistant organisms where antibiotic medication regimens are
not followed.
Prisons, jails and other correctional environments are, as Goffman
(1961) indicates, ‘total institutions’. As such, they are characterised by
closure (restricted access to the outside world), the reconstruction of
everyday life according to a tight, uniform schedule, and bureaucratic,
authoritarian organisation with a sharp distinction between staff and
inmates, and strong disciplinary control (Burns 1982). As part of total
institutions such as mental institutions and prisons, Goffman (1961)
indicates, one of the functions of the guard is the control of information
from inmates to higher staff levels. Typically, inmates are excluded from
such medical decisions, and such exclusion ‘gives staff a special basis of
distance from and control over inmates’ (p.9). Such control of health and
medical information, where staff may act as filters or conduits in passing
requests for medical consultations on to health services, gives the staff a
powerful role in a prison medical system, even where the health personnel
may be contracted or employed from outside of the system. Further, staff
may also pass on informal information to health services that may negate
requests for health services (for example, information on an inmate being
known to malinger or seek psychoactive drugs). Conversely, prison staff
may facilitate health referrals by noting sick inmates and advising health
services or encouraging a consultation. Thus, the prison climate is likely to
have an impact on prison health services by virtue of its intermediary
position between inmates and health personnel. It may also be the case,
however, that a prison’s culture infiltrates the nursing professionals
working inside the prison.1 Sim (2002) argues, in discussing the NHS
takeover of prison health care, the need to challenge the punitive prison
culture in providing health care of an equivalent standard to NHS care
available in the community.
Prison climate might be expected, then, to relate to health service access
and provision. Where the prison health service is directly provided by
prison staff, the correlation between prison climate and health service is
likely to be higher. Where the prison staff act as a ‘filter’ between inmates
and health services, it is likely to be moderate. In settings where there are
no filters between inmates and health services, and those health services
are run as an open-access community health service, the correlation
between prison climate and health service should be lower, or will depend
on the degree of congruence between prison climate and the philosophy of
the health service. Indeed, Liebling assisted by Arnold (2004) warn that it is
misleading to believe that programmes delivered in prisons provide an
answer to rehabilitation and recidivism, without also considering the context
within which they are delivered (p.166). This is equally the case for the
provision of health care services.
In the US Federal Bureau of Prisons and most US states, health
monitoring at the service evaluation level is more common than in the UK
and this may be due to two factors. First, lack of adequate health care is

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more likely to be subject to judicial review or lawsuits in the US, such as the
Ruiz v. Estelle case (503 F.Supp. 1265 (S.D. Tex. 1980)). Second, in the UK,
prison health care is assumed to be roughly equivalent to the NHS care
available outside the prison (indeed, there has been recent legislation to
move prison health care under the NHS in England/Wales (Wise 1996; Sim
2002; Niveau 2007; Senior and Shaw 2007)). In practice, the NHS is
responsible for commissioning prison health care but does not necessarily
provide it. However, there are considerable differences in health care
utilisation: Marshall, Simpson and Stevens (2001) note evidence suggesting
that doctor consultations in prisons may be three times higher than in the
community in the UK. Better access, and the fact that the institutional
culture of prisons restricts prisoners’ ability to self-care and almost
eliminates their access to over-the-counter medication, may also account
for their finding that health care worker access is 77 times more frequent
(males) and 59 times more frequent (females) than in a demographically-
equivalent community population (although there may be no direct
equivalent of the prison health care worker in the general community).
Senior and Shaw (2007) also note that the Prison Medical Service has been
criticised as invisible and lacking external accountability. In the US, where
prisoners are likely to have access to better health care than might be
available outside, given the high levels of no health insurance among
prisoners (estimated to be as high as 93% (Conklin, Lincoln and Flanigan
1998)), correctional settings are an important site for health care that
would otherwise be unavailable (Niveau 2007). This paradox of prison
health care vis-à-vis community health care between the two countries may
argue for different inmate perceptions of health care in the two nations
(and different relationships between prison climate and health care).
However, attempts to provide equivalent health care in prisons have been
hampered by prison environment and culture across settings in the UK
and US (Sim 2002; Niveau 2007).
It is possible to measure both prison climate and, as part of that climate,
prison health service access and patient satisfaction. Liebling assisted by
Arnold (2004) designed the Measuring the Quality of Prison Life (MQPL)
instrument. This 102-item self-report instrument, developed after ex-
tensive qualitative research on prison climate using prisoner focus groups
to devise the questionnaire items and getting prisoners’ and staff views on
what they consider make a well-functioning prison, has empirically-
derived subscales measuring prison dignity and cleanliness, humanity,
visits in prison, trust, fairness, prison order and organisation, prisoner
safety, development via activities, preparation for release, staff-prisoner
relationships, respect, response to entry into custody, self-harm preven-
tion, race relations, offending behaviour programmes, and health care.
Staff and prisoners independently produced the same set of dimensions,
suggesting a shared vision of prison social order – how the prison is lived
and what shapes it (Liebling assisted by Arnold 2004, p.145). These
subscales summarise what are seen as being the key components that
describe life in prison. The MQPL is oriented toward a caring and decency
model, with items emphasising prisoners’ response to situations (Liebling

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assisted by Arnold 2004; Ross et al. 2008). It is a self-report measure which

is now routinely used to assess prison climate in England and Wales, and
subject to the common limitations of self-report measures, including social
desirability bias, systematic response distortions, the psychometric proper-
ties of the questionnaire scales, and if used alone, mono-method bias. In
the present study, we look at the health care scale and its relationships with
other subscales measuring prison climate to determine which measures of
prison climate are most closely related to access to, and satisfaction with,
prison health care. We examine these at the level of both bivariate and
multivariate predictors.
We also draw on qualitative research conducted in twelve local prisons
in England and Wales as part of an evaluation of suicide prevention
procedures (Liebling et al. 2005a; Liebling et al. 2005b). Ten of these
prisons had higher-than-expected suicide rates. Five were given sub-
stantial investment to improve buildings (including health care centres)
and processes, although all were making significant efforts to address
prisoner suicide and self-harm. Two prisons were included as high-
performing comparators, as they were housing vulnerable populations but
had comparatively low prisoner suicide rates. The qualitative data on the
relationship between prison climate and health care provision was
reviewed to inform interpretations of statistical findings.

Sample
The quantitative sample consisted of 4,887 inmates in English/Welsh
prisons in 2003. Forty-nine institutions were sampled (based on selecting a
random sample of 100 from the total prison population in each institution
sampled). Nearly 90% of respondents were male, and 400 from young
offender institutions. A range of institutions was represented, with
respondents from Category C and local institutions representing the
majority of respondents. The MQPL was filled out anonymously by
inmates and information from the paper forms was entered into a database
and analysed using the Statistical Package for the Social Sciences (SPSS)
version 15.0. Data describing the sample are presented in Table 1.
Qualitative data were obtained from detailed surveys of the quality of
life, in six of these prisons selected for the ‘Safer Locals’ study (Liebling
et al. 2005a; Liebling et al. 2005b). They were carried out with all staff
attending a full staff meeting and presentation, and with 100 randomly
selected prisoners at each site on each occasion; long semi-structured
interviews with staff and prisoners involved in suicide prevention work;
‘off-site’ interviews with all establishment governors and some deputy
governors; and further observation. The ‘Safer Locals’ qualitative research
was conducted between November 2001 and November 2004.

Methods
Data were analysed using SPSS version 15.0 for windows. The ten items of
the health care scale were subject to factor analysis along with a related

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TABLE 1
Sample Demographics

Age in years (n 5 4,837) %

18–20 13.9
21–30 39.0
31–40 26.8
41–50 13.2
 51 7.0
Gender (n 5 4,887)
Male 89.6
Female 10.4
Type of prison (n 5 4,887)
Category B 15.2
Category C 30.2
Category D 2.0
Young offender 8.2
Local 25.5
High security 7.5
Closed female 6.9
Resettlement facilities 2.3
Norwich (mixed use) 2.2
Race/ethnicity (n 5 4,860)
White 78.5
Black 15.1
Asian 4.8
Other 1.6
Regime level (n 5 4,805)
Basic 3.2
Standard 51.8
Enhanced 42.7
Other 1.5
Length of time in this prison (n 5 4,878)
o1 month 12.2
1–6 months 40.3
7–12 months 19.7
13–24 months 14.6
424 months 13.2
First time in prison (n 5 4,871) 35.6
Number of times previously in prison (n 5 3,130)
Once 21.0
2–5 42.9
6–9 19.2
 10 17.0
Length of sentence (n 5 4,237)
o1 year 11.6
1 year buto2 years 9.6
2 years buto4 years 23.0
4 years buto10 years 33.0
10 years butolife 8.2
Life 14.0
Been in this prison before (n 5 3,105) 44.8
Began sentence or remand in this prison (n 5 3,668) 26.8
Done induction course in this prison (n 5 3,704) 80.5

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health care item (question 77: ‘Wing staff take an interest in helping to sort
out my health needs’). Items were subject to principal axis factor analysis
followed by oblique (direct oblimin) rotation (D 5 0). Data indicated that
there was only one latent dimension based on both eigenvalues and scree
test.2 The eleven items were summed to create a health care scale. The
health care scale was correlated (Pearson correlation, with Bonferroni
correction3) with the other prison climate scales of the MQPL, scored as
described by Liebling assisted by Arnold (2004). The MQPL scales were
regressed on the health care scale using simultaneous-entry linear
regression.4

Results
Demographic data (Table 1) indicate that the modal age group of prisoners
was 21–30 years, with the majority in a standard regime. Modal length of
time in the prison in which they were incarcerated at time of filling out the
questionnaire was 1–6 months, over a third had not been previously in
prison, and of those who had, the modal number of previous incarcera-
tions was 2–5. Modal length of sentence was 4–10 years, and nearly half of
those with previous prison experience had been in that prison before. Of
the respondents, 4,011 (82.6%) indicated that they had used health care
services while in the prison. Subsequent data analyses were limited to this
group.
Health care scale scores across prison types were significant on ANOVA
with the health care scale score for Resettlement facility inmates (24.6)
significantly different from all other institutions (range 29.4 to 33.2) at
po0.001 (F 5 13.4, df 5 5), indicating that Resettlement facility respon-
dents had significantly better health care access and satisfaction. ‘Resettle-
ment’ is where prisoners and their families receive assistance and support
from the prison and probation services, and voluntary agencies to help
them prepare for life after prison. Males reported significantly better
access to, and satisfaction with, health care (30.7) than did females (34.0)
(t 5 4.4, df 5 1,147, p 5 0.001). There was no difference on race/ethnicity
comparing the white sample with all other races/ethnicities (t 5 1.4,
df 5 1,141, p 5 0.17), nor for time in that prison split at the median (6
months or less vs46 months: t 5 0.55, df 5 1,147, p 5 0.59).
Table 2 illustrates the items of the health care scale and their loadings.
The scale has high internal reliability (Cronbach’s a 5 0.93) and is
characterised by questions covering the interest of health care staff in
helping inmates, access to services, response to treatment, and response to
mental as well as physical health concerns. Data in Table 3 indicate that all of
the prison climate scales were very significantly (despite Bonferroni
correction) correlated with the health care scale, at correlations of between
0.29 and 0.58. Regression of all scales on the health care scale score
accounted for over 30% of variance in the health care scale, with
‘Relationships with staff ’, ‘Safety’, ‘Feedback and care’, ‘Fairness’ and
‘Care for vulnerable’ all independently and significantly contributing to
predicting variance.

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TABLE 2
Items of the Health Care Scale and their Loadings

H1 Health care staff explain things (treatment and diagnosis) clearly to me 0.62
H2 I can usually see a doctor within a reasonable amount of time 0.51
H3 I can usually see a dentist within a reasonable amount of time 0.35
H4 Health care staff show understanding for my mental health and emotional concerns 0.66
H5 The doctors here believe me when I tell them about my health problems 0.66
H6 I am happy with the treatment I have received in this prison for my health problems 0.34
H7 It is easy to get to see a nurse in this prison 0.48
H8 Health care staff are interested in helping me with my physical health concerns 0.77
H9 The doctors here take the time to listen to my physical health complaints 0.68
H10 I feel cared for by staff on the health care unit 0.77
Q77 Wing staff take an interest in helping to sort out my health care needs 0.38
Cronbach’s a 5 0.93

Discussion
These data demonstrate that concerns about health care – access, time to
service, explanations, quality of treatment, and interest and care of health
staff, form a coherent scale. Of particular interest is the fact that the interest
of wing staff in helping to sort out health needs loads as part of this scale,
suggesting that the continuum of prison health care begins with the
intercession or facilitation of wing staff. This is entirely consistent with
Goffman’s (1961) observation that access to health care facilities in total
institutions is filtered by institution staff.
There is a clear interrelationship between all the dimensions of prison
climate and health care (Table 3), with primarily moderate intercorrelations
as judged by Cohen’s (1988) classification of correlation size. The
correlation with the ‘Feedback and care’ scale was, using Cohen’s criteria,
large. Despite the substantial intercorrelations between scales, multiple
regression indicated that five MQPL subscales accounted for nearly a third
of the variance in prisoners’ assessment of health care services (indicating
that a substantial amount of variance in health care scale score is accounted
for by these other variables). Chief among these were ‘Relationships with
staff ’, ‘Safety’ and ‘Feedback and care’. ‘Relationships with staff ’, Liebling
assisted by Arnold (2004) note, are central to prison life (p.228). This
dimension reflects good levels of staff-prisoner interaction, good relations,
and a lack of confrontational style of staff toward prisoners. It is relevant to
health care in that it implies that as part of staff-prisoner interaction, the
staff will have an understanding of the prisoners’ health issues and be able
to facilitate a referral where appropriate. ‘Safety’, note Liebling assisted by
Arnold (2004, p.296), may be linked to a relaxed atmosphere and a stable
set of social relations within the prison. Feeling safe in prison (to the extent
possible) is closely linked to staff responsiveness (Liebling assisted by Arnold
2004, p.300). Particularly for those at risk of suicide and self-harm, feelings
of safety expanded from concern over direct threats to a general sense of
psychological security, of trust in their environment (Liebling et al. 2005b).

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TABLE 3
Bivariate and Multivariate Relationships of Health Care with Prison Climate

Bivariate correlations of prison climate measures with health care

Correlationn n
Relationships with staff 0.49 1,138
Overall treatment 0.46 1,071
Relationships with other prisoners 0.29 1,146
Fairness 0.44 1,076
Safety 0.49 1,143
Order and organisation 0.49 1,137
Race relations 0.33 1,135
Decency 0.38 1,147
Personal development 0.50 1,145
Offending behaviour courses 0.29 348
Family contact 0.36 1,038
Feedback and care 0.58 1,073
Care for vulnerable 0.47 1,136
Entry into custody 0.38 1,141
Well-being 0.42 1,063
(Note: nAll significant, po0.0009.)

Multiple regression of variables on health care scale score

Beta t Sig.
Relationships with staff 0.27 2.66 0.008
Safety 0.22 2.50 0.013
Feedback and care 0.24 2.31 0.022
Fairness 0.12 1.88 0.06
Care for vulnerable 0.13 1.71 0.08

R 5 0.58, Adj. R2 5 0.30, F 5 9.49, df 5 15, p 5 0.0009

Safety commonly included ‘having someone to talk to’ and having officers
take an interest in their well-being:
What’s happening here to feel safe this time?
Just the fact that there’s somebody keeping an eye on you, people watching you, you
know, somebody’s coming to check that I’m OK, you know? (prisoner, Liebling et al.
2005a)

Staff responsiveness and interest may link prisoners’ perceptions of safety

and their evaluations of health care provision. Further, ‘Feedback and care’
was a significant predictor of health care access and satisfaction. The
‘Feedback and care’ scale contains items indicating that respondents felt
that correctional staff behave in a way that they feel that they can be
trusted, are concerned about how their actions will affect prisoners, and
provide feedback, and are good at explaining decisions on things that
affect the inmate. This dimension suggests that satisfaction with access and
level of care is significantly associated with officers who seem to feel some
responsibility towards prisoners and provide feedback to them.

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These dimensions suggest that there is both a direct and indirect link
between prison culture and health care satisfaction. Good staff relationships
directly facilitate access to health care; but equally, responsive staff may create
a climate of confidence that health care needs will be attended to by officers
should they arise. Tait (2008) found that health concerns were one of three
main prisoner needs that could be mitigated by officers. As health care
operated ‘at a distance’ and often required personal efforts from officers (for
example, to correct medication errors), officers’ approach to prisoner care
was an important factor in access to medical care. Officers who listened to
prisoners’ needs and took action to help them also counteracted the
significant frustration, powerlessness, and uncertainty that medical problems
experienced in prison engendered. Plugge, Douglas and Fitzpatrick (2006)
similarly argue that relations with wing staff cannot be divorced from the
experience of health and well-being in the prison environment.
The qualitative data from the suicide prevention evaluation suggested
several links between prison culture and health care provision. Wing and
health care staff were mutually dependent. Health care staff depend on
officers to unlock prisoners on time for appointments and medication, and
the application system involves officers directly with access (see Plugge,
Douglas and Fitzpatrick 2006, p.66). Health care staff, particularly mental
health nurses, could provide valuable insight and guidance in dealing with
disruptive prisoners and those at high risk of suicide and self-harm. Staff
working in the four ‘best’ prisons (the two high-performing comparator
prisons and two prisons which implemented new suicide-prevention
initiatives fully) tended to see health care as a resource. While staff at these
prisons acknowledged that there was still some ‘misunderstanding’
between discipline and health care staff, relations were good:

It’s an open jail . . . you don’t have a lot of barriers, staff on the wing know they can
pick the phone up and talk to health care. They know that OK, we’re a small unit,
and we may not be able to respond immediately, but we will respond. (health care
manager, Swansea, ‘Safer Locals’ data)
We need them and they need us, and we both know that. (prison officer, segregation
unit, Forest Bank, ‘Safer Locals’ data)

Conversely, the health care climate at institutions with poor cultures

tended also to be negative, with inmates being provided with substandard
or negligent care:

The culture at [Prison X] was characterised by poor leadership, low staff morale,
disorganisation, and staff apathy towards prisoners. . . . Health care staff were
described as unresponsive and uncommunicative, and [prison] staff felt that ‘things
go on that shouldn’t go on and it’s accepted’ (for example, nurses giving the wrong
medication, or withholding medication because they didn’t believe that prisoners
needed it, negative staff attitudes, and prisoners were told to ‘stop mythering’ when
in distress). (‘Safer Locals’ data)

A negative prison culture may actively degrade the standards of health

care, as one governor suggested:

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What we have found is that we had hoped that bringing a whole lot of nurses in
would infuse a nursing culture into our healthcare but what we’ve found is that we
have infused a prison culture into our nurses. (governor, ‘Safer Locals’ data)
These comments indicate that prison climate may act on health care
climate by contaminating the ethical and care-giving standards of prison
health care staff. Sim (2002) has previously observed that health care staff
may take on the values of the prison climate by seeing prisoners as
‘malingerers’, and Niveau (2007) notes the difficulties of doctors working
in prisons being manipulated, by either inmates or warders. Thus, prison
climate may have a direct effect on health care climate through the
acculturation of health care staff into the prison climate.
In all the study prisons, vulnerable prisoners tended to seek respite from the
wings on health care units. The smaller size, fewer people, and expectation of
sympathetic staff provided a less threatening atmosphere, and prisoners felt
there would be less stigma in talking about their problems:
What difference did it make to you going down to the hospital?
Knowing I didn’t have to cope with the stress straight away. Knowing I could get
onto a ward and just chill out for a few days, just try and get my head round my
sentence and knowing if I did have a genuine problem, there’s trained staff and
nurses down there to cope with people like me. (prisoner, ‘Safer Locals’ data)
However, in prisons with poor climates, many wing staff were unsympa-
thetic to prisoner efforts to find respite on health care units. Prisoners were
accused of ‘manipulation’ to have an ‘easier life’ by threatening to self-
harm or to kill themselves in order to be admitted. Those already finding
the wing environment frightening and in considerable distress were thus
subject to further hostility, rather than understanding, at critical vulnerable
moments. Health care practitioners aimed to return prisoners to normal
location where possible so that beds were available for others in critical
need, and so that prisoners had access to better regimes. In prisons with
good working relationships, case conferences were held with relevant
discipline and health care staff before the prisoner was moved. Where
communication links were poor, prisoners and wing staff felt helpless when
they were moved back to the wings too quickly following assessment, and
wing staff became embattled with health care managers over who had
responsibility for the prisoner.
Only two demographic variables indicated significant differences in
health care evaluation. Health care scale scores were significantly lower
(indicating greater satisfaction with access and quality of health care) in
Resettlement facilities compared with other levels of correctional institu-
tions, and for males compared with females. Resettlement facilities have
lower security and encourage greater links with the community through
home and work leave programmes. With more permeable boundaries,
staff and health care climates in such prisons may reflect fewer
characteristics of a ‘total institution’. Women have significantly greater
health care needs compared with women in the community (Plugge,
Douglas and Fitzpatrick 2006) and require additional care around
pregnancy, sexually transmitted diseases, and mental health (HM Chief

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The Howard Journal Vol ]]] No ]]. ]]] 2011
ISSN 0265-5527, pp. 1–13

Inspector of Prisons 1997). The connections between physical and mental

health are complex; every day approximately 20% of women prisoners ask
to see a doctor or nurse – twice the rate of their male counterparts in prison
– due to mental health problems, substance misuse, boredom, loneliness
and fear (HM Chief Inspector of Prisons 1997). Further, women have been
found to hold higher standards of care from prison staff, requiring, on
average, more time and affective depth of caring than do men (Tait 2008).
Women’s greater need and higher expectations may contribute to poorer
evaluations of health care services in prison.
These data are subject to the limitations that they are from one
jurisdiction (England and Wales) where prison health services are being
integrated into the National Health Service (NHS), and it is possible that
there may be significant health care variation across the 49 institutions
studied. However, it is only since April 2006, subsequent to data collection,
that commissioning responsibility for health care services in prisons has
been fully devolved to NHS Primary Care Trusts. Second, it is unclear how
well these data would generalise to other western prison systems, given the
prison health care paradox noted previously. However, it would probably
generalise at least to provision of health education programmes to inmates
(Ross 2011).
In conclusion, these data from a large and representative sample of inmates
of English and Welsh correctional institutions suggest that health care can be
measured in terms of access and satisfaction with quality of service, and that this
health care index is predicted by four dimensions of prison climate. These
dimensions include ‘Relationships with staff ’, ‘Feedback and care’, ‘Safety’ and
‘Care for vulnerable’. These data strongly suggest that access to health care is
mediated through wing staff and that the overall climate of health care strongly
relates to the institution’s climate of care for the welfare of inmates. Health care,
it appears, is related to the prison climate partially because correctional officers
are gatekeepers for entry to the health care system. However, correctional
health care characteristics are also apparently related to the climate of care for
inmates in the system. Improvements in health care in institutions cannot, it
seems, proceed without parallel changes in prison climate and prison officer
attitudes toward inmates.5

Notes
1 In addition, we would not wish to claim that all nursing and medical working cultures
are therapeutic or benign. Poor prison climates are founded on views of prisoners as
less deserving; health care practitioners are not immune to such societal views (see
Plugge, Douglas and Fitzpatrick 2006).
2 Thus, the items formed a coherent single scale rather than two or more subscales.
3 Taking into account a correction for performing multiple correlations, and thus
increasing the magnitude of correlation needed to achieve statistical significance.
4 This procedure controls for the intercorrelations between the scales, leaving only the
independent effects significant.
5 Acknowledgements: Grateful thanks are due to members of the Prison Service Standards Audit
Unit team for allowing us to use data collected as part of their routine audit process, using a
version of the MQPL survey developed by the University of Cambridge team.

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 The Howard Journal Vol ]]] No ]]. ]]] 2011
ISSN 0265-5527, pp. 1–13

References
Burns, T. (1982) Erving Goffman, London: Routledge.
Cohen, J. (1988) Statistical Power Analysis for the Behavioral Sciences, 2nd edn, Hillsdale,
NJ.: Lawrence Erlbaum Associates.
Conklin, T.J., Lincoln, T. and Flanigan, T.P. (1998) ‘A public health model to connect
correctional health care with communities’, American Journal of Public Health, 88,
1249–50.
Goffman, E. (1961) Asylums: Essays on the Social Situation of Mental Patients and Other
Inmates, Garden City, NY.: Anchor.
HM Chief Inspector of Prisons (1997) Women in Prison: A Thematic Review, London:
Home Office.
Khanna, R. (2008) ‘Injured inmate spent two days on cell floor: medical staff withheld
drug because dying prisoner couldn’t come to get it’, Houston Chronicle, 1 January, 1, 6.
Liebling, A. assisted by Arnold, H. (2004) Prisons and Their Moral Performance:
A Study of Values, Quality and Prison Life, Oxford: Oxford University Press.
Liebling, A., Durie, L., Stiles, A. and Tait, S. (2005a) ‘Revisiting prison suicide: the role
of fairness and distress’, in: A. Liebling and S. Maruna (Eds.), The Effects of
Imprisonment, Cullompton: Willan.
Liebling, A., Tait, S., Durie, L., Stiles, A. and Harvey, J. (2005b) ‘Safer Locals
evaluation’, Prison Service Journal, 162, 8–12.
Marshall, T., Simpson, S. and Stevens, A. (2001) ‘Use of health care services by prison
inmates: comparisons with the community’, Journal of Epidemiology and Community
Health, 55, 364–5.
Niveau, G. (2007) ‘Relevance and limits of the principle of ‘‘equivalence of care’’ in
prison medicine’, Journal of Medical Ethics, 33, 610–13.
Plugge, E., Douglas, N. and Fitzpatrick, R. (2006) The Health of Women in Prison: Study
Findings, Oxford: Department of Public Health, University of Oxford.
Ross, M.W. (2011) ‘Pedagogy for prisoners: an approach to prison health education
for inmates’, Journal of Correctional Health Care, 17, 6–18.
Ross, M.W., Diamond, P., Liebling, A. and Saylor, W. (2008) ‘Measurement of prison
climate: a comparison of an inmate measure in England and the U.S’, Punishment
and Society, 10, 447–74.
Senior, J. and Shaw, J. (2007) ‘Prison healthcare’, in: Y. Jewkes (Ed.), Handbook on
Prisons, Cullompton: Willan.
Sim, J. (2002) ‘The future of prison health care: a critical analysis’, Critical Social Policy,
22, 300–23.
Tait, S. (2008) ‘Prison officer care for prisoners in one men’s and one women’s prison’,
(unpublished PhD thesis, University of Cambridge).
Wise, J. (1996) ‘NHS takeover of prison health proposed’, British Medical Journal, 313,
1099.

Date submitted: August 2010

Date accepted: December 2010

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