Developing health and wellbeing in prisons: an analysis of prison inspection reports in Scotland.

Background: The Scottish Prison Service (SPS) has been long regarded for its progressive policy approach to health promotion in prison. It is one of the few countries with a strategic plan for health promotion implementation. Given the paucity of understanding in relation to the concept of a health promoting prison, this study assessed routinely collected prison inspection data to understand and distil learning in regard the practical implementation of health-promoting prisons.

Methods: Her Majesty's Chief Inspector of Prisons for Scotland (HMIPS) oversees the independent inspection of all prisons. This desk-based study analysed openly accessible inspection reports from a public repository. The sample was limited to inspection reports using the 2018 revised Standards to ensure comparability between reports. Eight unique inspection reports meeting this criterion were downloaded between January and October 2020. The prisons had their inspections undertaken between May 2018 and January 2020. Data from the reports which focused on 'health and wellbeing' were inductively coded using NVivo 12 to support thematic analysis.

Results: Results are presented against the values and principles outlined in the SPS' own framework for promoting health in prison. All of the institution reports contained evidence of fairness and justice in their prison and understandings of health inequalities were recognised by staff. There were also examples of mutual (peer) support between people in prison; good relationships between staff and prisoners; and strong health promotion leadership. Conversely, some environmental conditions hindered the development of health promotion - this included staffing shortages and some practices fostering health inequity. Even where a prison was reported as having health promotion activities in place these were focused on a narrow range of individual risk factors such as smoking cessation or substance misuse. Far less attention was paid to wider health determinants.

Conclusions: Scotland has been at the forefront of attempts to embed a health promoting prison philosophy in their justice system. Inspection data focusing on 'health and wellbeing' were analysed, but the analysis suggests that more could be done to ensure a health promoting setting. The way prisons inspectors are assessing health and wellbeing in particular areas is very narrow, with the focus exclusively on healthcare without a wider appreciation of how other areas of prison life can impact.