Incarcerated women develop a nutrition and fitness program: participatory research Ruth Elwood Martin, Sue Adamson, Mo Korchinski, Alison Granger-Brown, Vivian R. Ramsden, Jane A. Buxton, Nancy Espinoza-Magana, Sue L. Pollock, Megan J.F. Smith, Ann C. Macaulay, Lara Lisa Condello and T. Gregory Hislop
Abstract Purpose – Women in prison throughout the world experience higher rates of mental and physical illness compared with the general population and compared with men in prison. The paper finds no published studies that report on men or women in prison engaging in participatory health research to address their concerns about nutrition and fitness. The purpose of this paper is to describe a pilot nutrition and fitness program, which resulted from a unique prison participatory health research project. Design/methodology/approach – Women in prison designed, led, and evaluated a six-week pilot fitness program in a minimum/medium security women’s prison. Pre- and post-program assessments included a self-administered questionnaire and body measures. Open-ended questionnaire responses illuminated the quantitative findings. Findings – Sixteen women in prison completed the program evaluation. Weight, body mass index, waist-to-hip ratio, and chest measurements decreased, and energy, sleep, and stress levels improved by the end of the program. Research limitations/implications – As a component of a participatory research project, incarcerated women designed and led a nutrition and fitness program, which resulted in improved body measures and self-reported health benefits. Originality Value – Incarceration provides opportunities to engage women in designing their own health programs with consequent potential long-term “healing” benefits. Keywords Women’s health, Health in prison, Prisoners, Health promoting prison, Mental health, Women prisoners Paper type Research paper
1. Background Women in prison globally experience greater mental and physical illness than the general population and men in prison (Plugge and Fitzpatrick, 2005; Gunter, 2004; Mooney et al., 2002; Young et al., 2005). The higher prevalence of mental health problems is frequently a result of lifetime abuse and victimization, including post-traumatic stress disorder, depression, anxiety, and phobias (Messina and Grella, 2006; Fogel, 1993; Zlotnick, 1997; Bastick, 2005; Covington, 2007; Møller et al., 2007; Nolan and Scagnelli, 2007; Meiklejohn et al., 2003; London et al., 2004; Mohs et al., 1990; Shaw et al., 1985; Gesch et al., 2002; Cropsey et al., 2008; Peterson and Johnstone, 1995; Cashin et al., 2008; Khavjou et al., 2007). Women in prison also report weight gain during their imprisonment, which has been attributed to the metabolic changes of drug withdrawal, high-carbohydrate prison diets, prison canteen options limited to high-calorie snacks, boredom, and inactivity (Nolan and Scagnelli, 2007; Meiklejohn et al., 2003; London et al., 2004; Mohs et al., 1990; Shaw et al., 1985). Internationally, it is recognized that imprisonment provides an opportunity to introduce beneficial health options (e.g. nutrition, exercise, and relaxation) as a means to “healing.” Several published reports describe prison programs in the UK and the USA that incorporate a wellness
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DOI 10.1108/IJPH-03-2013-0015
model, including nutrition and exercise life-style changes (Gesch et al., 2002; Cropsey et al., 2008; Peterson and Johnstone, 1995; Cashin et al., 2008; Khavjou et al., 2007). In addition, two recent UK publications highlight male offenders’ beliefs, preferences, and activity levels as they relate to the concept of exercise in prisons (Fischer et al., 2012; Plugge et al., 2011). However, these programs do not report on benefits following release from prison; nor were the programs developed, conducted, or evaluated by incarcerated individuals themselves. We found no published studies reporting on participatory action research to address nutrition and fitness issues in prison. We previously reported on a prison participatory action research project in which incarcerated women identified nine health goals essential for their successful reintegration into society following release from prison (Martin et al., 2008, 2009a, 2012). One goal was improved awareness and integration of healthy life-styles, including exercise and nutrition. In keeping with this health goal, members of our inmate participatory research team designed, implemented, and evaluated a prison pilot nutrition and fitness program, with the following three primary objectives: to offer a regular nutrition and fitness program to women in prison; to catalyze the adoption of long-term values in personal health and fitness among incarcerated women participants; and, to assess the beneficial health effects of the program. The aim of this paper is to describe the implementation and evaluation of the exercise component of a nutrition and fitness prison pilot program; and the resulting benefits of the fitness program to participants during incarceration and after release from prison.
2. Methods This project occurred in a Canadian provincial medium security correctional center, housing up to 150 women with sentences under two years and an average length of stay 63 days. One woman in prison, a member of the participatory research team and a certified instructor of health and fitness (and first author S.A.), led the project as project coordinator (PC). She and other members of the inmate participatory research team first surveyed all women in prison about their perception of physical fitness, nutrition, gym equipment use, and how fitness and health relates to other factors such as sleep and stress. Based on these findings, they designed, implemented, and evaluated a six-week prison nutrition and fitness pilot program which met industry standards. In July 2007, the inmate research team invited all incarcerated women through word of mouth and posters in all living units to an introductory seminar and invited them to sign up for the pilot program which contained both a nutritional component and a personal exercise component. For the nutritional component, participants were given the Canada Food Guide and a personalized food chart that enabled them to self-monitor their progress in eating behavior for six weeks. An educational nutrition Powerpoint presentation was offered to all inmates every Saturday morning during the six-week pilot program (available at: www.womenin2healing.org/ ). This paper focusses on the exercise component. Interested women attended a general gym facility orientation, during which proper use and maintenance of the fitness equipment was demonstrated. The gym facility orientation was designed to ensure that women wanting to exercise independently would exercise safely. All participants were interviewed by the PC prior to starting the personal fitness component, to ensure their safety. Participants were offered the option of exercising in a group circuit classes or of developing an individual exercise plan. All participants were invited to join a group circuit class that was appropriate for all fitness levels; it included a group cardio warm-up; circuit stations integrating equipment, free weights and free-standing movements that targeted core, strength, balance and agility; cardio intervals; group cool-down and flexibility. The circuit stations and aerobic routine were altered every two weeks and group circuit class sessions were held twice a day. Participants were given an exercise program card to assist in tracking their progress in cardio, strength, and flexibility measures. The card and complementary training enabled participants to practice personal healthy goal setting, follow-through with personal commitments, and to establish healthy habits and routines. Women who attended as “drop ins” (who were the majority of the participants) were not included in the evaluation of the program.
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A pre- and post-program assessment was done on the 16 incarcerated women who completed the pilot program. Prior to the commencement of the pilot program, participants were asked to: complete a Physical Activity Readiness Questionnaire (PAR-Q), which included personal health information pertaining to physical activity and doctor’s recommendations; and provide body measures (weight, chest, hips, body mass index (BMI) and waist-to-hip (W-H) ratio). At the end of the pilot program, participants were asked to: to complete a follow-up questionnaire, which included open and closed-ended questions about program participation and its effects on energy, sleep, and stress levels; and provide the same body measures. The PC trained two other incarcerated women as program trainees to assist her with the above assessments and with class instruction. Differences between pre- and post-program measurements were determined and tested for significance among the participants who completed the program with paired t-test. Thematic analysis was conducted for open-ended responses to provide illuminating insights for the quantitative findings. We also correlated these findings with verbal observations from the prison interdisciplinary staff. This study was approved by the University of British Columbia Behavioural Research Ethics Review Board. All people working with data signed a confidentiality agreement. Author R.E.M., on behalf of the academic research team, signed a five-year research agreement with the assistant deputy minister, Ministry of Public Safety Solicitor General, corrections branch, to conduct participatory health research with women in prison.
3. Results In all, 50 women in prison attended the introductory seminar, of whom 28 signed up for the pilot program and 16 completed the program (see Figure 1). The demographics and pre-program measures for women who completed, and did not complete the program are shown in Table I. Those who completed the program tended to be younger, of heavier body weight and BMI, and with larger chest size. W-H ratio was similar between the two groups. Reasons for not completing the program include: release from prison (n ¼ 5), interpersonal conflicts (n ¼ 4), and medical conditions (e.g. surgery) precluding exercise (n ¼ 3). The decrease in mean W-H ratio approached statistical significance (p ¼ 0.06 paired t-test) and the decrease in mean chest measurement was statistically significant (p ¼ 0.002 paired t-test) for the 16 women who completed the program (see Table II). Weight and BMI also decreased, however, these were not statistically significant (p ¼ 0.25 and 0.11 paired t-test). The mean changes per person were: 0.02 (standard deviation, SD ¼ 0.04) for W-H ratio, 0.98 (SD ¼ 1.04) for chest size, 2.80 (SD ¼ 8.98) for weight, and 0.73 (SD ¼ 1.67) for BMI. The majority of participants (60 percent or more) showed a decrease in body measures (see Table III). Four of the five participants who gained weight over the course of the program had low BMI (between 23.8 and 25.4) at the start of the program, while the fifth participant weighed 250 pounds (BMI ¼ 34.9) and reported that she intended to remain in the program “cuz I feel better than I ever have.” The majority of participants reported an improvement in energy level, sleep, and stress level at the completion of the program (Table IV). All 16 participants who completed the program also completed the follow-up questionnaire. When asked, “Did you exercise regularly before joining the circuit class?” Nine women reported “yes,” and when asked, “Do you think you will continue exercising after your release?” 15 women reported “yes”: To stay clean and healthy. I like the way I feel.
When asked, “have you noticed improvements since you started participating in the fitness program?” All reported “yes,” with ten women reporting improvement in both self-esteem and
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Figure 1 Description of participant invitation and data collection for the pilot program
All women in prison were invited and could choose to attend
Timeline
July 25
Introductory seminar: recruitment for pilot program and distribution of food charts, Canada Food Guide and eating plans (n = 50 attendees)
July 31
Pre program assessment: questionnaire and body measures (n = 28) August 2
Weekly nutrition seminars
Food charts, Canada Food Guide, eating plans
Weekly gym facility orientation
August 5 Group fitness program offered 7×/week, with minimum commitment 3×/week for 6 weeks (n =16 completed program)
Personal exercise program card
Anonymous feedback questionnaire
Post program assessment: questionnaire and body measures (n =16)
September 11
September 13
Table I Demographics and pre-program body measures for women who signed up for the program Factor Age (years) 18-29 30-39 40 þ Ethnicity Caucasian Aboriginal Other Weight (lb)a Body mass index (BMI)a Waist-to-hip ratio (W-H ratio) Chest (inches)
Did not complete program (n ¼ 12) No. %
Completed program (n ¼ 16) No. %
3 5 4
25 42 33
6 6 4
38 38 25
12 0 0 Mean 153.36 24.46 0.81 36.72
100 0 0 SD 31.01 4.44 0.06 2.88
9 5 2 Mean 170.93 27.00 0.82 37.97
56 31 13 SD 38.47 4.78 0.06 2.99
Notes: SD, standard deviation; n ¼ 28; amissing value for weight for one person in both “Did not complete program” and “completed program”
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Table II Mean pre- and post-program body measures for women who completed the program Factor
Pre-program measures Mean SD
Post-program measures Mean SD
Weight (lbs)a BMIa W-H Ratio Chest (inches)
170.93 27.00 0.82 37.97
168.13 26.27 0.80 36.98
38.47 4.78 0.06 2.99
36.26 4.11 0.06 2.93
Paired t-test p-value 0.25 0.11 0.06 0.002
Notes: SD, standard deviation, BMI, body mass index, W-H ratio, waist-to-hip ratio; n ¼ 16; amissing value for weight for one person in both “Did not complete program” and “completed program”
Table III Frequency of change in body measures for women who completed the program Factor Weight a Loss Same Gain BMI a Loss Same Gain W-H ratio Loss Same Gain Chest Loss Same Gain
No.
%
9 1 5
60 7 33
9 1 5
60 7 33
10 3 3
63 19 19
14 0 2
88 0 13
Notes: BMI, body mass index, W-H ratio, waist-to-hip ratio; n ¼ 16; apost-program weight was missing for one participant
Table IV Reported change in selected health measures at the end of the pilot in women who completed the program Factor Energy level Worse/same Somewhat improved Really improved Sleep Worse/same Somewhat improved Really improved Stress level Worse/same Somewhat improved Really improved Note: n ¼ 16
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No.
%
0 5 11
0 31 69
3 8 5
19 50 31
1 6 9
6 38 56
weight loss, nine with increased strength, eight with increased stamina, and five with improved posture: I feel good, increased energy, decreased body pain. I feel like I’ve lost fat but gained muscle. I learnt that when I am exercising every day I don’t crave drugs as much.
When asked “What do you like about participating in the circuit class?” Women responded that in addition to the personal benefits, they enjoyed the social support and fun provided by the group. It reduces stress. I felt very good afterwards and it was fun. The group works to know I’m not alone. I didn’t feel as depressed as I did before – exercise makes me feel better in my mind. This exercise program was FUN! Because it was organized and led by another woman in prison [y] she understands us [y] not someone coming in from the outside saying, you must do this because it is healthy for you
The PC commented that the socialization aspect of the circuit class amazed her. It was truly an amazing experience to witness the women come together and support and empower one another! An elderly aboriginal woman approached me during one of the classes with tears of joy in her eyes as she pointed out two recently incarcerated young aboriginal women who were sharing a circuit station and laughing together. She said “You have no idea what wonderful things you are doing here, those two girls were sworn enemies on the streets [y].”
Interdisciplinary prison contract staff observed an increased interest and use of the gym equipment during the six-week pilot program. The gym was frequently used by others doing independent exercise outside of the group circuit classes.
4. Discussion This pilot program, which resulted from participatory action research, closely follows the Precede-Proceed framework for health promotion planning (Green and Kreuter, 1991). The women in prison themselves identified a need within prison for a healthier life-style, as many women gained weight due to a high-carbohydrate diet, lack of exercise, boredom in prison, and drug cravings. Pre-disposing factors of knowledge, attitudes, and values were identified by these women. With a supportive warden and management staff, inmates were enabled by having regular access to a gym and health and nutrition education. Several reinforcing factors encouraged healthy behavior; these included weight loss, decreased stress, improved sleep, and overall feelings of health. These findings are consistent with the known benefits of exercise programs and with a recent report of decreased hopelessness and improved mental well-being among prisoners who engaged in a prison exercise program (Cashin et al., 2008). Women who participated in the exercise program reported decreased cravings for illicit drugs, a reinforcing factor for long-term health. An unexpected finding was that women highly rated the social aspect of the prison exercise circuit class. There was also a ripple effect of enthusiasm resulting in increased numbers of women participating as drop-ins to the gym. Others have also described women’s health as relational (Lewis and Bernstein, 1996), suggesting that a non-competitive exercise program was a reinforcing factor for healthy behavior. This approach contrasts the competitive exercise programs that are described in youth and male prison populations (Andrews and Andrews, 2003). A major strength of this program is that it was designed and implemented for and by incarcerated women. Women said that the peer-led nature of the program encouraged them to participate and stay involved because they felt trust and non-judgment in this environment. The prison gym facilities became increasingly popular during the time of the program and many
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inmates who otherwise did not participate in physical exercise chose to work out independently of the program. A limitation of data collection affecting weight measures was that different scales were required for the post-program assessments because participants were not allowed to use the medical facility scales. Another limitation was the small number of participants who completed the pilot program and its assessments. The pilot program had a positive long-term impact for some participants. The participatory research team, now operating in the community and called Women in2 Healing (Women in2 Healing Internet, cited October 29 2012) has continued the goal of healthy living. Co-author (M.K.) and other former participants began fitness programs in the community modeled on the prison pilot program.
5. Conclusions Incarceration provides a unique opportunity to influence behavioral and environmental factors that can promote healthy changes for the female prison population. A peer-led group nutrition program and circuit fitness class offered participants a safe, fun, effective alternative to exercise and the opportunity to experience group motivation in a supportive environment. The facilitators provided fun and motivation, encouraging participants to go at their own pace and in proper form for the exercises.
Acknowledgement The authors declare no potential conflict of interest in the research. This health research project was supported by an operating grant from the BC Medical Services Foundation of the Vancouver Foundation, and by collaborative funding support from the Fraser Health Authority, Women’s Health Research Institute and BC Women’s Hospital. Acknowledgements: The authors thank Benjamin Martin and Anna Chan for their research assistance and data entry; and, Rebecca James and Sally Yue Lin for formatting the manuscript for publication. For a complete list of individuals who were involved as peer researchers and other contributors in the prison participatory research project, please visit the project website at www.womenin2 healing.org
References Andrews, J.P. and Andrews, G.J. (2003), “Life in a secure unit: the rehabilitation of young people through the use of sport”, Soc Sci Med, Vol. 56 No. 3, pp. 531-50. Bastick, M. (2005), A Commentary on the Standard Minimum Rules for the Treatment of Prisoners, Quaker United Nations Office, Geneva. Cashin, A., Potter, E. and Butler, T. (2008), “The relationship between exercise and hopelessness in prison”, J Psyichiatr Ment Health Nurs, Vol. 15 No. 1, pp. 66-71. Covington, S. (2007), “Women and the criminal justice system”, Women’s Health Issues, Vol. 17 No. 4, pp. 180-2. Cropsey, K., Eldridge, G., Weaver, M., Villalobos, G., Stitzer, M. and Best, A (2008), “Smoking cessation intervention for female prisoners: addressing an urgent public health need”, Am J Public Health, Vol. 98 No. 10, pp. 1894-901. Fischer, J., Butt, C., Dawes, H., Foster, C., Neale, J., Plugge, E., Wheeler and Wright, N. (2012), “Fitness levels and physical activity amongst class a drug users entering prison”, British Journal of Sports Medicine, Vol. 46 No. 16, pp. 1142-44. Fogel, C.I. (1993), “Hard time: the stressful nature of incarceration for women”, Issues in Ment Health Nurs, Vol. 14 No. 4, pp. 367-77. Gesch, H., Hampson, E., Crowder, M.J., Gesch, C.B., Hammond, S.M., Hampson, S.E., Eves, A. and Crowder, M.J. (2002), “Influence of supplementary vitamins, minerals and essential fatty acids on the antisocial behaviour of young adult prisoners”, Br J Psychiatry, Vol. 181, pp. 22-8.
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Green, L.W. and Kreuter, M.W. (1991), Health Promotion Planning: An Educational and Ecological Approach, 3rd ed., Mayfield Publishing Co., Mountain View, CA. Gunter, T.D. (2004), “Incarcerated women and depression: a primer for the primary care provider”, J Am Med Women’s Assoc, Vol. 59 No. 2, pp. 107-12. Khavjou, O.A., Clarke, J., Hofeldt, R.M., Lihs P., Loo R.K., Prabhu M., Schmidt N., Stockmyer, C.K. and Will J.C. (2007), “A captive audience: bringing the WISEWOMAN program to South Dakota prisoners”, Women’s Health Issues, Vol. 17 No. 4, pp. 193-201. Lewis, J.A. and Bernstein, J. (1996), Women’s Health: A Relational Perspective Across the Life Cycle, Jones and Bartlett Publishing Inc, Sudbury, MA. London, E.D., Simon, S.L. and Berman, S.M. et al. (2004), “Mood disturbances and regional cerebral metabolic abnormalities in recently abstinent methamphetamine abusers”, Arch Gen Psychiatry, Vol. 61 No. 1, pp. 73-84. Martin, R.E., Chan, R., Torikka, L., Granger-Brown, A. and Ramsden, V.R. (2008), “Healing fostered by research”, Can Fam Physician, Vol. 54 No. 2, pp. 244-5. Martin, R.E., Murphy, K., Chan, R., Ramsden, V.R., Granger-Brown, A., Macaulay, A.C., Kahlon, R., Ogilvie, G. and Hislop, T.G. (2009a), “Primary health care: applying the principles within a community-based participatory health research project that began in a Canadian women’s prison”, Global Health Promotion, Vol. 16 No. 43, pp. 43-53. Martin, R.E., Buxton, J.A., Smith, M. and Hislop, T.G. (2012), “The scope of the problem: the health of incarcerated women in BC”, BCMJ, Vol. 54 No. 10, pp. 502-8. Meiklejohn, C., Sanders, K. and Butler, S. (2003), “Physical health care in medium secure services”, Nurs Stand, Vol. 17 No. 17, pp. 33-7. Messina, N. and Grella, C. (2006), “Childhood trauma and women’s health outcomes in a California prison population”, Am J Public Health, Vol. 96 No. 10, pp. 1842-8. Mohs, M.E., Watson, R.R. and Leonard-Green, T. (1990), “Nutritional effects of marijuana, heroin, cocaine, and nicotine”, J Am Diet Assoc, Vol. 90 No. 9, pp. 1261-7. Møller, L., Sto¨ver, H., Ju¨rgens, R., Gatherer, A. and Nikogosian, H. (Eds) (2007), “Health in prisons: a WHO guide to the essentials in prison health, WHO regional office for Europe, Copenhagen”, available at: www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf (accessed February 25 2013), p. 179. Mooney, M., Hannon, F., Barry, M., Friel, S. and Kelleher, C. (2002), “Perceived quality of life and mental health status of Irish female prisoners”, Ir Med J, Vol. 95 No. 8, pp. 241-3. Nolan, L.J. and Scagnelli, L.M. (2007), “Preference for sweet foods and higher body mass index in patient being treated in long-term methadone maintenance”, Subst Use Misuse, Vol. 42 No. 10, pp. 1555-66. Peterson, M. and Johnstone, B.M. (1995), “Effects on drug-involved federal offenders”, J Subst Abuse Treat, Vol. 12 No. 1, pp. 43-8. Plugge, E. and Fitzpatrick, R. (2005), “Assessing the health of women in prison: a study from the United Kingdom”, Health Care Women Int, Vol. 26 No. 1, pp. 62-8. Plugge, E., Neale, J., Dawes, H., Foster, C. and Wright, N. (2011), “Drug using offenders’ beliefs and preferences about physical activity: implications for future interventions”, International Journal of Prisoner Health, Vol. 7 No. 1, pp. 18-27. Shaw, N.S., Rutherdale, M. and Kenny, J. (1985), “Eating more and enjoying it less: US prison diets for women”, Women Health, Vol. 10 No. 1, pp. 39-57. Women in2 Healing-Home. available at: www.womenin2healing.org/ (accessed October 29 2012). Young, M., Waters, B., Falconer, T. and O’Rourke, P. (2005), “Opportunities for health promotion in the Queensland women’s prison system”, Aust N Z J Public Health, Vol. 29 No. 4, pp. 324-7. Zlotnick, C. (1997), “Posttraumatic stress disorder (PTSD), PTSD comorbidity, and childhood abuse among incarcerated women”, J Nerv Ment Dis, Vol. 185 No. 12, pp. 761-3.
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Further reading Martin, R.E., Murphy, K., Hanson, D., Hemingway, C., Ramsden, V., Buxton, J., Granger-Brown, A., Condello, L.-L., Buchanan, M., Espinoza-Magana, N., Edworthy, G. and Hislop, T.G. (2009b), “The development of participatory health research among incarcerated women in a Canadian prison”, Int J Prison Health, Vol. 5 No. 2, pp. 95-107.
About the authors Ruth Elwood Martin is based at Collaborating Centre for Prison Health and Education, University of British Columbia, Vancouver, Canada. Ruth Elwood Martin is the corresponding author and can be contacted at: [email protected] Sue Adamson and Mo Korchinski are based at Women in2 Healing, Vancouver, Canada and Collaborating Centre for Prison Health and Education, University of British Columbia, Vancouver, Canada. Alison Granger-Brown is based at Fraser Valley Institution for Women, Vancouver, Canada. Vivian R. Ramsden is based at Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, Canada. Jane A. Buxton and Nancy Espinoza-Magana are based at School of Population and Public Health, University of British Columbia, Vancouver, Canada. Sue L. Pollock is based at Interior Health Authority, Kelowna, Canada. Megan J.F. Smith is based at Collaborating Centre for Prison Health and Education, University of British Columbia, Vancouver, Canada. Ann C. Macaulay is based at Department of Family Medicine, McGill University, Montreal, Canada. Lara Lisa Condello is based at Department of Justice Studies, Nicola Valley Institute of Technology, Vancouver, Canada. T. Gregory Hislop is based at School of Population and Public Health, University of British Columbia, Vancouver, Canada and Cancer Control Research, BC Cancer Agency, Vancouver, Canada.
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Abstract Purpose – Women in prison throughout the world experience higher rates of mental and physical illness compared with the general population and compared with men in prison. The paper finds no published studies that report on men or women in prison engaging in participatory health research to address their concerns about nutrition and fitness. The purpose of this paper is to describe a pilot nutrition and fitness program, which resulted from a unique prison participatory health research project. Design/methodology/approach – Women in prison designed, led, and evaluated a six-week pilot fitness program in a minimum/medium security women’s prison. Pre- and post-program assessments included a self-administered questionnaire and body measures. Open-ended questionnaire responses illuminated the quantitative findings. Findings – Sixteen women in prison completed the program evaluation. Weight, body mass index, waist-to-hip ratio, and chest measurements decreased, and energy, sleep, and stress levels improved by the end of the program. Research limitations/implications – As a component of a participatory research project, incarcerated women designed and led a nutrition and fitness program, which resulted in improved body measures and self-reported health benefits. Originality Value – Incarceration provides opportunities to engage women in designing their own health programs with consequent potential long-term “healing” benefits. Keywords Women’s health, Health in prison, Prisoners, Health promoting prison, Mental health, Women prisoners Paper type Research paper
1. Background Women in prison globally experience greater mental and physical illness than the general population and men in prison (Plugge and Fitzpatrick, 2005; Gunter, 2004; Mooney et al., 2002; Young et al., 2005). The higher prevalence of mental health problems is frequently a result of lifetime abuse and victimization, including post-traumatic stress disorder, depression, anxiety, and phobias (Messina and Grella, 2006; Fogel, 1993; Zlotnick, 1997; Bastick, 2005; Covington, 2007; Møller et al., 2007; Nolan and Scagnelli, 2007; Meiklejohn et al., 2003; London et al., 2004; Mohs et al., 1990; Shaw et al., 1985; Gesch et al., 2002; Cropsey et al., 2008; Peterson and Johnstone, 1995; Cashin et al., 2008; Khavjou et al., 2007). Women in prison also report weight gain during their imprisonment, which has been attributed to the metabolic changes of drug withdrawal, high-carbohydrate prison diets, prison canteen options limited to high-calorie snacks, boredom, and inactivity (Nolan and Scagnelli, 2007; Meiklejohn et al., 2003; London et al., 2004; Mohs et al., 1990; Shaw et al., 1985). Internationally, it is recognized that imprisonment provides an opportunity to introduce beneficial health options (e.g. nutrition, exercise, and relaxation) as a means to “healing.” Several published reports describe prison programs in the UK and the USA that incorporate a wellness
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DOI 10.1108/IJPH-03-2013-0015
model, including nutrition and exercise life-style changes (Gesch et al., 2002; Cropsey et al., 2008; Peterson and Johnstone, 1995; Cashin et al., 2008; Khavjou et al., 2007). In addition, two recent UK publications highlight male offenders’ beliefs, preferences, and activity levels as they relate to the concept of exercise in prisons (Fischer et al., 2012; Plugge et al., 2011). However, these programs do not report on benefits following release from prison; nor were the programs developed, conducted, or evaluated by incarcerated individuals themselves. We found no published studies reporting on participatory action research to address nutrition and fitness issues in prison. We previously reported on a prison participatory action research project in which incarcerated women identified nine health goals essential for their successful reintegration into society following release from prison (Martin et al., 2008, 2009a, 2012). One goal was improved awareness and integration of healthy life-styles, including exercise and nutrition. In keeping with this health goal, members of our inmate participatory research team designed, implemented, and evaluated a prison pilot nutrition and fitness program, with the following three primary objectives: to offer a regular nutrition and fitness program to women in prison; to catalyze the adoption of long-term values in personal health and fitness among incarcerated women participants; and, to assess the beneficial health effects of the program. The aim of this paper is to describe the implementation and evaluation of the exercise component of a nutrition and fitness prison pilot program; and the resulting benefits of the fitness program to participants during incarceration and after release from prison.
2. Methods This project occurred in a Canadian provincial medium security correctional center, housing up to 150 women with sentences under two years and an average length of stay 63 days. One woman in prison, a member of the participatory research team and a certified instructor of health and fitness (and first author S.A.), led the project as project coordinator (PC). She and other members of the inmate participatory research team first surveyed all women in prison about their perception of physical fitness, nutrition, gym equipment use, and how fitness and health relates to other factors such as sleep and stress. Based on these findings, they designed, implemented, and evaluated a six-week prison nutrition and fitness pilot program which met industry standards. In July 2007, the inmate research team invited all incarcerated women through word of mouth and posters in all living units to an introductory seminar and invited them to sign up for the pilot program which contained both a nutritional component and a personal exercise component. For the nutritional component, participants were given the Canada Food Guide and a personalized food chart that enabled them to self-monitor their progress in eating behavior for six weeks. An educational nutrition Powerpoint presentation was offered to all inmates every Saturday morning during the six-week pilot program (available at: www.womenin2healing.org/ ). This paper focusses on the exercise component. Interested women attended a general gym facility orientation, during which proper use and maintenance of the fitness equipment was demonstrated. The gym facility orientation was designed to ensure that women wanting to exercise independently would exercise safely. All participants were interviewed by the PC prior to starting the personal fitness component, to ensure their safety. Participants were offered the option of exercising in a group circuit classes or of developing an individual exercise plan. All participants were invited to join a group circuit class that was appropriate for all fitness levels; it included a group cardio warm-up; circuit stations integrating equipment, free weights and free-standing movements that targeted core, strength, balance and agility; cardio intervals; group cool-down and flexibility. The circuit stations and aerobic routine were altered every two weeks and group circuit class sessions were held twice a day. Participants were given an exercise program card to assist in tracking their progress in cardio, strength, and flexibility measures. The card and complementary training enabled participants to practice personal healthy goal setting, follow-through with personal commitments, and to establish healthy habits and routines. Women who attended as “drop ins” (who were the majority of the participants) were not included in the evaluation of the program.
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A pre- and post-program assessment was done on the 16 incarcerated women who completed the pilot program. Prior to the commencement of the pilot program, participants were asked to: complete a Physical Activity Readiness Questionnaire (PAR-Q), which included personal health information pertaining to physical activity and doctor’s recommendations; and provide body measures (weight, chest, hips, body mass index (BMI) and waist-to-hip (W-H) ratio). At the end of the pilot program, participants were asked to: to complete a follow-up questionnaire, which included open and closed-ended questions about program participation and its effects on energy, sleep, and stress levels; and provide the same body measures. The PC trained two other incarcerated women as program trainees to assist her with the above assessments and with class instruction. Differences between pre- and post-program measurements were determined and tested for significance among the participants who completed the program with paired t-test. Thematic analysis was conducted for open-ended responses to provide illuminating insights for the quantitative findings. We also correlated these findings with verbal observations from the prison interdisciplinary staff. This study was approved by the University of British Columbia Behavioural Research Ethics Review Board. All people working with data signed a confidentiality agreement. Author R.E.M., on behalf of the academic research team, signed a five-year research agreement with the assistant deputy minister, Ministry of Public Safety Solicitor General, corrections branch, to conduct participatory health research with women in prison.
3. Results In all, 50 women in prison attended the introductory seminar, of whom 28 signed up for the pilot program and 16 completed the program (see Figure 1). The demographics and pre-program measures for women who completed, and did not complete the program are shown in Table I. Those who completed the program tended to be younger, of heavier body weight and BMI, and with larger chest size. W-H ratio was similar between the two groups. Reasons for not completing the program include: release from prison (n ¼ 5), interpersonal conflicts (n ¼ 4), and medical conditions (e.g. surgery) precluding exercise (n ¼ 3). The decrease in mean W-H ratio approached statistical significance (p ¼ 0.06 paired t-test) and the decrease in mean chest measurement was statistically significant (p ¼ 0.002 paired t-test) for the 16 women who completed the program (see Table II). Weight and BMI also decreased, however, these were not statistically significant (p ¼ 0.25 and 0.11 paired t-test). The mean changes per person were: 0.02 (standard deviation, SD ¼ 0.04) for W-H ratio, 0.98 (SD ¼ 1.04) for chest size, 2.80 (SD ¼ 8.98) for weight, and 0.73 (SD ¼ 1.67) for BMI. The majority of participants (60 percent or more) showed a decrease in body measures (see Table III). Four of the five participants who gained weight over the course of the program had low BMI (between 23.8 and 25.4) at the start of the program, while the fifth participant weighed 250 pounds (BMI ¼ 34.9) and reported that she intended to remain in the program “cuz I feel better than I ever have.” The majority of participants reported an improvement in energy level, sleep, and stress level at the completion of the program (Table IV). All 16 participants who completed the program also completed the follow-up questionnaire. When asked, “Did you exercise regularly before joining the circuit class?” Nine women reported “yes,” and when asked, “Do you think you will continue exercising after your release?” 15 women reported “yes”: To stay clean and healthy. I like the way I feel.
When asked, “have you noticed improvements since you started participating in the fitness program?” All reported “yes,” with ten women reporting improvement in both self-esteem and
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Figure 1 Description of participant invitation and data collection for the pilot program
All women in prison were invited and could choose to attend
Timeline
July 25
Introductory seminar: recruitment for pilot program and distribution of food charts, Canada Food Guide and eating plans (n = 50 attendees)
July 31
Pre program assessment: questionnaire and body measures (n = 28) August 2
Weekly nutrition seminars
Food charts, Canada Food Guide, eating plans
Weekly gym facility orientation
August 5 Group fitness program offered 7×/week, with minimum commitment 3×/week for 6 weeks (n =16 completed program)
Personal exercise program card
Anonymous feedback questionnaire
Post program assessment: questionnaire and body measures (n =16)
September 11
September 13
Table I Demographics and pre-program body measures for women who signed up for the program Factor Age (years) 18-29 30-39 40 þ Ethnicity Caucasian Aboriginal Other Weight (lb)a Body mass index (BMI)a Waist-to-hip ratio (W-H ratio) Chest (inches)
Did not complete program (n ¼ 12) No. %
Completed program (n ¼ 16) No. %
3 5 4
25 42 33
6 6 4
38 38 25
12 0 0 Mean 153.36 24.46 0.81 36.72
100 0 0 SD 31.01 4.44 0.06 2.88
9 5 2 Mean 170.93 27.00 0.82 37.97
56 31 13 SD 38.47 4.78 0.06 2.99
Notes: SD, standard deviation; n ¼ 28; amissing value for weight for one person in both “Did not complete program” and “completed program”
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Table II Mean pre- and post-program body measures for women who completed the program Factor
Pre-program measures Mean SD
Post-program measures Mean SD
Weight (lbs)a BMIa W-H Ratio Chest (inches)
170.93 27.00 0.82 37.97
168.13 26.27 0.80 36.98
38.47 4.78 0.06 2.99
36.26 4.11 0.06 2.93
Paired t-test p-value 0.25 0.11 0.06 0.002
Notes: SD, standard deviation, BMI, body mass index, W-H ratio, waist-to-hip ratio; n ¼ 16; amissing value for weight for one person in both “Did not complete program” and “completed program”
Table III Frequency of change in body measures for women who completed the program Factor Weight a Loss Same Gain BMI a Loss Same Gain W-H ratio Loss Same Gain Chest Loss Same Gain
No.
%
9 1 5
60 7 33
9 1 5
60 7 33
10 3 3
63 19 19
14 0 2
88 0 13
Notes: BMI, body mass index, W-H ratio, waist-to-hip ratio; n ¼ 16; apost-program weight was missing for one participant
Table IV Reported change in selected health measures at the end of the pilot in women who completed the program Factor Energy level Worse/same Somewhat improved Really improved Sleep Worse/same Somewhat improved Really improved Stress level Worse/same Somewhat improved Really improved Note: n ¼ 16
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No.
%
0 5 11
0 31 69
3 8 5
19 50 31
1 6 9
6 38 56
weight loss, nine with increased strength, eight with increased stamina, and five with improved posture: I feel good, increased energy, decreased body pain. I feel like I’ve lost fat but gained muscle. I learnt that when I am exercising every day I don’t crave drugs as much.
When asked “What do you like about participating in the circuit class?” Women responded that in addition to the personal benefits, they enjoyed the social support and fun provided by the group. It reduces stress. I felt very good afterwards and it was fun. The group works to know I’m not alone. I didn’t feel as depressed as I did before – exercise makes me feel better in my mind. This exercise program was FUN! Because it was organized and led by another woman in prison [y] she understands us [y] not someone coming in from the outside saying, you must do this because it is healthy for you
The PC commented that the socialization aspect of the circuit class amazed her. It was truly an amazing experience to witness the women come together and support and empower one another! An elderly aboriginal woman approached me during one of the classes with tears of joy in her eyes as she pointed out two recently incarcerated young aboriginal women who were sharing a circuit station and laughing together. She said “You have no idea what wonderful things you are doing here, those two girls were sworn enemies on the streets [y].”
Interdisciplinary prison contract staff observed an increased interest and use of the gym equipment during the six-week pilot program. The gym was frequently used by others doing independent exercise outside of the group circuit classes.
4. Discussion This pilot program, which resulted from participatory action research, closely follows the Precede-Proceed framework for health promotion planning (Green and Kreuter, 1991). The women in prison themselves identified a need within prison for a healthier life-style, as many women gained weight due to a high-carbohydrate diet, lack of exercise, boredom in prison, and drug cravings. Pre-disposing factors of knowledge, attitudes, and values were identified by these women. With a supportive warden and management staff, inmates were enabled by having regular access to a gym and health and nutrition education. Several reinforcing factors encouraged healthy behavior; these included weight loss, decreased stress, improved sleep, and overall feelings of health. These findings are consistent with the known benefits of exercise programs and with a recent report of decreased hopelessness and improved mental well-being among prisoners who engaged in a prison exercise program (Cashin et al., 2008). Women who participated in the exercise program reported decreased cravings for illicit drugs, a reinforcing factor for long-term health. An unexpected finding was that women highly rated the social aspect of the prison exercise circuit class. There was also a ripple effect of enthusiasm resulting in increased numbers of women participating as drop-ins to the gym. Others have also described women’s health as relational (Lewis and Bernstein, 1996), suggesting that a non-competitive exercise program was a reinforcing factor for healthy behavior. This approach contrasts the competitive exercise programs that are described in youth and male prison populations (Andrews and Andrews, 2003). A major strength of this program is that it was designed and implemented for and by incarcerated women. Women said that the peer-led nature of the program encouraged them to participate and stay involved because they felt trust and non-judgment in this environment. The prison gym facilities became increasingly popular during the time of the program and many
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inmates who otherwise did not participate in physical exercise chose to work out independently of the program. A limitation of data collection affecting weight measures was that different scales were required for the post-program assessments because participants were not allowed to use the medical facility scales. Another limitation was the small number of participants who completed the pilot program and its assessments. The pilot program had a positive long-term impact for some participants. The participatory research team, now operating in the community and called Women in2 Healing (Women in2 Healing Internet, cited October 29 2012) has continued the goal of healthy living. Co-author (M.K.) and other former participants began fitness programs in the community modeled on the prison pilot program.
5. Conclusions Incarceration provides a unique opportunity to influence behavioral and environmental factors that can promote healthy changes for the female prison population. A peer-led group nutrition program and circuit fitness class offered participants a safe, fun, effective alternative to exercise and the opportunity to experience group motivation in a supportive environment. The facilitators provided fun and motivation, encouraging participants to go at their own pace and in proper form for the exercises.
Acknowledgement The authors declare no potential conflict of interest in the research. This health research project was supported by an operating grant from the BC Medical Services Foundation of the Vancouver Foundation, and by collaborative funding support from the Fraser Health Authority, Women’s Health Research Institute and BC Women’s Hospital. Acknowledgements: The authors thank Benjamin Martin and Anna Chan for their research assistance and data entry; and, Rebecca James and Sally Yue Lin for formatting the manuscript for publication. For a complete list of individuals who were involved as peer researchers and other contributors in the prison participatory research project, please visit the project website at www.womenin2 healing.org
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Green, L.W. and Kreuter, M.W. (1991), Health Promotion Planning: An Educational and Ecological Approach, 3rd ed., Mayfield Publishing Co., Mountain View, CA. Gunter, T.D. (2004), “Incarcerated women and depression: a primer for the primary care provider”, J Am Med Women’s Assoc, Vol. 59 No. 2, pp. 107-12. Khavjou, O.A., Clarke, J., Hofeldt, R.M., Lihs P., Loo R.K., Prabhu M., Schmidt N., Stockmyer, C.K. and Will J.C. (2007), “A captive audience: bringing the WISEWOMAN program to South Dakota prisoners”, Women’s Health Issues, Vol. 17 No. 4, pp. 193-201. Lewis, J.A. and Bernstein, J. (1996), Women’s Health: A Relational Perspective Across the Life Cycle, Jones and Bartlett Publishing Inc, Sudbury, MA. London, E.D., Simon, S.L. and Berman, S.M. et al. (2004), “Mood disturbances and regional cerebral metabolic abnormalities in recently abstinent methamphetamine abusers”, Arch Gen Psychiatry, Vol. 61 No. 1, pp. 73-84. Martin, R.E., Chan, R., Torikka, L., Granger-Brown, A. and Ramsden, V.R. (2008), “Healing fostered by research”, Can Fam Physician, Vol. 54 No. 2, pp. 244-5. Martin, R.E., Murphy, K., Chan, R., Ramsden, V.R., Granger-Brown, A., Macaulay, A.C., Kahlon, R., Ogilvie, G. and Hislop, T.G. (2009a), “Primary health care: applying the principles within a community-based participatory health research project that began in a Canadian women’s prison”, Global Health Promotion, Vol. 16 No. 43, pp. 43-53. Martin, R.E., Buxton, J.A., Smith, M. and Hislop, T.G. (2012), “The scope of the problem: the health of incarcerated women in BC”, BCMJ, Vol. 54 No. 10, pp. 502-8. Meiklejohn, C., Sanders, K. and Butler, S. (2003), “Physical health care in medium secure services”, Nurs Stand, Vol. 17 No. 17, pp. 33-7. Messina, N. and Grella, C. (2006), “Childhood trauma and women’s health outcomes in a California prison population”, Am J Public Health, Vol. 96 No. 10, pp. 1842-8. Mohs, M.E., Watson, R.R. and Leonard-Green, T. (1990), “Nutritional effects of marijuana, heroin, cocaine, and nicotine”, J Am Diet Assoc, Vol. 90 No. 9, pp. 1261-7. Møller, L., Sto¨ver, H., Ju¨rgens, R., Gatherer, A. and Nikogosian, H. (Eds) (2007), “Health in prisons: a WHO guide to the essentials in prison health, WHO regional office for Europe, Copenhagen”, available at: www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf (accessed February 25 2013), p. 179. Mooney, M., Hannon, F., Barry, M., Friel, S. and Kelleher, C. (2002), “Perceived quality of life and mental health status of Irish female prisoners”, Ir Med J, Vol. 95 No. 8, pp. 241-3. Nolan, L.J. and Scagnelli, L.M. (2007), “Preference for sweet foods and higher body mass index in patient being treated in long-term methadone maintenance”, Subst Use Misuse, Vol. 42 No. 10, pp. 1555-66. Peterson, M. and Johnstone, B.M. (1995), “Effects on drug-involved federal offenders”, J Subst Abuse Treat, Vol. 12 No. 1, pp. 43-8. Plugge, E. and Fitzpatrick, R. (2005), “Assessing the health of women in prison: a study from the United Kingdom”, Health Care Women Int, Vol. 26 No. 1, pp. 62-8. Plugge, E., Neale, J., Dawes, H., Foster, C. and Wright, N. (2011), “Drug using offenders’ beliefs and preferences about physical activity: implications for future interventions”, International Journal of Prisoner Health, Vol. 7 No. 1, pp. 18-27. Shaw, N.S., Rutherdale, M. and Kenny, J. (1985), “Eating more and enjoying it less: US prison diets for women”, Women Health, Vol. 10 No. 1, pp. 39-57. Women in2 Healing-Home. available at: www.womenin2healing.org/ (accessed October 29 2012). Young, M., Waters, B., Falconer, T. and O’Rourke, P. (2005), “Opportunities for health promotion in the Queensland women’s prison system”, Aust N Z J Public Health, Vol. 29 No. 4, pp. 324-7. Zlotnick, C. (1997), “Posttraumatic stress disorder (PTSD), PTSD comorbidity, and childhood abuse among incarcerated women”, J Nerv Ment Dis, Vol. 185 No. 12, pp. 761-3.
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Further reading Martin, R.E., Murphy, K., Hanson, D., Hemingway, C., Ramsden, V., Buxton, J., Granger-Brown, A., Condello, L.-L., Buchanan, M., Espinoza-Magana, N., Edworthy, G. and Hislop, T.G. (2009b), “The development of participatory health research among incarcerated women in a Canadian prison”, Int J Prison Health, Vol. 5 No. 2, pp. 95-107.
About the authors Ruth Elwood Martin is based at Collaborating Centre for Prison Health and Education, University of British Columbia, Vancouver, Canada. Ruth Elwood Martin is the corresponding author and can be contacted at: [email protected] Sue Adamson and Mo Korchinski are based at Women in2 Healing, Vancouver, Canada and Collaborating Centre for Prison Health and Education, University of British Columbia, Vancouver, Canada. Alison Granger-Brown is based at Fraser Valley Institution for Women, Vancouver, Canada. Vivian R. Ramsden is based at Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, Canada. Jane A. Buxton and Nancy Espinoza-Magana are based at School of Population and Public Health, University of British Columbia, Vancouver, Canada. Sue L. Pollock is based at Interior Health Authority, Kelowna, Canada. Megan J.F. Smith is based at Collaborating Centre for Prison Health and Education, University of British Columbia, Vancouver, Canada. Ann C. Macaulay is based at Department of Family Medicine, McGill University, Montreal, Canada. Lara Lisa Condello is based at Department of Justice Studies, Nicola Valley Institute of Technology, Vancouver, Canada. T. Gregory Hislop is based at School of Population and Public Health, University of British Columbia, Vancouver, Canada and Cancer Control Research, BC Cancer Agency, Vancouver, Canada.
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