Table 4 Interactions between structural & relational factors influencing health

1. Nutritional Status: Prison rations, visitation, and group membership

Women’s nutritional status was influenced by the interaction between prison rations, structural and administrative factors influencing visitation, and relationships formed in prison. Inadequate prison rations were a critical health concern and their paucity resulted in heavy dependency by inmates on donations from friends and family. However, many women reported rarely receiving visitors, citing a range barriers including the limited female-holding capacity of local prisons, and frequent transfers to prisons geographically removed from their place of residence. Such factors made the costs of travel for friends and family prohibitive. In this context, the formation of inmate social and/or cooking groups took on great significance. Officer-appointed groups such as those in Facilities 1 and 2 encouraged resource-sharing among women prisoners of differing socio-economic backgrounds with some protective effects vis-à-vis nutritional status. Conversely, in facilities where groups were self-formed and more self-interested, some women were more exposed to the compounding effects of limited prison rations and lack of visitation.

2. Health service access: prison resourcing, administrative bias and inmate-officer relations

Women’s access to health services was shaped by a combination of prison resourcing, administrative bias and inmate-officer relationships. Basic availability of health services for female prisoners was weak due to the absence of internal health services in any of the women’s facilities. In some sites, moreover, priority was given to male prisoners in accessing already limited transport to external health centres. Compounding these barriers, women reported varied and often ad hoc officer responsiveness to requests to access healthcare, with positive responses often based on inmates’ wealth or long-term relationship with the officer. Women prisoners with no visible physical symptoms of ill-health, as well as those looking after children, reported particular difficulties in persuading officers to commit resources to helping them access services.

3. Victimisation: Wealth, power and resource grabs.

Longer-serving female prisoners and those appointed to senior inmate ranks tended to have closer relationships with prison officers, a situation enabled and cemented by behaviours including collusion on ‘resource grabs’ from Church donations. Such behaviour helped to ensure ranking inmates accumulated tradable items that could be used to ensure officer responsiveness to later requests for help, including requests for access to healthcare. Non-ranking inmates and those with no access to tradable goods were, by contrast, prone to vicitimisation by both officers and senior inmates. Women with chronic conditions and those looking after children were particularly vulnerable to verbal and physical belittlement since (as a result of ill-health or childcare duties) they were often unable to complete mandated chores or labour duties. An officer culture that accepted the use of psychological and occasionally physical abuse as a means of discipline and control meant less powerful inmates had little or no recourse.