Physical Activity in Prison
The effects that prison incarceration has on the health and well-being of inmates are multi-faceted and complex. The prison environment presents stressors not experienced outside of the prison context that can bring about exacerbated health problems and psychological difficulties. Health care delivery in prisons is an important issue, as primary healthcare initiatives designed to focus on disease prevention are required in order to maintain health in the prison population that is comparable to the outside world. An important component for many primary health programs is a physical exercise regimen. The following discussion outlines the issue of including organized physical activity as a component to prison programming, examining its many benefits and suggestions are made with regard to how exercise programs within prisons could be improved upon in order to best serve the health and well-being of prisoners and contribute to inmate rehabilitation.
Prisoners’ rights to physical activity in prison
Since prisoners are not a visible demographic to the general population, the health and well-being of this group is not often reflected upon in typical healthcare considerations. Little is known about the health conditions and needs for healthcare within prison because in the United States, inmates are not included in national health surveys that assess the prevalence of chronic diseases (Binswanger et al., 2009). Health care in prisons, especially primary care focused on the prevention of disease is very important from both human rights and public health perspectives (Elger, 2011). Primary care efforts are designed in order to provide individuals with information and tools in order to best choose behaviors that are conducive to optimal health. Physical exercise programs are an important part of primary care due to the powerful effects exercise has on the prevention and treatment of many ailments. It has been determined by the European Court of Human Rights that it is inhumane and degrading for prisoners to receive insufficient healthcare in relation to the general population (Elger, 2011). Furthermore, depriving prisoners of valuable physical activity programming targeted at improving health outcomes would be considered in violation to the European convention on Human Rights. However, although denying health promotional activities to inmates is considered to be inhumane, most countries do not place the protection of prisoners’ right to adequate health care as a high priority (Elger, 2011).
It has been demonstrated through research that there exist dramatic health inequalities for inmates in correctional institutions, especially in regard to exercise and nutrition (Agozino & Volpe, 2009). Furthermore, inmates do not have access to the same level of primary preventive healthcare with regard to exercise and diet in comparison to the community. The researchers looked at the exercise and diet practices of inmates and compared them to those of the community. Findings indicated that poor diet and exercise lifestyle factors among inmates correlated with increased frequency of obesity, type 2 diabetes, and hypertension among both populations (Agozino & Volpe, 2009). This provides evidence indicating a crucial need for more effective primary healthcare in prisons that includes a physical activity component.
Why is it important that prisoners have access to physical activity programs in prison? There are several reasons why importance should be place on initiating and implementing exercise programs in prison that affect not only the prisoner, but also the staff within the prison context, as well as society at large. How is it possible for this type of programming to have a ripple effect outwards that impacts all of society? Physical activity positively impacts the physical, mental, and emotional health of individuals. Improved well-being among inmates in these respects may contribute to less demands placed on the staff in the prison. Furthermore, physical activity may contribute to more effective rehabilitation of inmates, which may result in inmates transitioning more successfully back into society upon their release from prison.
Essentially, prisoners have a right to health just as much as any member of the general population. However, the health care available to prisoners in the United States often falls below standards that would be considered as acceptable (Exworthy et al., 2012). Improvements have been made in regards to health services offered to inmates, but the demand for quality services is growing at a rate too fast for services to keep up to, due to growing numbers of inmates and the fact that prisoners present with needs that are often more numerous ad complex than those of individuals in the general population (Exworthy et al., 2012). Health care services and programs in prisons need to be improved in order to address the many and complex needs of inmates, and the inclusion of physical exercise components as a part of this care could significantly benefit the level of health exhibited by inmates. A framework promoting equivalence in healthcare for inmates was proposed by Exworthy et al. (2012). This framework promoted healthcare for prisoners that is available, accessible, acceptable, and demonstrating high quality, represented by the acronym AAAQ. In regards to physical activity programming, its inclusion in healthcare services could also be promoted through this type of framework. The authors suggested that the AAAQ framework would result in healthcare that meets more acceptable standards for the inmate population (Exworthy et al., 2012).
Physical activity as an important component to primary healthcare
Exercise is an important and effective component to the prevention of many illnesses, and furthermore may be useful as a part of primary care programs for health promotion in prisons. The effectiveness of the promotion of exercise based in primary healthcare was investigated by Orrow et al. (2012). These researchers explored whether physical activity promotion delivered as part of primary care was effective in developing into sustained effects on fitness with sedentary adults. The results of the study indicated that exercise promotion as a part of primary care was effective at increasing the physical activity levels of sedentary adults 12 months after intervention thus also sustaining the beneficial effects resulting from the regular exercise including disease prevention, weight control, and stress relief (Orrow et al., 2012). Based on these findings it may be suggested that inmates also would respond similarly to physical activity as a component of primary care, with sedentary inmates especially benefiting from the intervention.
Health conditions among inmates that would benefit from exercise interventions
Healthcare personnel in prisons are continually implementing programming aimed at health promotion for inmates (Condon et al., 2007). It is important to have a comprehensive understanding of the specific healthcare needs present among the inmate population. Condon et al. (2007) conducted a study in which they provided an overview of literature pertaining to the needs of prisoners with regard to primary healthcare. The results of this study indicated that with regard to the areas of general health needs demonstrated by the prisoners, chronic disease management, and health promotion, the inmate population exhibited greater health needs than that shown by the community at large (Condon et al., 2007). Furthermore, these demanding health needs necessitate a greater demand for effective primary healthcare, which may often be insufficient in the prison setting (Condon et al., 2007). The researchers concluded that future research must explore aspects pertaining to primary care nursing in the prison context that effectively address the healthcare needs of inmates (Condon et al., 2007). Physical activity as a component to this primary care should be investigated as a potential enhancement for the healthcare provided to inmates.
The healthcare needs of prisoners were also explored through a review conducted by Watson et al. (2004). The researchers recognized that the ever-increasing population of inmates in prison are presenting with considerable health conditions and issues necessitating primary and treatment interventions. Also, it was described how the main aims and objectives of prisons, which are punishment, correction, and community rehabilitation may be at odds with healthcare goals (Watson et al., 2004). It was also suggested by these researchers that one of the main desirable aims of healthcare within prisons is health promotion as a part of primary care, which would include the development and implementation of physical activity programs. Furthermore it was emphasized that effective health care for prisoners is highly dependent on cooperative partnerships between prison services and health services (Condon et al., 2007). Therefore effective exercise programming for inmates would require collaboration with professionals, such as exercise physiologists, who could develop the most effective exercise programs as part of primary care that would most effectively improve health outcomes for inmates.
How healthy are inmates in general? Research has indicated that prisoners present higher incidences of physical and psychological issues and disorders in comparison to the general population (Voller et al., 2011). The health conditions exhibited by inmates may be due to various lifestyle and behavioral factors. Voller et al. (2011) showed that a vastly greater proportion of inmates smoke tobacco than the general population, with 70.6% of prisoners and only 33.6% of the general population smoking cigarettes. Common health conditions experienced by the inmates included digestive disorders, parasitic conditions, pathologies of the teeth and oral cavity, diseases of the bones and connective tissues, circulatory disorders, conditions affective the endocrine and metabolic systems including diabetes, heart disease, respiratory conditions, an diseases of the nervous system (Voller et al., 2011). It was indicated by the results of the study that the prevalence of certain health conditions such as diabetes, obesity, and heart disease were significantly higher among prisoners than the general population (Voller et al., 2011).
Similar results were obtained by Binswanger et al. (2009), in a study that demonstrated higher risk of several health conditions among prisoners, including hypertension, asthma, and arthritis. Findings indicated that the inmates had a significantly higher rate of chronic health conditions in comparison to the general population even when adjustments were made for major differences in sociodemographic variables and for the consumption levels of alcohol (Binswanger et al., 2009). Considering physical exercise is an important component to effective prevention and treatment for those disorders, this provides evidence supporting the critical necessity for physical activity programming in prisons.
The prevalence of chronic medical conditions among prisoners was also assessed in a study conducted by Harzke et al. (2010). These researchers investigated health conditions presented by inmates within the prison system in Texas, and emphasized the importance of further understanding the healthcare needs of prisoners due to the growing population in prisons and the implications chronic medical conditions present as a public health concern (Harzke et al., 2010). The prevalence estimates of disease rates among the inmates indicated that the most commonly experienced health conditions were hypertension, asthma, diabetes, and heart disease, and that one quarter of the inmates in the study had at least one of these medical conditions (Harzke et al., 2010). Furthermore, many inmates were afflicted with more than one of these health conditions necessitating treatment including medications which add up to costly expenses paid for by tax payer dollars. It was expected that as the population in prisons increases both in numbers and in age, so too will the burden placed on health care services within institutions, providing further evidence for the necessity of exercise as an integral part of health and well-being (Harzke et al., 2010). This further illuminates the value that physical activity programs provide in the prison environment as a component to primary health care.
Diabetes is a growing and critical health problem within prisons in the United States. The American Diabetes Association (2008) indicated that there are over 2 million individuals incarcerated in correctional institutions in the United States at any one time, and that approximately 80,000 of these prisoner have diabetes, which represents a prevalence rate equaling 4.8%. It is suggested that the rate of diabetes within prisons will continue to grow exponentially due to increasing prison populations due to growing numbers of aging prisons as a result of changes to current sentencing guidelines, as well as growing incidences of diabetes among younger people (American Diabetes Association, 2008). Therefore, primary care among inmates directed toward diabetes prevention is of the utmost importance. An integral component to this preventive care is exercise, which reduces the risk for the development of diabetes, and any subsequent health problems. Serious health problems that result from diabetes include cardiovascular issues, loss of vision, amputation, and renal failure (American Diabetes Association, 2008).
One significant risk factor for several health conditions including heart disease, diabetes, and hypertension that is highly prevalent among the prison population in obesity. Rates of obesity and rates of prison incarceration have both dramatically increased in present years in the United States (Leddy et al., 2009). Therefore, it may be deduced that the prison system will contain ever increasing numbers of inmates who are obese and are suffering from or will eventually experience diseases related to obesity (Leddy et al., 2009). It is common for inmates to become obese during incarceration and the rate of inmates developing obesity-related conditions in prison, such as diabetes, is ever increasing (Leddy et al., 2009). The economic and financial effects this will have on prison systems as they adapt to pay for health care services for inmates will be detrimental as costs will continue to rise. It is therefore important that policy makers within the prison system evaluate strategies for disease prevention among inmates, including the implementation of effective physical activity programs. Leddy et al. (2009) indicated that Japanese prison systems could provide a model for preventive care that could be emulated by the United States, in which inmates are given a healthy restrictive diet and must take part in enforced physical activity. These initiatives within Japanese prisons have resulted in improved overall health among inmates (Leddy et al., 2009).
In order to effectively deliver physical activity programming within prisons, it is necessary for accurate health assessments to be carried out with inmates. Assessments should routinely screen inmates for symptoms of chronic medical conditions so that prevention and early intervention strategies can be put into place. Exercise activities should be implemented as a main part of these interventions. Along with the exercise, it would be of benefit for the inmates to receive education surrounding risk factors for prevalent health conditions such as cardiovascular disease and diabetes, so that there is a clear understanding of the value that exercise brings to overall health and well-being (D’Souza et al., 2005).
The effectiveness of exercise interventions
It is an unfortunate fact that inmates incarcerated in prison often demonstrate poor status of health as well as an increased risk for suffering from chronic conditions that may be debilitating (Perez-Moreno et al., 2007). As noted earlier, Japanese prisons have implemented restrictive dietary programs and enforced physical activity in order to improve the health of inmates through prevention and effective disease management (Leddy et al., 2009). Chronic diseases such as diabetes, cancer, and cardiovascular disease presently account for approximately 65% of all deaths among the general population worldwide, and these conditions are expected to be responsible for more than 75% of deaths by the year 2030 (Blair et al.,2012). Since the prevalence of these chronic medical conditions is higher among inmates in prison, it may be suggested that the death rate due to these afflictions is even higher among prisoners. Research has established a direct, causal relationship between these chronic health conditions and preventable lifestyle factors, such as the effects exercise has on obesity (Blair et al.,2012).
In particular, diabetes is becoming a growing public health concern both within prisons and in the general population. Exercise is one of the most practical and effective non-pharmacological interventions that diabetes patients can utilize in order to significantly improve levels of blood glucose (Zisser et al., 2011). Specifically, blood glucose levels usually drop significantly both during and after physical exercise (Zisser et al., 2011). This observed drop is due to the body’s efficient use of glucose as a fuel during exercise. However, when diabetes patients begin exercise programs, it is necessary to assess nutrition and medications in order to account for the differences in blood glucose that are caused by the physical activity (Zisser et al., 2011). Therefore, although exercise programs for inmates with diabetes are needed and could provide many benefits, it would be necessary to have proper assessment and monitoring of inmates while they exercise to ensure health and safety.
Furthermore, sedentary lifestyle, which is an issue among inmates, has been determined one of the most critical and significant problematic health issues facing society in the twenty-first century (Blair et al.,2012). According to Blair et al. (2012), this statement is undeniable due to the evidence available on the direct and indirect effects that physical activity has on mortality and morbidity from chronic health conditions like heart disease, obesity, diabetes, and hypertension. Prison health care services could benefit from the development and implementation of exercise programs such as the one developed by the American Medical Association called Exercise is Medicine (Blair et al.,2012). This initiative was developed in recognition of the primary importance that physical activity has on general health and well-being, as well as disease prevention. The goals of the program are to reduce sedentary lifestyles, introduce exercise counseling as an integral component in clinical practice, and to emphasize the importance of exercise therapy as a valid intervention across several diverse populations (Blair et al.,2012). Researchers stress the importance of exercise intervention as a means to ameliorate chronic diseases that are induced by inactivity and the financial burdens that accompany them. Moreover, prison health care services would reap both health and financial benefits from exercise interventions, and these initiative should therefore be further appreciated and promoted within the prison context (Blair et al.,2012).
What forms could physical activity interventions take that would help promote the health and well-being of prisoners? It may be suggested that behavioral counseling could be effective in delivering education to inmates surrounding the health benefits of exercise. However, the question remains as to how successfully inmates will put into practice the advice heeded through educational initiatives. Results of a study investigating the effectiveness of behavioral counseling in the prevention of cardiovascular disease in the general population may provide a general sense of how effective behavioral counseling regarding exercise would be with a prison population. Bock et al. (2012) recognized that cardiovascular disease presents a significant public health burden and that the advice provided by physicians with regard to behavioral risk factors associated with the disease (such as sedentary lifestyle) is valuable. Through a systematic review, the authors concluded that primary care settings focusing on disease prevention are in need of increased behavioral counseling, especially in the realm of physical activity (Bock et al., 2012). Therefore, inmates would also most likely benefit from behavioral counseling regarding the practice of physical activity.
Cardiorespiratory and resistance training programs in prisons have been demonstrated to have success in the improvement on cardiorespiratory fitness, dynamic strength endurance, muscle mass, as well as quality of life (Perez-Moreno et al., 2007). In particular, the inmates under investigation in a study by Perez-Moreno et al. (2007) showed improved peak cardiovascular function as well as improved bench press and knee extensor performance as a result of exercise programming. Based on these findings, it was concluded by the researchers that supervised physical exercise training has the ability to promote positive outcomes in the physical fitness of inmates incarcerated in prison.
Another type of exercise intervention that has had demonstrated success with the inmate populations in prison is yoga. Harner et al. (2010) conducted a study to explore the effects that a yoga program could have on the psychological well-being of women incarcerated in prison. Specifically, the researchers aimed to address how feasible it was to develop and implement an exercise intervention within the prison context, as well as make observations regarding the effects that a group yoga program that ran bi-weekly for three months had on depression, anxiety and perceived level of stress among the women prisoners. Data was obtained through the use of various instruments such as inventories for depression and anxiety, as well as scales to measure perceived stress. These measures were applied before treatment to establish a baseline, and then were applied again during and after the treatment. The findings of the study indicated that the yoga intervention resulted in a significant decrease in depression, anxiety, and stress among inmates (Harner et al., 2010). These findings highlight how yoga interventions specifically designed for prisons could prove to be highly effective for the improvement of well-being among prisoners, potentially leading to less reliance on medications or other therapeutic interventions that may be more costly.
The cost of exercise programming
When exploring the costs involved in developing and implementing physical exercise programming as a part of primary healthcare services in prisons, it is important to take all angles of the expenses involved into account. The argument may be presented that the development of this type of programming is costly, and that doing so would require increased tax payer fueled funding from the government, which would be considered a serious drawback. However, it is necessary to take a broader perspective and approach the issue holistically. Physical activity programming in prisons has the ability to effectively prevent chronic health conditions among inmates. Medical conditions experienced by inmates necessitate regular medication and treatment interventions which end up being extremely costly. Preventing health conditions through exercise programs would cost dramatically less than the delivery of treatment for disease management. Furthermore, physical activity interventions provide a cost-effective way of delivering health benefits to prison inmates (Blair et al.,2012).
Conclusion
An active lifestyle is one of the most important components to good health. This rings true not only for the general population, but also for prisoners. Due to certain factors, little has traditionally been know about the state of health and healthcare within prisons, but this is beginning to change as research is starting to pay increasing attention to this population. Incarcerated inmates are at a higher risk for developing chronic medical conditions that can have dire consequences, such as obesity, cardiovascular disease, and diabetes. However, these health conditions and others can be effectively prevented through regular exercise. Therefore, it is of the utmost importance that efforts and resources be allocated towards the development and implementation of physical activity programs as part of primary healthcare services within prisons. Doing so will improve the health and well-being of inmates and will improve cost-effectiveness with regard to service delivery. This is due to the vast amounts of funds that could be saved if medication and treatment for chronic disorders in prison were reduced due to the positive effects of exercise on inmate health.
References
Agozino, B., Volpe, S.L. (2009). Health inequalities in correctional institutions: implications for health inequalities in the community. Journal of Correctional Health Care, 15(4), 251-67.
American Diabetes Association (2008). Diabetes management in correctional institutions. Diabetes Care, 34(1), S27-S81.
Binswanger, I.A., Krueger, P.M., Steiner, J.F. (2009). Prevalence of chronic medical conditions among jail and prison inmates in the U.S.A. compared with the general population. Journal of Epidemiology and Public Health, 63(11), 912-9.
Blair, S.N., Sallis, R.E., Hutber, A., Archer, E. (2012). Exercise therapy — the public health message. Scandinavian Journal of Medicine & Science in Sports, Epub.
Bock, C., Diehl, K., Schneider, s., Diehm, C., Litaker, D. (2012). Behavioral counseling for cardiovascular disease prevention in primary care settings: a systematic review of practice and associated factors. Medical Care Research and Review, Epub.
Cashin, A., Potter, E., Stevens, W. Davidson, K., Muldoon, D. (2008). Fit for prison: special population health and fitness programme evaluation. International Journal of Prisoner Health, 4(4), 208-16.
Condon, L., Gill, H., Harris, F. (2007). A review of prison health and its implications for primary care nursing in England and Wales: the research evidence. Journal of Clinical Nursing, 16(7), 1201-9.
D’Souza, R.M., Butler, T., Petrovsky, N. (2005). Assessment of cardiovascular disease risk factors and diabetes mellitus in Australian prisons: is the prisoner population unhealthier than the rest of the Australian population? Australian and New Zealand Journal of Public Health, 29(4), 318-23.
Elger, B.S. (2011). Prison medicine, public health policy and ethics: the Geneva experience. Swiss Medical Weekly, 141, w13273.
Exworthy, T., Samele, C., Urquia, N., Forrester, A. (2012). Asserting prisoners’ right to health: progressing beyond equivalence. Psychiatric Services, 63(3), 270-5.
Harner, H., Hanlon, A.L., Garfinkel, M. (2010). Effect of Iyengar yoga on mental health of incarcerated women: a feasibility study. Nursing Research, 59(6), 389-99.
Harzke, A.J., Baillargeon, J.G., Pruitt, S.L., Pulvino, J.S., Paar, D.P., Kelley, M.F. (2010). Prevalence of chronic medical conditions among inmates in the Texas prison system. Journal of Urban Health, 87(3), 486-503.
Leddy, M.A., Schulkin, J., Power, M.L. (2009). Consequences of high incarceration rate and high obesity prevalence on the prison system. Journal of Correctional Health care, 15(4), 318-27.
Orrow, G., Kinmonth, A.L., Sanderson, S., Sutton, S. (2012). Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomized controlled trials. BMJ, 344, e1389.
Perez-Moreno, F., Camara-Sanchez, M., Tremblay, J.F., Riera-Rubio, V.J., Gil-Paisan, L., Lucia, A. (2007). Benefits of exercise training in Spanish prison inmates. International Journal of Sports Medicine, 28(12), 1046-52.
Voller, F., Silvestri, C., Orsini, C., Aversa, L., Da Fre, M., Cipriani, F. (2011). The health conditions of prison inmates in Tuscany. Epidemiologia e prevenzione, 35(5-6), 297-306.
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