Evidence
Alert

Male prisoners develop unhealthy hearts at younger ages than people on the outside

The risk of cardiovascular disease (CVD) is higher among male prisoners than among men of the same age who live in the community. CVD affects the heart and blood vessels and increases the risk of heart attacks and strokes.

The largest European study of the heart health of prisoners found that more than one in ten of those who had a health check had a high risk of future heart disease. This is the same rate as the general population, even though the prisoner population is on average ten years younger. The study also estimated that prisoners were twice as likely as the general population to have significant anxiety and depression.

Three-quarters of the prisoners had the health checks they were offered but ethnic minority prisoners were less likely to accept. Health checks are normally offered only to prisoners serving sentences of more than two years. The study found that many prisoners serving shorter sentences also had significant heart disease risks and could benefit from the same health checks.

What’s the issue?

Heart disease is the most common natural cause of death among prisoners in the UK. As part of a national cardiovascular health screening programme, male inmates over 35 are eligible for NHS checks.

There is growing awareness of the need for better health services inside prisons. But there is little useful data to plan improvements, such as how the risk of CVD among male prisoners compares with the general population. Prior to this study, there was little evidence to support new policies around health checks in prisons. These include lowering the age threshold for the checks from 40 to 35, and limiting checks to inmates serving sentences of more than two years.

What’s new?

The observational study invited all eligible inmates at six male prisons in the East Midlands, UK for a health check. Between September 2017 and January 2019,  1207 prisoners accepted and were questioned on family history of heart disease and relevant lifestyle factors such as smoking and alcohol use. Blood tests for glucose, fats such as cholesterol and other components were taken, or results from recent tests were obtained. Prisoners were questioned using standard tools to assess their mental health, specifically measures of depression and anxiety.

The study found that:

  • three-quarters of invited prisoners accepted the checks
  • black prisoners were more than twice as likely to decline a health check compared to prisoners of other ethnic groups (2.7 times more likely)
  • of the prisoners who took part, more than one in ten (12%) had a high risk of cardiovascular disease (CVD)
  • CVD risk was similar to community levels, but the prison population was ten years younger
  • symptoms of depression were estimated to be in one in five (21%) prisoners, with almost as many (18%) estimated to have significant anxiety, which is double the rates found in the general population
  • prisoners serving less than two years had a similar risk of developing CVD in the next decade, compared to those serving longer sentences.

Why is this important?

The results offer one of the first large-scale assessments of health inside UK men’s prisons – traditionally an under-served population. It therefore provides an important baseline of the levels of CVD and its risk factors  among the prison community. This information can be used to design better evidence-based healthcare.

For example, the findings showed that significant numbers of inmates serving sentences of less than two years would benefit from receiving the health checks. The advice and possible interventions (such as being prescribed drugs to reduce levels of cholesterol) could reduce their risk of heart attacks or stroke. But, at present, such prisoners are not included in the health check programme.

The study also confirmed high levels of anxiety and depression among prisoners. For health check programmes to succeed, mental health services  need to address these problems adequately, alongside existing physical healthcare.

What’s next?

The study results will feed into an ongoing review of the health check programme. For example, within prisons there is a case for offering the checks to male prisoners serving less than two years. This could increase costs. On the other hand, lowering the minimum eligible age for screening prisoners from 40 to 35 does not appear to bring significant benefit. Overall, the changes could be cost neutral for the screening.

The study results show only how many prisoners had the checks and what they found. They do not track what happened next: how many of the prisoners flagged as having symptoms or high risk of developing heart problems received follow-on care, and how successful it was. Further research is needed to confirm this, and so to quantify and confirm the benefits expected.

The study also shows that a sizeable group – one in four– of prisoners refused the checks. Future research is needed to explore this and to find ways to increase uptake, perhaps by analysing a possible link to poor mental health.

You may be interested to read

The full study: Packham C, and others. Cardiovascular risk profiles and the uptake of the NHS Healthcheck programme in male prisoners in six UK prisons: an observational cross-sectional survey. BMJ Open. 2020;10:1-8

The Offender Health Research Network, which focuses on offender healthcare provision and research

Funding

This research was supported by NIHR Clinical Research Network, Nottingham NIHR Biomedical Research Centre, Leicester NIHR Biomedical Research Centre and NIHR MindTech MedTech and in-vitro Collaborative.

 

Commentaries

Study author

We struggle to provide healthcare inside prisons and we don’t know basic information such as the risk profile for cardiovascular disease across the prison population. So it’s vital to collect this kind of information, as well as the data on mental health.

I wasn’t surprised by what we found but it’s still really helpful to quantify it. It gives us an evidence base for policy, and for suggesting changes to policy. It would be useful to understand why one-in-four prisoners chose not to have the checks. This is a good opportunity to help but we also need to understand how to reduce remaining barriers to providing activity that can aid prevention of ill health in this very vulnerable population.

Chris Packham, Associate Medical Director, Nottinghamshire Healthcare NHS Trust

Researcher

This paper provides important epidemiological data with implications for healthcare practice and public health for male prisons. It provides important outcomes on the effects of imprisonment and on the health inequalities associated with material deprivation, ethnicity and CVD.

The findings should therefore inform prison health policy, commissioning and practice, not only in providing adequate healthcare and screening responses but also in terms of tackling inequality to reduce the burden of non-communicable diseases such as CVD on this population.

Nick de Viggiani, Senior Lecturer in Public Health, University of the West of England, Bristol

Conflicts of Interest

None declared.