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How do policymakers interpret and implement the principle of equivalence with regard to prison health? A qualitative study among key policymakers in England
  1. Nasrul Ismail,
  2. Nick de Viggiani
  1. Centre for Public Health and Wellbeing, University of the West of England, Bristol, UK
  1. Correspondence to Nasrul Ismail, Centre for Public Health and Wellbeing, University of the West of England, Bristol, Bristol BS16 1QY, UK; Nasrul.Ismail{at}


Background The principle of equivalence in prison health has been established for nearly four decades. It seeks to ensure that prisoners have access to the same level of healthcare as members of society at large, which is entrenched within the international legal framework and England’s national health policies.

Aims This study examined how key policymakers interpret and implement the principle of equivalence in English prisons. It also identified opportunities and threats associated with the application of the principle.

Methods In total, 30 policymakers took part in this research. These participants engaged in policymaking activities and occupied positions of authority in the prison field.

Results Despite the policymakers’ consensus on the importance of the equivalence principle, there was a varying degree of understanding regarding what constitutes ‘equivalence’. Participants described how the security culture impedes prisoners’ access to healthcare services. Additionally, the increasing size and complexity of the prison population, coupled with a diminishing level of resources, reduce the level of care being provided in prisons and thus compromise implementation of equivalence in English prisons.

Conclusions Inconsistent interpretation of equivalence, the prevailing security drive, increasing numbers and health complexities of prisoners and fiscal austerity threaten the implementation of equivalence in English prisons. This research calls for new guidance on how to interpret and implement equivalence, along with measures to educate prison governors and staff on the prison rehabilitation value, ensure greater investment in prison health and consider alternatives to imprisonment to future-proof the principle of equivalence in the English prison system.

  • prisoners
  • ethics
  • health promotion
  • public health ethics

Statistics from


  • Contributors NI and NdV conceptualised the study. NI conducted interviews with participants. NdV audited the audio interviews and checked the transcripts against the audio files. NI coded the data and conducted initial data analysis. Both authors undertook data interpretation. NI prepared the first draft of the article. Both authors provided feedback and contributed to subsequent revisions of the article. All authors approved the final version of the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval This study complied with the guidelines of the University of the West of England’s Faculty Research Ethics Committee (approval number R1261).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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