Nurses’ Perceptions of Weight Gain and Obesity in the Prison Environment

Abstract

This study aimed to improve understanding of obesity in prison by investigating prison nurses’ perceptions of weight gain and obesity. In-depth semistructured interviews were carried out with 17 nurses who worked in two male prisons in the United Kingdom. Nurses identified a variety of factors that they believed contributed to obesity and weight gain in the prison setting. These included factors caused by prisoner behavior, such as poor food choices and sedentary lifestyle. Factors influenced by the prison environment, such as stress of imprisonment, prison regime, and prison culture, were also seen as significant. These factors were seen as barriers to the role of nurses delivering care in prison. Nurses explained how they adapted their role to overcome these barriers.

Keywords

prison health obesity prison nurse prisoner obesogenic

Introduction

Obesity is a growing problem in the United Kingdom. In 2014, it was estimated that 24% of men and 27% women were obese (Health and Social Care Information Centre, 2015). It is predicted that by the year 2050, nearly 60% of men and 50% of women will be obese (Foresight, 2007). The issue of obesity in prison has received much attention recently (Clarke & Waring, 2012; Herbert, Plugge, Foster, & Doll, 2012; Plugge, Foster, Yudkin, & Douglas, 2009). This new evidence emphasized the missed opportunity for public health intervention in a vulnerable group of people, but no specific guidance on how to reduce growing obesity levels in prisoners is offered.

The inherent nature of prisons can create a difficult environment (e.g., unpredictable access to patients, volatile nature) in which to deliver care (Norman & Walsh, 2014). Still, health care professionals (particularly nurses) are expected to deliver the same level of care as to community-living patients (Joint Prison Service and National Health Service Executive Working Group, 1999). The prison population includes some of the most deprived and vulnerable groups of people in society. For example, a recent report (The Scotland Institute, 2015) found that 80% of prisoners in Scotland suffered two or more mental illnesses. These attributes of the prison environment create specific challenges to health care delivery in general and to obesity management in particular. National guidelines (National Institute for Health and Care Excellence, 2014, 2015) provide strategies for health care professionals to help individuals stay healthy. However, there is very limited evidence about the challenges and opportunities associated with the implementation of these guidelines in a prison environment. This study addresses this knowledge gap by exploring nurses’ perceptions of weight gain and obesity management in the prison environment.

Method and Data

Due to the lack of research in this subject area, a constructivist grounded theory methodology was used (Charmaz, 2014). Constructivist grounded theory methodology allows the collection of rich data with greater depth to ensure a greater understanding of nurses’ views on weight change and obesity in the prison setting. Moreover, the constructive approach promotes the reflexivity of the researcher (Charmaz, 2014). The setting for the study was two male prisons: a Category A/B prison and a Category C prison located in the UK. Nurses were interviewed on a one-to-one basis by the researcher. The interviews took place in the treatment rooms in the prison to allow the nurses to feel more comfortable.

Nurses with at least 2 years of experience working in prisons were invited to a one-to-one semistructured qualitative interview to explore their view of obesity management. All eligible nurses were given an information sheet and allowed 7 days to consider participation. From those who agreed to participate, individuals were selected randomly. A total of 17 nurses were recruited and interviewed for the study.

The interview method used was intensive interviewing as described by Charmaz (2014). This allowed an in-depth exploration of the nurses’ perceptions of weight change and obesity by using open-ended questions (Table 1) and obtaining detailed responses. Interviews were conducted one at a time. Notes were taken, but interviews were also audio-recorded, transcribed, and analyzed. Initial questions were broad and allowed the participants to discuss those areas that they believed were important. Interviews lasted for around 30 to 60 minutes. After analysis of each transcript, the interview schedule was amended to allow important themes to be explored in subsequent interviews (Table 2).

Table 1.

Initial Questions for Nurses.

1. What is your current knowledge on the causes and management of obesity? (Prompts: actors that lead to its development, guidelines, treatment options)

2. What role do you believe a prisoner plays in the development of his or her obesity within prison? (Prompts: change in eating habits, patients do not care anymore, choose not to be healthy)

3. How do you believe prison influences a patient’s weight? (Prompts: poor diet, lack of activity, being locked up)

4. What opportunity is there for a patient to manage his or her weight in prison? (Prompts: gym, choose what they eat, what behaviors they can dictate)

5. What do you see your role as in helping patients being healthy in prison? (advisory role, monitoring, encouraging, no role)

6. What can be done to prevent obesity developing within prison?

Table 2.

Further Questions Utilized After Data Analysis.

1. To what extent do you believe prisoners care about their weight?

2. What is your knowledge of the food available on the prison menu and canteen?

3. Can you give an example of where you have given specific advice to an individual to lose weight? (Prompts: What was their response? How did you feel? How often do you give advice to prisoners?)

4. What role does working in prison play in prisoners’ weight gain/obesity?

5. What role do you believe prison officers could play in weight management of prisoners? (Prompts: Does their relationship have a different dynamic than that of nurses?)

6. To what extent does a prisoner’s age affect his or her weight management in prison?

7. How does working in a prison environment affect your professional role? (Prompts: Does it make a difference to your role as a nurse? Does it help or hinder yourself?)

8. What factors do you believe motivate prisoners to be healthy?

9. How do you think different prisoners manage their weight in prison?

10. How does a prisoner’s behavior on the outside affect his or her health within prison?

11. What role do you think prisoners have on each other’s weight?

12. How do you help prisoners manage their weight within prison?

Each interview was analyzed according to a grounded theory approach as described by Charmaz (2014), using Atlas.ti software (Version 7; 2013). First an initial coding was carried out by reading through the interviews and identifying common themes on a line-by-line basis. During this initial coding, constant comparative methods were used (Glaser & Strauss, 1967). Secondly, theoretical coding was carried out (Glaser, 1978) by analyzing the focused codes and seeing how they interrelate to form a theoretical framework that explained the data. These codes aimed to show the relationship between the substantive codes rather than replace them (Charmaz, 2014). The theoretical codes and final memos were used to generate a cohesive theory that explained the results obtained. Data collection ceased when data saturation was achieved. Data saturation was achieved when no new codes or themes were identified from interviewing.

Findings

The mean age of the participants was 48 years. Three male nurses and 14 female nurses were recruited. All participants were employed full time and had spent the last 2 years continuously working in the prison environment. The nurses identified various factors that could adversely affect a prisoner’s weight; these fall into two categories: prisoner behavior and prison constraints (Table 3).

Table 3.

Prisoner Behavior and Prison Constraints.

	Theme	Example
Prisoner as a barrier	Makes unhealthy food choices	“The prison has healthy options on the menu, but they choose not to have it, they don’t care, like I said they are in prison what do they really have to look forward to or enjoy? If you could see some of their plates piled with food, there’s no way that they do not know that the food they are choosing is not healthy for them. Seriously who thinks that chips is good for you?” (P: J)
	Trades food	“The amount of trading of food that goes on is wrong. People swap food for other food or for other things, I say things but it’s mainly tobacco in here.” (P: Q)
	Manipulates health care services	“Look at the Complan, I have guys coming to me asking me how do they get that, not I need that, but how can they get that. I know why they want it, they’re gonna trade it pure and simple. That means there must be people in here who want to buy it doesn’t it? Even the guys who are prescribed it for a reason, you know? If they’ve got a serious disease, like hep C, a lot of them will trade it if they can.” (P: H)
	Chooses to be inactive	“When they unlock the doors for association, so when they can get out and walk around the wings, get a little activity, a lot of them don’t because they are watching their favorite show on TV or something else.” (P: O)
	Does not care about health	“With experience you learn that some of the prisoners don’t really care about their health. A lot of them will carry on smoking, not care what they eat, carry on doing drugs and stuff.” (P: F)
	More interested in being muscular	“But it’s not always about losing weight its more about being fitter and stronger. A lot of these lads they go to the gym, you see them exercising on the landings. A lot of them want to put on weight—that’s not right, they want to put on muscle. It’s an image thing, isn’t it? They want to look big and tough in front of their mates.” (P: L)
	Not enough food choice	“One is that they do not have a lot of choice or option when they come into prison, because they are quite restricted on what they can eat.” (P: B)
	Activity levels restricted	“They are locked up too much in prison, especially recently. In the past year or so, they have had less exercise. They have said that the gym time has been cut down. They don’t go to the gym as often. So maybe lack of exercise.” (P: C)
	Healthy food is expensive	“It’s like I was talking about the sweets, chocolates and crisps, when you go to their cells and tell them that’s not good for them, all of them will say what else are they meant to order, the fruits are so expensive that it is not worth it for them. They don’t really earn a lot and I think it’s like 50p for a banana or something like that, that’s a lot of money for them it really is, so you can understand it.” (P: P)
	Regime is inconsistent	“Our role is to give advice, encourage them to go to the gym, then at the end of the day they have to want to change. I don’t think we get the opportunity, mainly due to the lack of the regime, but even if we do give them advice they can’t always follow it. Like they can’t always go to the gym because of the restrictive regime. One of the main ways to lose weight is to exercise more, or increase your activity, right? That’s what we should be telling them, yeah? But the fact that they can’t always go when they supposed to, makes it harder for us, what are we supposed to give for advice? Do cell work outs?” (P: L)
	Stress caused by imprisonment	“They are preoccupied with other issues. Like their liberty has been taken away from them, they are in distress aren’t they? They are stressed thinking about their case and that sort of thing.” (P: F)

Prisoner Behavior

Most nurses viewed prisoners as making unhealthy food choices, often going for the unhealthy option on the prison menu. Similar views emerged with regard to food purchased from the prison canteen: Nurses considered that prisoners purchase and consume excessive amounts of sweets and confectionary. A similar perception was seen in regard to prisoners’ activity levels, with nurses considering that prisoners tend to have a sedentary lifestyle and do not engage with the opportunities for physical activities offered in the prison.

The prison culture was also viewed as an important contributor to prisoners’ weight. This included trading of food for other items (e.g., tobacco, phone credit), which nurses interpreted as prisoners not considering their health a priority. Furthermore, nurses underscored prisoners’ interest in bodybuilding, which was viewed as a means to obtain peer approval. Prisoners’ interest in bodybuilding was also blamed for prisoners trying to manipulate health care services to obtain food supplements.

Prison as a Barrier

The limited food choices provided in the prison were viewed as an important factor influencing unhealthy food choice. Also, the higher cost of healthy food in the prison canteen was felt to have driven prisoners toward cheaper unhealthy food.

The prison regime was viewed as causing prisoners to spend too much time locked up in their cells, being inactive. Furthermore, the inconsistency of the prison regime was viewed as detrimental to prisoners’ health, via demotivating healthy lifestyles—the main factor being the cancellation of planned activities (e.g., gym, time on exercise yard).

Imprisonment was also felt to indirectly affect the weight of prisoners. The clearest example of this is nurses feeling that stress caused by imprisonment could lead them to overeat (i.e., comfort eating). This includes factors such as being away from family and friends and the realization that they were in prison.

Barriers Undermine Role

The combined effect of these barriers causes a recognition that these factors not only affect an individual’s weight and health but also can undermine nurses’ role in supporting prisoners to manage their weight. Nurses felt that they could not use the full set of skills that they would use in the community to achieve the desired outcomes. For example, they felt unable to establish similar relationships with prisoners as they would with community patients, due to the security requirements. This was viewed as a major barrier in promoting healthy behavior with prisoners:

When I worked in the community you could talk to the patients about things that you do to be healthy, you know? Like “I walk around X park, it’s a really nice walk, you should try it.” But in here you can’t say stuff like that. Basically, because it’s dangerous you could end up with somebody getting you there. You know threatening you? (P: D)

Furthermore, these barriers can lead to feelings of inadequacy within a nurse role:

To be honest other people are not really receptive. The amount of people who’ve come and seen me after they have put weight on when coming into prison and you spend time with them telling them what to do, but they don’t do what you discuss and it’s because they don’t want to, it makes you feel like you’ve failed. (P: Q)

Make Sense of These Barriers

Nurses tried to contextualize these barriers in the prison setting. There was a realization that eating behaviors are affected by many factors intrinsic to the prison environment. This includes boredom, which is due to the amount of time that prisoners spend in their cell. This was felt to lead to eating for the “sake of eating:”

Boredom plays a big part, sitting in the cell for most of the day, if they have food in there they are going to eat it. There’s so many guys who say that they eat stuff not because they are hungry but because it’s there, they say “it’s not my fault, I was bored.” (P: L)

While boredom can be viewed as a direct consequence of imprisonment, nurses recognize the indirect impact of how being in prison can affect health. A significant part of this is the stress caused by being in prison. Stress was regarded to also influence food choice, causing prisoners to consume food that is more enjoyable yet unhealthier for them:

I suppose they could choose better foods, but they don’t, like I said they choose the nicer foods. I suppose maybe the temptation gets too much, you know? They are in prison, they are away from their family and friends and you know? They want something nice. So, they choose the more enjoyable food, you know? Wouldn’t you? I think there is healthy options, I haven’t seen the menu, but they say there is healthy options. (P: G)

Nurses also felt that prisoner behavior was influenced by the prisoner’s background prior to incarceration. This includes factors such as health literacy level:

A lot of the time the prisoners don’t really understand what foods are bad for them, like saturated fats, the lives some of them have had, has not really allowed them to get that sort of knowledge. Some of them haven’t gone to school, they don’t come from normal families where they would be taught by their parents what sort of food is good for them or not. They don’t have normal lives where they are going to think “I want to lose weight, how am I going to achieve this?” (P: I)

Nurses also felt that the prison culture was responsible for prisoners wanting to bulk up:

I do think quite a lot of them care about their weight, but it’s not all about losing weight but also gaining weight. They just want to get big, muscly big. It’s a prison thing. I think a lot of them are influenced by weight gain in here, they come in and they want to get big. I think it becomes a guy thing for some of them. They compete with one another, you see them on the wings working out a lot. For those it’s more about gaining weight rather than losing weight. (P: E)

Similarly, nurses regarded that the distrust prisoners have toward nurses’ work was influenced by the culture of the prison.

They associate us with them being in here, maybe not putting them in here, but definitely part of the people that keep them here. So, if we just kept telling them what to do, I don’t think we would get the response that we wanted, you know? I hope I’m making sense, but it’s like that they are fighting against the system. A lot of them think that they are here to be punished and they can’t get that out of their system, no way. So, whatever happened, that’s their opinion. So, you have to be careful what you say, or maybe how you say it. (P: M)

While the above example illustrates nurses’ views on how the prison culture can influence prisoners to focus on their weight, nurses also believe that imprisonment and the prison culture can lead prisoners to become demotivated with regard to their health. This can lead them to not being concerned about their weight:

They are not motivated to lose weight. Would you be motivated? No one is really helping them are they? They don’t get out of their cell much and the food is poor. If they wanted to be healthy it would be very hard, almost impossible. Why would they want to be healthy? There’s nothing in here to make them want to be healthy you know? (P: D)

The nurses felt that the prison environment is influenced by macro-level factors such as the financial constraints caused by budget cuts:

Most of the people are generally really negative about the food, they will compare to what they have on the outside and says it’s not as good as what they have at home. That’s not realistic, they only have a couple of pounds to spend per person per day, so for them to think they are going to get the same quality or choice of food it’s a bit silly. (P: Q)

Nurses adapt to these barriers. The process of making sense of and understanding these barriers supports nurses’ adaptation to the prison environment and helps them to carry out their role effectively.

A key area where they apply this learning is in attempts to ensure that interactions with prisoners strengthen nurse–prisoner relationships. For instance, nurses viewed the way advice was conveyed to prisoners as important:

If you tell them to stop eating this and that, they will think that, that’s the prison trying to punish them, you’ve got to try to get through to them why you’re doing it. It sounds funny, but that’s really important in here, trust me if you don’t do that they are just going to hate you. Well you have to explain what you’re saying, like if you tell them to stop eating sweet stuff, tell them that they can still have one once in a while, but not a regular basis. What I do is book them in again in a week or so and say to them that if they follow my advice they will see their weight change. It’s just something I’ve learnt over the years. (P: M)

Furthermore, nurses changed the way that they communicate information based on this adaptation:

When I first starting working in prison and used to do healthy man clinics, I used to tell them what foods to eat and what foods to avoid. But I found that when I saw them again they were still eating those foods. It was because some of them didn’t understand what I was saying, you know because they aren’t really educated to a good level. A lot of them didn’t even finish school. Like I was using words like carbohydrates and they didn’t know what that meant. I’m not being rude but some of them are not the smartest tools in the box. So, I’ve learnt to be more specific. I won’t just say avoid carbohydrates, but tell them to reduce the amount of rice, potatoes, chips that they have. That works a lot better. That’s not always the case, but it’s better to do that. You know they are more likely to understand. (P: F)

While improved communication is important to build trust, there is also a recognition that advice needs to be specific to the prison environment, showing prisoners that the nurses are aware of their lifestyle and the barriers they face:

Try to encourage them to get a job. There is jobs for them and I think this is important for them. Work is important because if they are not getting to the gym and they are not getting exercise. Then, if they are working they are getting out of their cell and they will be moving around. For example, cleaning jobs they will be moving around and be quite active. If they stay in their cell they will eat more. (P: C)

The nurses’ depth of understanding of how prison affects weight is illustrated by the suggestions for potential interventions:

One of the biggest changes they should make is letting the prisoners help choose the food on the menu and on the canteen, it will take away a lot of the negativity towards the food and it may let them make better selections. (P: A)

I think it would be better if we trained some of the prisoners to do that. You know, train a couple of them on each wing so that they can show the others what they can do. I think it will work better. Mainly because they trust each other, you know? Because coming from somebody in the prison they are just more likely to do it. Like if they say you could choose this and that off the menu, they would believe them because they are in here. That would make a big difference and it’s not just the food, but telling them to get out of their cell more and not just watching TV. Maybe it would be a bit too much but getting them to run some sort of exercises on the wings, maybe. (P: K)

Discussion

This study explored the views of nurses about the constraints and challenges associated with weight management in a prison population. The findings revealed that nurses perceived that prisoners’ food and activity preferences (factors judged important in the development of weight gain in community samples) were important determinants but were mediated by the prison environment.

Nurses portrayed a concept of food as a commodity and traded by prisoners. A prisoner’s diet was seen as an outcome of this closed “market.” Nurses extend the trade concept of food to the utilization of health care services whereby prisoners attempt to manipulate health care services to obtain food supplements for bodybuilding purposes. This goal might be explained by a prison culture that prioritizes masculine appearance and behavior (Curtis, 2014; Evans & Wallace, 2008). However, although there seems to be a link between masculinity and food choices and health (Jewkes, 2002; Newton, 1994), it could be a consequence of the negative effect that prison has on an individual’s masculine identity (Jewkes, 2002). Being muscular helps prisoners get more respect from their peers and reduces the risk of bullying (de Viggiani, 2012)—but this culture mitigates against effective weight management. Prisoners’ preference toward bodybuilding was viewed by nurses as an important determinant of unhealthy weight gain, possibly underlining a lack of consideration that bodybuilding may favor a higher ratio of lean muscle mass to body fat, a valid measure of healthy weight.

Nurses also viewed prison-associated stress as possibly indirectly influencing prisoners’ poor eating behavior, including poor food choices and increased portion sizes. The role that stress can play in obesity and weight gain has been well-documented (Moore & Cunningham, 2012; Sominsky & Spencer, 2014; Torres & Nowson, 2007) and is suggested to act through a combination of biological and behavioral changes. Stress, for example, may stimulate glucocorticoids production, which can increase an individual’s appetite and also promote increased consumption of food high in sugar and fat (Sominsky & Spencer, 2014; Torres & Nowson, 2007). Overeating is also suggested to be used as a stress mechanism during stressful experiences, such as being in prison (Spoor, Bekker, Van Strien, & van Heck, 2007). These experiences can lead to long-term changes in eating behavior that can increase the risk of obesity (Tryon, Carter, Decant, & Laugero, 2013). These suggestions highlight a potential obesogenic prison environment (Swinburn & Egger, 2002).

While acknowledging the barriers to weight management in the prison context, the study nurses expressed feelings of responsibility toward prisoners’ weight management. Nurses outside prisons tend to view their weight management role with some ambivalence (Nolan, Deehan, Wylie, & Jones, 2012). The nurses in this study felt that it is their role to manage obesity and considered that they possessed the skills and knowledge to promote healthy weight in prisoners (Phillips, Wood, & Kinnersley, 2014). Yet, nurses expressed a certain degree of ambivalence toward fulfilling their responsibilities, including skepticism about the impact of interventions offered. They also felt that success or failure was down to the prisoners’ motivation rather than nurse’s influence (i.e., prisoners were often viewed as “lazy” or anxious to gain weight).

To some extent, nurses’ negative attitudes on weight management reflect widespread views in Western societies (Puhl & Brownell, 2001). These negative views and attitudes can lead to discrimination and stigmatization, which can affect an individual’s well-being (Kolotkin, Meter, & Williams, 2001). Considering weight management as being under the control of the individual, it justifies unhealthy weight as being somehow “deserved” (Crandall, 1994; Crandall & Martinez, 1996). However, the nurses in this study contextualized this behavior in relation to the effects of imprisonment and the prison environment.

The difficulties nurses experienced delivering care have been found in other studies of nurses working in the prison environment (Crampton & Turner, 2014; Weiskopf, 2005). Interestingly, these studies found that nurses mentioned the same barriers as in this study. These include not being able to disclose personal information to prisoners, prisoners’ attempts to manipulate health care services, and the negative effect the prison has on nurses’ ability to deliver care.

The concept of emotional labor may explain how the numerous barriers affect the nurse and why nurses need to adapt to the requirements of the prison environments. Emotional labor has been defined as having three main components (Mann, 2004, p. 208): “(1) the faking of emotion that is not felt, (2) the hiding of emotion that is felt, and (3) the performance of this emotion management in order to meet expectations within a work environment”. An example of emotional labor is typified by how nurses manage prisoners who try to manipulate health care service to obtain food supplements. In this instance, they felt that they have to deal with this process professionally and so maintain the expected standard. While prisoner and prison barriers cause emotional labor, the adaptation process may be achieved through the utilization of emotional intelligence (Mayer, Salovey, & Caruso, 2004).

Accordingly, it could be argued that this study supports the theory that emotional intelligence is important for prison nurses to manage emotional labor and to provide care that is appropriate for the prison environment. For example, in the scenarios described earlier, nurses used emotional intelligence to realize that it is part of the prison culture for prisoners to try to manipulate health care services. They have realized that identifying and preventing this behavior is beneficial to improving the health of the prison population, as it reduces the trading of medication. Hence, this behavior does not offend them or make them think any less of the prisoner; in contrast, they learn to empathize with the prisoner and provide care that reduces this behavior.

Limitations

The investigator was a health care professional working in prison and possibly this influenced the response nurses gave during the interviews. For example, they may have felt that they needed to give responses that were expected of them. However, the risk of social desirability bias was minimized by using questions that explored the nurses’ inner thoughts and feelings. The interviewees were also informed at the start of the interview that anything that they stated would be confidential and would not be shared with any other person. The interview was also conducted in a manner to ensure they felt comfortable and relaxed.

Furthermore, the study relied on nurses to volunteer and it may be that only those nurses who felt comfortable discussing obesity and weight change volunteered. It may be that nurses who had a different viewpoint did not volunteer, as they felt their views may not be appreciated. The study was not able to compare differences in characteristics (e.g., expertise) between nurses who volunteered and those who refused participation.

Conclusion

The nurses in this study felt that both prisoner and prison factors played a role in weight gain and obesity in the prison environment. Many of these factors were similar to those associated with weight gain in the community, mainly physical inactivity and unhealthy food choices, but the study also identified factors that were specific to the prison environment. In many ways, the latter magnified the factors that are known to be important outside prison walls. In the prison, food was used to relieve stress, as in the community, but arguably the stresses were greater. Food was also viewed as acquiring a symbolic and economic value as a tradable commodity. The opportunity for physical activity was inevitably very much more limited and even when it occurred was not pursued with the enthusiasm that nurses might have expected.

This study also highlights the difficulties that nurses face in their daily roles in the prison environment. They are exposed to behavior that they would experience less in the community and they face a population whose priority is not their health.

From this study, it is evident that national guidelines on managing weight and obesity have relevance to the prison setting and certainly nurses accept that physical inactivity and unhealthy food play a significant role in weight gain and obesity in prison. However, it is evident that while they understand many of the pressures in the prison environment, the weight management strategies deployed outside of prison have only limited use within. The prison environment is uniquely obesogenic, and this context needs recognition.

Footnotes

Declaration of Conflicting Interests

The authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Program.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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