Prisons have been identified as a health promotion setting in a variety of policy documents, ranging from the World Health Organization to the continental European Union to the UK and other countries. Within the last 25 years the idea of a prison setting for health promotion has taken root and spread. Over 30 European countries are now members of the Health in Prisons Project (HIPP) network. Prisons have been identified as a key setting for health promotion for several reasons. Prisoners are one of the most socially excluded groups in society, so addressing their health is a means of addressing health inequalities. However there are also challenges to promoting health within prisons, and there are many features of prison life that would seem to militate against a healthy lifestyle. There is a range of possible interventions and a growing body of evidence for their effectiveness. As with all settings, the evidence suggests that an integrated whole-systems approach works best within the prison setting to promote the health of prisoners, staff and the wider community.

There are several reasons why prisons have been identified as a suitable setting for health promotion:

Imprisonment tends to exacerbate social exclusion and mental ill health, and increase the risk of some behaviours such as shared use of needles for drug injections. Overcrowding is an ongoing problem within prisons. A recent estimate suggests that 12000 prisoners (out of a total prisoner population of around 75000) are being held two to a cell designed for one (Howard League for Penal Reform 2005). Overcrowding leads to unsafe and degrading conditions, increases the risk of transmission of infectious diseases and impedes prisoners’ access to purposeful training opportunities, exercise and fresh air. From a health inequalities perspective prisoners are a key target group.

Prisons are by their nature closed communities. For some this may mean the use of prisons as a health-promoting setting is a contradiction in terms, as key principles of health promotion such as free choice and empowerment are severely restricted (De Viggiani 2006a). The prison regime allows prisoners little opportunity to make decisions, exert their autonomy or become empowered. The monotony and boredom of prison life may predispose some prisoners towards risk-taking behaviour, such as smoking or drug use. Prison culture is known for its bullying, victimization and violence – all factors that contradict health promotion principles. It has been argued that preventive measures in prison, such as mandatory drug testing, may backfire, as prisoners may switch from cannabis to heroin (which cannot be so easily detected) or use other harmful methods to conceal their drug use (such as ingesting bleach) (Smith 2000). Instead of empowering prisoners, health promotion initiatives may become punitive.

Other commentators however see the nature of the prison setting as an advantage, as it guarantees access to prisoners and a long-term stable environment where any changes will have a direct impact on inmates (Ramaswamy & Freudenberg 2007). The prison population would normally be considered ‘hard to reach’, so their accessibility within the prison setting is unique. Prisoners have very high rates of physical and mental ill health and risky behaviours (Smith 2000). In all, 90% of prisoners have a diagnosable mental health problem or a substance misuse problem or both. A total of 80% of prisoners smoke and 24% have injected drugs, making them a key target group for health promotion.

Targeting prisoners also potentially enables health promotion programmes to reach out beyond the prison to prisoners’ families and deprived communities. There are an estimated 1 million relatives affected by imprisonment each year (Williams 2006). The imprisonment of one family member often leads to emotional, psychological and financial stress for the rest of the family. Conversely, providing health promotion for prisoners can have a positive effect on their families and communities. For example, providing health education about human immunodeficiency virus (HIV) transmission for prisoners has been shown to diffuse outwards to their family (Scott et al 2004). It is likely that in the long term this reduces the demand on services, and therefore represents sound economic sense (Curd et al 2007).

Finally, targeting the prison as a setting enables interventions to reach prison staff as well. Prison staff are an important, if neglected, target group in their own right. The positive health and well-being of staff can also be expected to have a favourable impact on the prisoners in their charge.