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Research report

Incontinence: enhancing care in women's prisons

This study aimed to inform prison health services on the issue of incontinence

In this article…

  • Establishing the scale of incontinence in a women’s prison
  • Improving awareness of incontinence issues
  • Enhancing support for women prisoners with incontinence
  • Challenging stigma and encouraging client engagement

Author

Vari Drennan is professor of healthpolicy and service delivery, Faculty of Health and Social Care Sciences, St George’sUniversity of London and Kingston University; Claire Goodman is professor of healthcare research, Centre for Research in Primary and Community Care, University of Hertfordshire; Christine Norton isprofessor of clinical nursing and innovation, Bucks New University and Imperial College Healthcare Trust; Amanda Wells is nurse consultant/head of department, bladder and bowel care service, Devon Primary Care Trust.

Abstract

Drennan V et al (2011) Incontinence: enhancing care in women’s prisons. Nursing Times; 107: 17: early-online publication.

Background There is no evidence on the prevalence of urinary and faecal incontinence symptoms in women prisoners.

Aim To explore the extent and management of bladder and bowel symptoms to inform prison health services and prison nursing practice.

Method An anonymous self-report questionnaire tailored to low levels of English literacy, and administered in one women’s prison.

Results Women prisons have a higher reported prevalence of urinary and faecal incontinence, constipation and nocturnal enuresis than community populations; this is an unrecognised health problem.

Conclusion Prison primary care nurses should consider introducing sensitive but direct questions on bladder and bowel symptoms into admission assessment processes.

Keypoints: Women’s health, Prisoners, Urinary incontinence, Faecal incontinence

  • This article has been double-blind peer reviewed.

5 key points

  1. Prisoners have significant unaddressed continence problems
  2. Continence problems can damage mental health and quality of life
  3. There is a lack of research on the prevalence or management of urinary or faecal continence problems in women prisoners
  4. Women prisoners may not want to disclose these problems because of the stigma associated with incontinence and fear of being bullied
  5. Prison nurses need to develop practices that address these types of  health needs of women in custody

It has long been recognised that women prisoners have high rates of mental health and addiction problems (Singleton et al, 1998) but less attention has been paid to their physical health problems (HM Chief Inspector of Prisons, 1997). Prison healthcare provision and commissioning was transferred from the Ministry of Justice to the local NHS with the expectation that primary healthcare would address all health needs in this population (Department of Health, 2004).

Background

According to the DH (2000), prison populations have significant unaddressed incontinence problems. Although most women prisoners are under 40 years of age (Home Office, 2003), the population has features – such as high levels of multiple parity – that could indicate higher concentrations of urinary and faecal continence problems than in a female community population.

Continence problems are known to affect mental health and quality of life negatively (Donovan et al, 2003). A research review found no published literature on the prevalence or management of urinary or faecal continence problems in women prisoners.

Before their first night in custody, prisoners must have an assessment of their immediate physical and mental health needs, as well their risk of self-harm or suicide, which is conducted by a GP; a more general health assessment is carried out in the week following reception to the prison, usually by a nurse or nurse practitioner (Ministry of Justice, 2010).

DH guidelines for these assessments do not refer specifically to bladder or bowel symptoms (DH, 2003). Given the stigma associated with incontinence and the problems of bullying in prisons (Ireland, 2002), women prisoners may be unwilling to disclose these types of problems readily.

Our study aimed to determine the extent and management of bladder and bowel symptoms such as incontinence to inform prison health services and nursing practice in prison.

Method

We conducted a survey using an anonymous, self-report questionnaire in a closed women’s prison. The questions were constructed so they could be understood by women with a reading age below nine years, using the everyday language of elimination, such as “peeing” and “pooing”.

We asked questions that would capture information about the women’s personal characteristics, patterns of elimination, related symptoms and problems, and their views and experiences of managing them.

We piloted it with a small group of women prisoners, the prison GPs and nurses, and the prison governor.

The prison governor and prison health service gave us permission to conduct the study. It was reviewed by an NHS research ethics committee designated for considering prison studies, as well as the prison service in accordance with HM Prison Service standing orders. Ethical issues included ensuring prisoners did not feel coerced into taking part and that their anonymity was preserved; we emphasised they were free to choose whether to take part, without penalty or effect on the length of their sentences.

A quantitative analysis was carried out and written comments were thematically analysed.

Results

In total, 246 women accepted the self-report questionnaires; 148 (60%) returned them. Of the women who returned questionnaires, 66% had children, 22% had three or more children and 9% were pregnant. Most women – 80% – were aged under 40. Only 20 (14%) of the questionnaires had all questions answered, with non-response to individual questions at 2-28%. Eleven women (7%) wrote that some questions were too embarrassing to complete and 35 women (24%) said they had given information not previously revealed to any professional.

The self-reported prevalence of bladder and bowel symptoms is outlined in Table 1.

Significantly more women who had three or more children reported stress incontinence than those who had not had children. More women who experienced a tear or an episiotomy in childbirth reported stress and urge incontinence than those who had not. Significantly more women aged 41 and over reported stress and urge incontinence than younger women.

The women used a variety of means to contain urine leakage. Three women reported using continence pads, nine used sanitary towels, nine used toilet paper and 22 used panty liners, while 13 stated they did not use any containment.

Forty-six women wrote additional comments on the questionnaire. The prison diet was seen by most as the cause of their constipation. Some reported that they had received treatment in prison for bladder and bowel problems that they had ignored because of their addictions while they were outside prison. Some women commented on the difficulties in accessing help for bladder and bowel problems while in prison. Some also felt confidentiality would not be observed by prison health staff.

Discussion

Rates of urinary incontinence were higher than those in the general female population (Hunskaar et al, 2005). Reported nocturia was also higher but may be explained by the environment and known sleep problems in prisoners (Smith, 1998). Reported nocturnal enuresis was higher than the 0.5% reported in the only published study of its prevalence in adult women (Hirasing et al, 1997), as was reported faecal incontinence, which has a prevalence of 2-5% in the community (Hunskaar et al, 2005). The small number of women using prison health service-issued continence pads suggested that few had revealed these problems to prison nurses.

Our study demonstrated that bladder and bowel problems are as common in women prisoners as in the general population, and that bedwetting and constipation in particular may be even more common. In the absence of any other data on these types of problems, this information is useful to nurses working in prisons and those involved in commissioning.

We suggest that during health assessments nurses should ask women prisoners directly about bladder and bowel problems. Prison nurses may require additional support through education and training on how to raise these questions sensitively with women prisoners; they may also need a greater knowledge about the treatment and management of bladder and bowel symptoms.

The challenges for prison health services are to ensure this specialist help and containment products are available for women prisoners, and that the women are followed up on their release.

Our findings warrant further investigation into the causes and frequency of bladder and bowel problems in other prison populations. Investigations should inform interventions and management strategies suitable for a prison environment that are acceptable to women prisoners.

Conclusion

Prison nurses, as well as commissioners for prison health services, need to be aware of the scale of the problems described here, and develop practice and systems that address the health needs of women in custody in a non-stigmatising manner. NT

This is a summary of Drennan V et al (2010) Incontinence in women prisoners: an exploration of the issues. Journal of Advanced Nursing; 66: 9, 1953-1967.

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