Introduction

Mental health status and quality of life of female prisoners were examined as part of a cross-sectional, healthcare study of the Irish prisoner population¹. There is evidence that female prisoners have higher levels of mental disorders than their male counterparts^2,3. Drug abuse has become a major problem in female prisons⁴. In some women poor mental health status and drug-related problems may be inter-related.

Quality of life is an important aspect of mental health. In order to examine the impact of drug use, gender, mental health status and imprisonment on quality of life of Irish female prisoners comparisons were made with drug-using and non drug-using male prisoners and with women from the general population of the same age and socioeconomic background. Quality of life is conceptualised as the individuals perception of their position in life, in the context of their culture and value systems and in relation to their goals, expectations and standards and modified by their physical and psychological state, social relationships and environmental factors^5,6.

Materials and Methods

Sample

A census sample was taken as the female prisoner population forms only 2-3% (60 - 90 women) of the total Irish prison population. Comparisons were made between women prisoners (the majority reporting hard drug use in the previous 12 months) and both drug-using and non drug-using male prisoners.

Frequency-matched samples of male prisoners were selected from the overall respondents in the General Healthcare Study of Prisoners in Ireland. Comparisons were also made with females from the general population matched for age and socio-economic status. This sample was selected from the national health and lifestyle (SLN) database.

Health Outcome Measures

The survey instruments comprised two psychometric measures (the WHOQOL-BREF and the GHQ-12), a modified version of the National Survey of Lifestyles, Attitudes and Nutrition, SLN questionnaire7 and a clinical history.

The WHOQOL-BREF

The WHOQOL-BREF (WHO, 1996) is an abbreviated version of the WHOQOL-100 quality of life assessment. The twenty-six individual items in the WHOQOL-BREF are representative of four domains related to quality of life: physical health, psychological, social and environment. Domain scores were found to correlate highly with the WHOQOL-100 domain scores⁵. A total quality of life score is obtained by summing up the individual scores on each item. Higher scores denote a higher quality of life with the highest possible score in each domain being 100.

The GHQ-12

The GHQ-12, a widely applied instrument to indicate psychological distress, is the short form of the General Health Questionnaire (GHQ) designed by Goldberg9 as a self-administered instrument for use in community settings. Two methods of scoring were used. In the Likert method values of 0-1-2-3 are assigned to the columns (total score range 0-36) with a higher score indicating greater distress. The second method assigns values of 0-0-1-1 to the columns (total score range 0-12) and chooses a cut-off score (2/3 in this study) that dichotomises the population into cases and normals. Caseness expresses the probability that a respondent might be found to have psychiatric illness at second stage interview.

Statistical analyses

All statistical analyses were carried out using SPSS 9.0 for MS Windows. Socio-demographic characteristics of the sample are reported. In addition to descriptive analyses, tests for differences between the four groups in reported quality of life using the WHOQOL~BREF and total GHQ-12 scores were performed using Analysis of Variance (ANOVA) and Kruskall-Wallis as indicated. Comparisons between female prisoners and drug-using male prisoners and drug-using male prisoners who were cases were carried out using independent t-tests and chi-square statistical procedures.

Results

Socio-demographic, lifestyle and self-reported health characteristics

A total of 59 female prisoners participated in the survey (75% of the total female prison population on the days when the data were collected). The demographic profile for the female and male prisoner samples and for the female sample from the general population is shown in Table 1. The mean length of time served on the current sentence was 4 years (SD 2). Fourteen of the female prisoners (24%) were on remand, seven (12%) had a sentence longer than 5 years and two (4%) were serving life.

83% of female prisoners (72% of male prisoners) had taken drugs at some stage in their life: 68% reported smoking heroin (38% of males) and 58% injecting drugs (25% of males) in the past 12 months During the same period, there was frequent use of other drugs such as ecstasy (52%), amphetamines (58%), cocaine (51%) and LSD (30%). Thus, poly-drug use is a major feature of drug-using female prisoners. Drug use in the prisoners was much greater than in the general population. All female prisoners in this study reported being cigarette smokers. More female prisoners than male prisoners had experienced adverse events due to someone elses drinking including verbal abuse (13% male, 33% female prisoners), physical assault (17% male, 28% female prisoners) and sexual assault (3% male, 16% female prisoners). Female prisoners were more likely to be taking prescribed medications (74% of female prisoners, 29% of male prisoners). The medicines most commonly in use were sleeping tablets, drugs for mental disorders and drug dependency maintenance drugs.
 

Quality of Life and Mental Health Status

Table 2 shows the mean domain and overall WHOQOL-BREF scores for the female prisoners, male prisoners, drug-using male prisoners and women from the general population.. Using the Kruskall-Wallis Test, significant differences in WHOQOL total scores were found between the four groups (x2 = 84.22, df 3, p < 0.001).

Significant differences were found between the groups on the physical domain (ANOVA: F = 9.76, df 3, p < 0.001) and on the other three domains (Kruskall-Wallis: psychological [x2 = 32.93, df 3, p< 0.001] social [x2 = 24.05 df 3, p< 0.001] and environmental [x2 = 54.54 df 3, p < 0.001]).
Female prisoners had higher total GHQ-12 mean scores (see Table 2) than the other three groups and 75% were cases. There were significant differences between the four comparison groups (Kruskall-Wallis Test: x2 = 47.22, df 3, p < 0.0001) on the GHQ-12 total scores.

Discussion

The findings from the present study clearly indicate that women in Irish prisons have a high level of psychological morbidity and poor quality of life and that this mental health profile is significantly poorer than their male prisoner counterparts and than women in the general population. While their quality of life profile was closer to that of their drug-using male counterparts significant differences remained on the physical and psychological domains of the WHOQOL~BREF between female prisoners and drug-using male prisoners. When compared to drug-using male prisoners who were cases female prisoners still had lower total WHOQOL~BREF quality of life scores (t = 4.67, df = 28, p < 0.001).

Quality of life is the product of a variety of determinants. The poorer quality of life of female prisoners and their extremely high levels of psychological distress may be associated in part with their high levels of drug use. If so, one could postulate that female prisoners would have similar quality of life profiles to drug-using male prisoners from similar socioeconomic backgrounds but not to other comparison groups.
 

The psychological distress of female prisoners reported here was higher than that reported in Australian female prisoners¹⁰. It has been pointed out that women experience consistently lower levels of mental health¹¹. This does not detract in any way, however, from the existence of worryingly high levels of psychological distress in this or other groups of female prisoners. Lindquist & Lindquist¹¹ analysed gender differences in distress in prison and proposed two possible interpretations to explain their findings. Female prisoners may experience a greater additive effect of the combined dimensions of environmental stress. The second interpretation, rather than focusing on environmental stress, proposes that the impact of incarceration on coping mechanisms may account for gender differentials They concluded that the answer might lie in an analysis of personal or social resources. It may also be true that many women who resort to drugs and crime have been exposed to particularly high levels of psychosocial adversity.

Women are more apt to state that their addiction to drugs and alcohol occurred as a response to severe stressors and family problems¹².
 
 

Significant proportions of women prisoners in this study reported problems due to other peoples drinking, including physical, sexual and verbal abuse and family difficulties and it has been reported elsewhere^13,14,15,16 that many forms of violence are common in the lives of women who use alcohol and other drugs.

Some consider that drug use by many women is an attempt to cope with violence^17,18,19. Adverse social circumstances, unhealthy lifestyles and negative life experiences undoubtedly contribute to the high levels of distress and poor quality of life in Irish women prisoners which may predate their drug abuse and criminal offences. If women are to be incarcerated a period of imprisonment should be seen as an opportunity to start the process of redressing disadvantage, attempting through an integrated health promoting prison strategy, their social and economic reintegration, Their specific needs must be addressed and their stress modifiers increased. Stress modifiers have been grouped²⁰ into social networks, social competence and resources within the community and might include increasing female prisoners positive coping skills, personal resources and sense of self-worth. It could also include a variety of agencies initiating and establishing enduring links with members of this vulnerable group while they are in prison. In addition to drug treatment programmes, traumas that may have triggered, complicated and protracted both their drug use, criminality, distress and depression need to be addressed.

In relation to female prisoners provision of more gender-specific knowledge to inform programme and policy decisions is required. Defining quality of life to include the culture and value system of the individual⁸ means that future research could include both a longitudinal design and qualitative methodology to further elucidate the determinants of mental health and quality of life.

Correspondence:
Maureen Mooney,
Department of Psychology, National  University of Ireland Galway.

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