Why Has the Health-Promoting Prison Concept Failed to Translate to the United States?

This paper is published in the American Journal of Health Promotion.  If referencing the material below, please use this citation:

Woodall, J. (2016) Why has the health promoting prison concept failed to translate to the United States?  American Journal of Health Promotion. DOI: 10.1177/0890117116670426


There is clear evidence which shows that the health of the prison population is poorer than groups in the wider community in relation to physical, mental and social dimensions of health (1).  However, the response to address the inequalities faced by prisoners has varied considerably across countries and continents (2).  Work in Europe, spearheaded by the World Health Organisation (WHO), for example, has been committed to addressing prison health.  Two decades ago, WHO Europe outlined its view of health promotion in prison which was underpinned by values such as empowerment and operationalized through a ‘settings approach’ (3) – the premise that efforts to improve prisoner health should not only focus on individuals but also on the environment and organisational infrastructure of the prison itself – to achieve health gains and improvements.  In-depth critique of the work by WHO Europe and the health promoting prison has been provided elsewhere (4), with conclusions suggesting that while much has been achieved in relation to lobbying European countries to integrate prison health into public health systems (e.g. Norway, France, and England), there is more that can be done in relation to addressing the needs of this marginalised group (5).

Despite challengus-flag-prison721es, WHO Europe remain one of the few organisations developing the health promoting prison concept at a macro-level with some countries within Europe, such as England and Wales and Scotland, adopting clear strategies for health promotion in prison (6).  Much of the prison population can be described as ‘transient and mobile’ in that they frequently shift between imprisonment and free society serving multiple and relatively short-term sentences.  Health promoting prisons, therefore, have the potential to reduce health inequalities through building the physical, mental and social dimensions of prisoners’ health and enabling prisoners to adopt healthy behaviours that can be taken back into the community (7).  One predicted indicator of success for the health promoting prison movement was the expansion of activity beyond European borders (5); yet two decades since the European model was put forward there has been very limited global activity.  Prison health advocates in the US have shown interest in the health promoting prison concept, but it has not been operationalised.  Shelton (8, p.194) makes this point:

“Given that the US is a world leader for incarcerating people of color, the mentally ill and other disparate populations, why then are we not leaders in health promoting prisons (HPP)?  The concept of HPP, introduced in England and Wales and Scotland has peaked interest in the US, but it has not become a reality.”

This paper does single-out the US for lagging Europe in its health promotion prison agenda, but recognises that other regions are lacking as well. However, some areas may have more obvious arguments to explain their deficiencies in policy and practice.  Dixey et al. (9) discussing the situation in the African continent, point to resource challenges and extremity of health need which has meant that African prisons have been unable to engage in health promoting actions.  The reluctance in the US, however, to move forward with a health promoting prison agenda remains puzzling – especially given that the health issues in prisons in Europe are similar to the US and moreover the US has embraced other healthy settings-based agendas (10).  This paper seeks to advance several potential explanations for the hesitancy of the US to embrace both the concept and practice of the health promoting prison.

The first explanation relates to the sheer magnitude of the incarcerated population.  There is no doubt that imprisonment rates in the US are far higher than any other country in Europe.  Currently the US imprison 698 per 100,000 of the population which overshadows the rate in other highly-industrialised nations, such as England and Wales (148 per 100,000), Spain (136 per 100,000), France (95 per 100,000) and Germany (78 per 100,000) prison-overcrowding2(11).  The scale of the prison population may in itself be a barrier to progressing the health promoting prison philosophy.  Indeed, overcrowded facilities were exposed as one of the key reasons why parts of Europe had struggled to implement the health promoting prison (5).

The second explanation relates to public and political perceptions about who is deserving and undeserving of health promotion intervention.  Arguably, health practices in prison populations are often ‘imported’ into the correctional system and so are heavily influenced by poverty, marginalisation and deprivation.  Manifestations of these influences results in behaviours which the general population may find unpalatable, such as injecting drug-use and hazardous alcohol use (12).  Additional spending on correctional health is not always publically endorsed and there have been previous instances where the US Government has blocked progressive prison health policy (13).  There is currently no politically-powerful advocate for progressive prison reform in the US and indeed political arguments to gain additional resource for the health promoting prison may be difficult to justify given that over $39 billion is spent on corrections in the US, the equivalent to $30,000 on average per prisoner (14).  Unlike settings where there exists a clear logic between settings-based health intervention and individual and societal gains – for example in schools – the arguments are more ‘thorny’ in a context whereby ideological views on prison vary (4).

Third, the WHO itself has been criticised for its excessive regionalisation in addressing global health concerns (15).  A unified voice for prison health has not been heard and yet the health of those detained and incarcerated is an issue for all continents, especially as the prison population has grown by 25-30% across the world (11).  It has been surprising that only one WHO region has actively engaged with this and moreover a greater surprise that sharing good practice with other WHO regions has not been seen through, for us-prison-1_0example, global conferences or symposia.

Fourth, there is little robust evidence that suggests that the health promoting prison concept improves health or addresses other outcomes.  Although the accumulation of strategy documents and policy drivers in relation to the health promoting prison have shown some promise in shifting perspectives on prison health away from a medical model toward a more holistic, social perspective of health (16), there has been minimal investment in evaluating the outcomes of the approach (17).  These problems perhaps stem from the difficulties and challenges in evaluating health promotion interventions per se (18) and the complications in evaluating settings based strategies which are inherently holistic and ecological.  However, unlike evaluative efforts in other health promoting settings, such as schools, there is little evidence to suggest that the health promoting prison model works or indeed pays dividends for health and well-being.  This may be exacerbated by a reluctance of funding agencies to support a health promotion research agenda in prisons. This lack of research and evidence may be a further reason why the US have been reluctant to replicate work in Europe.

In conclusion, there is little doubt that the health of the prison population is of global concern and requires immediate attention.  One suggested approach to tackle the disproportionate health and social issues faced by people in prison is to adopt a settings approach – a model which recognises that health is created in the places which people live their lives.  In prison, a settings approach has been espoused in Europe as a way to address health inequalities, but uptake in other parts of the world has been slow, particularly in the US.  One of the indicators of success in prison health in Europe was the translation of the concept to other parts of the world.  However, this has failed to occur with this paper offering several potential explanations for why uptake in the US particularly has not occurred.  It is hoped that the paper will stimulate further debate and dialogue on the issues so that best approach to tackling the health of the prison population is found.


1 WHO. Prisons and health. Copenhagen: WHO; 2014.

2 Woodall J, Dixey R. Advancing the health promoting prison: a call for global action. Global Health Promotion. 2015.

3 WHO. Health in prisons.  Health promotion in the prison setting.  Summary report on a WHO meeting, London 15-17 October 1995. Copenhagen: WHO; 1995.

4 Woodall J. A critical examination of the health promoting prison two decades on. Critical Public Health. 2016(DOI: 10.1080/09581596.2016.1156649):1-7.

5 Gatherer A, Møller L, Hayton P. The World Health Organization European health in prisons project after 10 years: persistent barriers and achievements. American Journal of Public Health. 2005 Oct;95(10):1696-700.

6 Woodall J. Health promoting prisons: an overview and critique of the concept. Prison Service Journal. 2012;202:6-12.

7 Woodall J, South J. Health promoting prisons: dilemmas and challenges. In: Scriven A, Hodgins M, editors. Health promotion settings: principles and practice. London: Sage; 2012. p. 170-86.

8 Shelton D. Health promoting prisons in the era of mass incarceration in the US. Archives of Psychiatric Nursing. 2015;29(3):194.

9 Dixey R, Nyambe S, Foster S, Woodall J, Baybutt M. Health promoting prisons–An impossibility for women prisoners in Africa? Agenda. 2015:1-8.

10 Story M, Nanney MS, Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Quarterly. 2009;87(1):71-100.

11 Walmsley R. World prison population list (11th edn). London: International Centre for Prison Studies; 2015.

12 Whitehead D. The health promoting prison (HPP) and its imperative for nursing. International Journal of Nursing Studies. 2006;43(1):123-31.

13 Wilper AP, Woolhandler S, Boyd JW, et al. The health and health care of US prisoners: results of a nationwide survey. American Journal of Public Health. 2009;99(4):666-72.

14 Henrichson C, Delaney R. The price of prisons: what incarceration costs taxpayers. New York: Vera Institute of Justice; 2012.

15 Gostin LO, Sridhar D, Hougendobler D. The normative authority of the World Health Organization. Public Health. 2015;129(7):854-63.

16 Woodall J, de Viggiani N, Dixey R, South J. Moving prison health promotion along: toward an integrative framework for action to develop health promotion and tackle the social determinants of health. Criminal Justice Studies. 2014;27(1):114-32.

17 Dooris M. Holistic and sustainable health improvement: the contribution of the settings-based approach to health promotion. Perspectives in Public Health. 2009;129(1):29-36.

18 McQueen DV. Evidence and theory: continuing debates on evidence and effectiveness. In: McQueen DV, Jones CM, editors. Global perspectives on health promotion effectiveness. New York: Springer; 2007. p. 281-304.



Why study health promotion? – a personal (and bias) blog

So why study health promotion?  Well, this is not an attempt to plug a postgraduate course that I am involved with and led for several years.  Although, as this is my blog I’ll leave the weblink just here in case anyone was interested.

The main purpose of the blog though is really to highlight that academic health promotion education in many institutions in the UK is in very good health.  This year in particular, I have been privileged to work very closely with several fantastic course teams delivering academic health promotion courses and there is, in my view, no doubt that these programmes offer excellent learning opportunities and employability prospects for those who enrol and subsequently graduate.

Yet, the case for studying health promotion is often poorly articulated which means that the very reasonable questions are always asked by potential applicants (and their parents quite often) and never fully answered.  What job will I get when I graduate?  What salary can I expect?  Why should I study health promotion and not course X, Y or Z?  Unfortunately I do not have a crystal ball, but I will try to outline one or two points which I share here.

First, the context and political landscape of health promotion has changed so much.  The halcyon health promotion days between the late 1980s and mid-to-late 1990s, where students could see a clear progression from their undergraduate or postgraduate course into health promotion units and departments has, I am afraid, long gone.  It was a naïve political move to disband such departments and to subsume health promotion into a broader ‘public health’ remit.  It was almost at that precise point, in the UK at least, that health promotion sadly lost some of its distinctiveness and in effect students were stopped from seeing a clear career trajectory.  Health promotion has not died and it has not gone away, it’s just been subsumed and is now not labelled as clearly.  Health promotion jobs for graduates are there, they are just not found in ‘health promotion departments’ – they are found in local government (often under the all-encompassing term ‘public health’) or in the voluntary and community sector.

What an undergraduate or postgraduate qualification in health promotion gives students, at least in my experience, is huge choice in the job market.  Health promotion is the greatest ‘Magpie’ discipline out there, as it literally steals ideas from sociology, psychology, education, political theory, epidemiology, economics, communication theory…….the list goes on.  This gives graduates phenomenal breadth of knowledge which offers huge potential for transferability to other vocations and professions.  You both become a ‘jack of all trades’ and master of, well, health promotion – that’s how I have always conceived it and seen it in both my own career and the graduates I have worked with.

My own, and I admit slightly bias view, is that a health promotion programmes will widen students’ views and horizons .  As per the point above, good health promotion courses have staff teaching on them with a myriad of expertise and experience and that this diversity of views and opinions is what gives richness to our discipline.

A health promotion degree, again from my perspective, is an international passport to global working.  While health promotion in the UK is being progressively weakened under a neo-liberal government, the discipline flexes huge muscle in other parts of the world.  Some of the most exciting and enlightening discussions I have had about health promotion has been when I have been in sub-Saharan Africa and Canada – places where the discourse, policy and practice of health promotion thrives.  There are other places too, like Australia and parts of Asia, where the values and principles of health promotion have really taken hold and offer genuine opportunities for graduates to earn salaries that they deserve.

So, as we approach another academic year, I hope this short (and very personally reflective) blog has made a case for studying health promotion.  There is no doubt that I am bias, but the opportunity to study academic health promotion has been so positive for me that it is only right that I share, what I see, is the best career choice that anyone can make.

Sex in prison happens, so how do we protect and promote people’s health?

Public health and health promotion have been given increased prominence within prison settings over the past decade and this has resulted in increased critique within academic discourse.  Prisons are an opportunity to address the health and social circumstances of prisoners – a group who experience disproportionate levels of health and social inequality– and a prime setting to tackle inequalities in health.  This recognition has resulted in strong political will, both on national and international levels, to regard the prison as a key social setting for health promotion.  Despite this endorsement, however, sexual health, a key dimension of health and well-being, continues to remain an area of neglect (1).

Research from the United States has demonstrated that the rate of confirmed HIV cases in prison is five times higher than in the general population  and the prevalence of AIDS in prisons has been identified as being three times higher (2). Similarly in the UK there are much higher rates of HIV and hepatitis C in UK prisons than in the general population because of the risks associated with sharing needles and having unprotected sex (3), risks that are exacerbated by a UK prison system where access to condoms (and needle exchange) is variable and often poor (4).

What we do know is that sex in prison does occur.  One study conducted by prisoners in England and Wales, showed that three per cent of adult males and 0.4% of young males had sex inside prison (5).  Research (6) also found that two per cent of a sample of 208 prisoner participants had had forced penetrative sexual intercourse.  If extrapolated to the entire prison population of England and Wales, this would equate to around 1700 incidences of forced penetrative sexual intercourse per year.  More recently, the National Offender Management Service reported that in 2011, 125 sexual assaults were reported in male establishments and 12 in female establishments (7).  No information, however, was provided on consensual sexual activity or in relation to the type of prison in which coercive sex is likely to occur.  Information such as: security level, single versus multiple occupancy cells and other variables which may make sexual activity more likely, were not provided.  Studies from outside the England and Wales, have shown a much higher occurrence of sex in prison (8), but this may be accounted methodological issues; for example, variation in defining ‘sex’ and ‘sexual activity’.

Broad policy drivers from the World Health Organisation, HM Prison Service and the Department of Health have called for prisons to be more ‘health promoting’ and yet there seems to be an absence of any strategic direction on sexual health in prison.  Despite the rhetoric of equivalence and human rights, the current provision of condoms in English and Welsh prisons is only available through a doctor’s prescription (9).  Research by the Prison Reform Trust and National AIDS Trust (3) shows that there are further barriers to prisoners accessing condoms, including:

  • The guidance on condom prescription is not always implemented by staff;
  • Prisoners are often inhibited from asking for condoms because of a perceived lack of confidentiality;
  • The process to obtain condoms may be very slow.

These barriers may be a causal factor in prisoners engaging in unprotected intercourse or using alternative (unsafe) methods (e.g. using surgical gloves) to protect themselves.  Indeed, research demonstrates that uptake of condoms in prison is higher where access to provision and disposal are more anonymous or discreet (10).

There is a clear research gap relating to sex in prison and how best to manage the issue from a public health perspective.  I welcome further research in this area to inform further policy and practice to ensure a safe and healthy prison environment as well as protecting the health of the wider community.



  1. Stewart EC. The sexual health and behaviour of male prisoners: the need for research. The Howard Journal of Criminal Justice. 2007;46(1):43-59.
  2. Maruschak L. HIV in prisons, 1997. Washington: National Institute of Justice, 1999.
  3. Prison Reform Trust, National AIDS Trust. HIV and hepatitis in UK prisons: addressing prisoners’ healthcare needs. London: PRT/NAT, 2005.
  4. National AIDS Trust. Prisons 2013 [cited 2013 20 June]. Available from: http://www.nat.org.uk/our-thinking/people-in-greatest-need/prisons.aspx.
  5. Weild A, Gill O, Bennett D, Livingstone S, Parry J, Curran L. Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey. Communicable Disease and Public Health. 2000;3(2):121-6.
  6. Banbury S. Coercive Sexual Behaviour in British Prisons as Reported by Adult Ex‐Prisoners. The Howard Journal of Criminal Justice. 2004;43(2):113-30.
  7. The Howard League for Penal Reform. Commission on Sex in Prison 2013 [cited 2013 16th July]. Available from: http://www.commissiononsexinprison.org/homepage/.
  8. Butler T, Richters J, Yap L, Donovan B. Condoms for prisoners: no evidence that they increase sex in prison, but they increase safe sex. Sexually Transmitted Infections. 2013;doi:10.1136/sextrans-2012-050856.
  9. HM Prison Service. Prison Service Order (PSO) 3845 on blood borne and related communicable diseases London: HM Prison Service, 1999.
  10. Department of Health, National AIDS Trust. Tackling Blood-Borne Viruses in prisons. A framework for best practice in the UK. London: NAT, 2011.


For me at least, the politics of academic publishing are so confusing…..

I was reminded of that euphoric feeling of having your work published for the first time when a student of mine managed to publish her dissertation findings in a peer-review journal.  It took me back to that moment when I was first published and the real excitement of seeing your work in a journal that you know had been reviewed and approved by your peers.

Back then, as a researcher setting out on his career in his early twenties, it was just about getting published and getting your work into the academic domain.  It didn’t really matter where it was published, it just had to be out there.  I remember when it was published my friends and family asked how much I had been paid to publish the work – they still ask that question now, to which the reply is always ‘nothing at all’.  I also remember friends of the family asking for the weblink to the article so they could read my work, but of course they couldn’t read the paper because there was a subscription charge to the journal.  I distinctly remember printing and posting copies out!

Fast forward ten-years and I still get that ‘buzz’ from publishing, I think all academics do, but the ‘buzz’ is not about self-indulgence or striving for credibility (as it was back then) it’s about being read and your work making a difference to policy and people.  Ten years ago I didn’t even question the reason why my work required a subscription charge to access it; it was just the normal thing that happened in academic publishing- the status quo, if you like.

I am by no means an expert or have the time to fully understand the political drivers around journal publications and how publishing houses work, but as I see it they created a ‘clique’ where access to knowledge and understanding through research was for the few not the many.  I have been lucky to have access to this ‘clique’ through excellent academic library facilities, but there are still lots of times when the article I want to read requires payment to access it.

In effect, it has always been that researchers do the research, submit their article to a journal, the journal accepts the work (rejecting too, of course) and then charges people and institutions at great cost to then access it.  It’s a business model and clear, to me at least, to see who are the winners are under this arrangement.  The general public and those outside of the ‘clique’ are certainly not the winners.  The journal publishers are the profiteers and arguably the ones that do best out of the arrangement.  Researchers often have to sign-over their work almost giving full control to the publishers – researchers have no choice as it is in their professional interests to have their work in journals – it leads to promotion, credibility and it’s part and parcel of the academic endeavour.

Things have thankfully changed and we now have Open Access journals – journals which allow anybody at all to access the research that they publish.  It’s a utopia for the general community interested in research and academic scholarship, but it comes at a price to the tune of around £1500-£2000 to the researcher or their institutions to make their work accessible.  This model (what they called ‘Gold’ Open Access) is attractive, but it fosters inequality as those institutions able to pay Open Access fees to publishers will likely to have greater representation in these journals than researchers in institutions where finance to do this may be prohibitive.  I’ve been lucky to have had papers published this way, but it’s surely an unsustainable model for everybody.

Another option is ‘Green’ Open Access (Silver would have been a more suitable colour choice, but who am I to argue) which allows researchers to submit their research to a University repository.  This is good in that anyone can access work on University repositories, but the downside is that the article on the repository is not the beautifully formatted publication from the journal publisher (the version I got excited about when I published for the first time), it’s a Microsoft word document that generally looks a bit drab and uninspiring.  This causes a few issues in my view (1) I’m never confident that the ‘Green’ version is the actual version that went on to be published in the journal – academics pride themselves on precision and I have had instances where Green Open Access work differed from that which was eventually published (2) Publishers call the shots on whether they will allow Green Open Access – they can set embargos often up to 18 months before work can be released on an institutional repository (their power is quite immense) and (3) Directly quoting from a Green Open Access paper is impossible to do as you don’t know the page number that it relates to in the actual published version.  It’s not ideal by any means.

So, what does this mean?  Well, I’m not sure to be honest.  If nothing else I am now far more politically aware of how academic publishers operate and consider much more carefully not only the journal I am submitting my work to, but what their policy is on Green and Gold publishing.  I am lucky to have colleagues who de-mystify all of this, as it is politically charged and contentious.  The direction of travel is exciting and I am optimistic that all of this debate will eventually be useful in ensuring that research is better able to make a difference to society.

Lifestyle drift is killing health promotion

In an earlier blog, I wrote about what health promotion is all about and what makes it distinct.  In a nutshell, health promotion is about key values (empowerment, control, choice) and approaches that enable individuals and communities to take greater control over the factors that influence their health.

Equating health promotion with trying to make populations healthier is broadly true, but how this is done is the key question.  Part of my frustration with the profession of health promotion is the obsession on individuals’ lifestyle – how they eat and exercise for instance – as though this is the answer to tackling complex problems like obesity, diabetes and hazardous alcA90RTE_2947220bohol consumption.  I reject this premise passionately on many levels, but mainly because it suggests that individuals live in a vacuum from social forces and that it assumes that human behaviour is simplistic and linear.  It largely assumes that
‘educating people’ (or in some cases telling people) about healthy ways of living is the answer to eradicating such perils like childhood obesity.  The social gradient of health shows that the poorer you are the younger you die and the more ill health you will have – so assuming that this body of epidemiological evidence is correct, the answer is not to address lifestyle, but to tackle poverty and everything associated with this bigstock_Healthy_Lifestyle__4731507(stigma, poor housing, marginalisation…etc) rather than addressing the issues that manifest as a result of poverty (drinking, smoking, poor diet).

Perhaps one a greater frustration for me is the issue of ‘lifestyle drift’ which I believe is killing progressive health promotion policy and practice.  In effect, ‘lifestyle drift’ is the design of policy that accepts that improving the health of individuals and communities is about tackling social determinants of health (education, housing, poverty, educational access) but only to revert back to addressing lifestyle issues, like smoking, drinking, exercise.  The policy has the right intention, but operationally it becomes difficult to execute…..but why?

Well, practically, lifestyle interventions are easier to devise than interventions that tackle ‘upstream’ issues like poverty and social disadvantage.  Next, political cycles don’t help.  For example, in order to demonstrate that things have improved as a result of a policy decisionhealthy-lifestyle-sports, it’s far easier to measure progress against the number of people accessing smoking cessation support than, let’s say, feel more included in society.  Moreover, in order to address social determinants it means that organisations working to address public health must work in partnership with others – something that can be difficult to do because of professional domains and territories.  Tackling poor housing, for instance, demands public health working alongside housing organisations, environmental health services, local residents, private landlords etc.

So, what’s the answer?  Well, it’s partly about highlighting the evidence about lifestyle interventions – yes, they can and, of course, do work but we need to think carefully about for whom they work for and for whom they further exclude.  Second, we need to embrace holism when we think about health.  Simply believing that education is the key is not the answer; we need to see the individual in the entire context in which tYoung-person-homeless-hun-007hey live.  Third, we need to do things that are difficult, not easy.  Tackling poverty, social exclusion and marginalisation are huge social problems that impact on people’s health.  If health promotion advocates, academics, policy-makers and practitioners shy away from this in favour of addressing smoking, drinking and exercise then lifestyle drift will kill health promotion.