Patient or prisoner? Perceptions of prison healthcare services in Norway and the conflict between care and control

Abstract

In Norway, prisons are part of the system of public welfare service provision, with the objective of providing equal high standards of public services to all. However, most incarcerated people seem to agree that the healthcare services available in prison are of a lower quality. This article explores this perception and what it tells us about the unsolvable conflict between care and control in prison. The article finds that, firstly, healthcare services in prison have objective shortcomings. Secondly, a gap between expectations and experiences can cause disappointment and thus create or exacerbate a negative perception. Incarcerated people anticipate, but do not always experience, to be treated as patients in a healthcare facility rather than as prisoners in a security-oriented setting. This inability to meet patients’ expectations, is arguably another shortcoming resulting from the prioritisation of control over care.

Introduction

‘You don’t get help here; I’m serious. There is a guy on one of the units who has attempted suicide twice, and he doesn’t get any help. They probably think it's a good thing that there’ll be an available spot’. This statement emerged during my ethnographic fieldwork in a conversation about healthcare in prison as I chatted with a group of people in a workshop in a Norwegian high-security prison. It was evident that people tried to stretch their coffee breaks for as long as possible, perhaps to avoid the repetitive work assigned to them or to use the opportunity to chat with one of the first external visitors in a long time following lengthy COVID-19 lockdowns. In response to my lack of reaction, the man asked, ‘Have you heard this from others as well? Seeing as you don’t seem surprised at all’. ‘It sounds familiar, yes’, I replied. Later, another person joined the group. Upon learning about the focus of my research, he launched into a similar indictment of healthcare in prison. The first person interrupted, pointing out, ‘You see, he didn’t even hear our conversation, and he says the exact same thing!’

I frequently encountered such sentiments throughout my fieldwork. Through comments or stories, people in prison often communicated the view that prison healthcare services were inferior to those available outside of prison in terms of access, quality, and care. These perceptions seemed to align with the prevailing consensus regarding prison healthcare services, as illustrated in the following interaction taken from the same day and location as the sequence above: ‘A little later, as the table cleared, one of the persons who had been more passive in the previous conversations offered his perspective. He spoke in a hushed tone, almost whispering: Health [care services] isn’t that bad. The nurses do their job, and many people here want medicines they can’t get’. The discreet, almost secretive manner in which this conflicting viewpoint was expressed underscores the dominance of the prevailing narrative, indicating an awareness of the popular opinion and a reluctance to voice disagreement openly.

Against the backdrop of scholarship and commentary about Scandinavian, or Nordic, penal exceptionalism over the last decade (De Vos, 2023; Pratt, 2008a, 2008b; Scharff Smith and Ugelvik, 2017; Ugelvik and Dullum, 2012), one might expect the Norwegian prison healthcare services to excel. Given the positive reputation enjoyed by both the penal system and the general healthcare system in Norway (Saunes et al., 2020), it is intriguing that prison healthcare services are perceived so negatively among the prison population. A greater understanding of this not only sheds light on potential deficiencies within prison healthcare but also offers further insights into the inherent conflict between care and control in prison settings. An underlying principle in Norwegian prisons is that of normalisation (De Vos, 2023; Engbo, 2017), the idea that punishment should solely entail the loss of personal freedom and that people in prison otherwise retain full legal rights. One way this is done is through providing people with a standard of public services equal to what is available within broader society, as far as security measures allow. This is known as the import model (Christie, 1970), meaning that public welfare services, such as social, educational, cultural, religious, and healthcare services, are provided in prison by external agencies outside the correctional system (Langelid, 1999). Prison healthcare professionals are thus part of and represent the national healthcare system, not the correctional services. However, as prisons inevitably impose certain security-related demands on healthcare professionals’ routines, it is unlikely that peoples’ experiences with healthcare professionals will truly mirror those in the outside world. This added security dimension serves as a constant reminder to healthcare personnel that people in prison are not only patients in need of care but also prisoners who may pose various risks. Consequently, when people in prison seek the help of healthcare professionals, they can be said to be the bearers of two competing identities: that of a prisoner who has broken the law and is being punished, and that of a patient in need of care and support. In this article, I will study people's perceptions of and experiences with the prison healthcare system through the lens of these two identities. Do people feel treated first and foremost as prisoners or as patients by the prison healthcare department? And how does their experience affect their overall perception of prison healthcare services?

I will show that, on the one hand, prison healthcare services sometimes exhibit what I see as objective shortcomings, which are reflected in the prevailing negative perceptions among the majority of participants. In addition to an examination of the delivery of healthcare services, objectively speaking, I will also, on the other hand, analyse the findings from the point of view of prison healthcare users’ expectations, including their expectations concerning health equality, health autonomy, and patient-centred compassion. The analysis will show that at the root of peoples’ experiences of the prison healthcare system, there is a discrepancy between their expectations and the actual delivery of services. People in prison often expect healthcare services to be disconnected from the mindset and routines found elsewhere in prisons. They, like most people, wish to be treated as patients in need of care when interacting with healthcare professionals. Consequently, they are disappointed when they find traces of the correctional services’ security-oriented thinking in places where a more patient-centred approach is expected. This study concludes that security and punishment permeate all facets of prison life, including the delivery of imported and, in many ways, formally and legally separated welfare services.

Care and/or control in prison healthcare

Several studies have explored the conflict between two seemingly opposing, and perhaps mutually exclusive, goals in prison: care and rehabilitation on one hand and control and punishment on the other. This tension is particularly salient in discussions surrounding substance use, which is considered both a welfare and a criminal issue (Walker et al., 2018), as well as in discussions of prison officers’ conflicting responsibilities of rehabilitation and punishment (Basberg, 1999; Tait, 2011). Efforts to promote health in prison have been seen both as an oxymoron (McCallum, 1995) and a contradiction in terms (Smith, 2000). Sim (1990) argues that, from the earliest times, control and medicine have been closely intertwined, with medical knowledge often subordinated to the priorities of discipline and control. Medicine has never been solely concerned with help and healing; rather, within the field itself, a tension exists between control and help-oriented projects. Nowhere is this tension as visible as in the delivery of healthcare within prisons. Prison healthcare departments have been seen as contradictory at their core, seeing as ‘the goals and assumptions of medical care often come into direct conflict with those of correctional policy and discipline’ (Prout and Ross, 1988: 11). For instance, a Swiss study explained how compassionate end-of-life care for ageing people in prison poses significant challenges, seeing as the roles of ‘prisoner’ and ‘seriously ill’ were considered fundamentally incompatible (Handtke et al., 2017). Qualitative studies from men's and women's prisons in the United Kingdom (Condon et al., 2007; Plugge et al., 2008) showed that although prison healthcare services played an important role in maintaining and improving health, the prison security regime was a potential barrier to accessing healthcare services. This included receiving treatment and medication, as well as ensuring medical confidentiality and patient autonomy (Condon et al., 2007). Patients complained about disrespectful treatment, and they believed that healthcare professionals in prisons were less qualified than their counterparts outside (Plugge et al., 2008). Condon et al. (2007) concluded that ‘at all points along the prison healthcare journey, the prison regime could conflict with optimal health care’. This conflict necessitates constant negotiation between custody and care among healthcare professionals in prison, requiring healthcare professionals to develop specific skills to ensure that people in prison receive the same type of healthcare within a setting designed for containment and punishment (Sasso et al., 2018). Taking the question to its extreme endpoint, Federman and Holmes (2000) study the involvement of healthcare professionals in the United States in administering executions, moving the discussion from care versus control to care versus killing.

Returning to the Norwegian context, we see examples of how the imported healthcare services may struggle to balance care and control. A study by Rua (2012) examining doctors in Norwegian prisons found that their scope of action, or authority, frequently conflicted with the prison's prioritisation of security and resources. The fact that security comes first was also, more often than not, although sometimes unwillingly, accepted by the doctors. Fredwall and Larsen (2020) found that nurses in Norwegian high-security prisons differed in their views on the role of care. Security-oriented nurses considered themselves part of the same team as prison officers, with an accompanying overarching loyalty to the prison. They aimed to contribute to peoples’ rehabilitation and re-entry, thus creating a safer society. Care-oriented nurses were more loyal to their patients and prioritised improving their health over reducing recidivism. This category of nurses sets boundaries when they must and provide help and care when they can. Even though the latter category of nurses was more prevalent in Fredwall and Larsen's study, it is reasonable to assume that elements of security-oriented care are still present within all Norwegian prison healthcare services.

Healthcare expectations and service delivery

One of the most important predictors of overall patient satisfaction is prior expectations (Bjertnaes et al., 2012). In contrast, sociodemographic factors and health status are weaker predictors of patient satisfaction (Hsieh and Kagle, 1991), underscoring the significance of knowledge about patient expectations when researching healthcare services. When seeking care in prison healthcare departments, people in prison, like other patients, have expectations about how they will be treated and the help they will receive. Several factors will shape these expectations, including official aims and purpose statements. As mentioned, the Norwegian correctional services are underpinned by the import model, and importing external welfare services is considered one measure to ensure that people in prison receive the healthcare services they are entitled to. The Norwegian universal and publicly funded healthcare system aims to provide high-quality and cost-free services to all citizens. However, these equality aims are challenged by various factors – including variations in access and quality depending on geographical location or cultural background. National and local health priorities can diverge, and few municipalities have formally committed to decreasing health inequalities (Tallarek née Grimm et al., 2013). Studies have found that minority ethnic groups may experience difficulties accessing healthcare in Norway due to language barriers (Kour et al., 2021; Thyli et al., 2007), cultural differences (Goth et al., 2010), lack of cultural knowledge (Ness and Munkejord, 2022) or unfamiliarity and mistrust in state institutions (Næss, 2019; Schein et al., 2019). Another pertinent factor challenging health equality is the fact that there are large rural areas in Norway with dispersed and low-density populations and few or no hospitals. These areas also struggle with limited public transport and experience difficulties attracting qualified health personnel. This makes comparing healthcare service delivery in and outside of prison challenging. It is plausible, for instance, that due to the import model, certain prisons in Norway face similar challenges in healthcare access as some rural areas do. Prior experiences may also shape expectations. Some people in prison will only have encountered healthcare services outside of the prison, others may have experience solely with the prison healthcare service. Studies have found that individuals’ experiences may also be shaped by the nature and severity of their previous health concerns, particularly stigmatised conditions like substance use disorders (van Boekel et al., 2013). Bukten et al. (2016) found that 65% of individuals in Norwegian prisons have a history of using narcotics or un-prescribed medication, with around half reporting daily use in the six months prior to incarceration. A considerable number of people in Norwegian prisons perceive their health as poorer compared to the general population (Revold, 2015) and an increasing proportion have a diagnosed mental health disorder when entering prisons (Bukten et al., 2024). There is limited research on the delivery of prison healthcare services in Norway. One quantitative survey by Bjørngaard et al. (2009) compared patient satisfaction among the prison population with that of users of mental healthcare services in the general population. The results showed low overall satisfaction with prison healthcare services: 41% of respondents stated they were ‘very or quite dissatisfied’, which was substantially lower than respondents outside prison. However, Bjørngaard et al. offer little explanation of this finding. A study on healthcare help-seeking behaviour in Norwegian prisons by Nesset et al. (2011) suggest that variations in healthcare use highlight the need to address the lack of prison healthcare standards. It is also likely that the previously discussed tension between care and control plays a role in the low satisfaction with prison healthcare services.

According to Crewe et al. (2014), prisons have ‘emotional zones’ where people allow themselves to display more feelings than elsewhere in the prison and remove their protective ‘front’, thus, perhaps, allowing for a more authentic display of identity. Following Crewe et al. (2014), prison healthcare departments should be seen as more than merely a physical space; they carry more profound significance within the emotional geography of prisons. Similarly, Goffman (1963) mentioned sick bays as a place in total institutions where people may open up for vulnerability. These areas work as intermediate zones where many conventions governing prison society are temporarily suspended, offering momentary ease from the otherwise challenging and often harmful aspects of prison life (Sykes, 1958; Toch, 1977). Within these emotional zones, people may find themselves treated as unique individuals rather than mere units or part of a batch (Goffman, 1961), participating in more ordinary conversations with staff who operated with less superficial interactions compared to the security staff (Crewe et al., 2014). When considered alongside the principles of the Norwegian import model, it can be argued that prison healthcare departments may provide potential ‘pockets of normality’ within the otherwise strict and highly regulated prison setting. As most people in Norwegian prisons know that the health and correctional systems function independently from one another, people likely expect the healthcare departments to be such pockets of normality. However, even though the import model is intended to work as a counterweight to the prison ‘bubble’, studies have often shown an inevitable conflict between correctional and healthcare values in practice (Fredwall and Larsen, 2020). This clash of values may impact the experience of healthcare services in prison, causing a dissonance between expectations and actual service delivery.

Methods

This study is based on data gathered through extensive ethnographic fieldwork conducted in four Norwegian prisons, two high-security and two low-security prisons. The data were accumulated over approximately 750 hours of immersive fieldwork spanning over 1 year, involving participatory observations, fieldnotes, and qualitative interviews. This research is part of a larger study on health-promoting prisons. As part of the study, I spent three and four months respectively in the two ‘open’ prisons offering more freedom and possibilities, and two weeks in each high-security prison. Despite the shorter duration in high-security settings, the data collected on prison healthcare is representative of both security levels, as nearly all individuals in low-security prisons frequently referenced their prior experiences in high-security environments. The participatory observations consisted of active participation in various tasks and socialising in work settings and spare-time activities. Informal conversations unfolded during numerous cups of coffee, training sessions, walks, laundry folding, card games, and many other activities. Due to limited time and resources within the healthcare services and the necessity of patient confidentiality, conducting ethnographic fieldwork within the healthcare facilities was not possible when patients were present. However, I received tours of the facilities and talked with healthcare professionals in several settings, both in the healthcare department and the general prison area. The ethnographic fieldnotes were produced shortly after each day of observation.

Most interviews were conducted with incarcerated individuals, hereafter referred to as participants, from two low-security prisons (51 participants), and two high-security prisons (two participants). Both quota and convenience sampling were used, ensuring the representation of diverse characteristics within the prison population and including all who expressed interested in participating. The participant sample reflects a broad range of experiences and demographics. The data primarily capture men's opinions, as only three out of 53 participants were women. ¹ Given the small number, women-specific issues were intentionally excluded, as they warrant a separate study. Participants’ ages ranged from 20 to 74, with an average age of 45. In terms of incarceration history, 25 participants were in prison for the first time, 14 had been imprisoned two to three times, and 14 had been imprisoned four or more times. The median sentence length was 4 years and 6 months, ranging from 4 months to 21 years. Nineteen participants reported no outspoken health needs, while others reported issues such as obesity, addiction, joint or muscle pains, sleep deprivation, mental health problems, and chronic diseases.

During conversations about healthcare services, it was also often unclear whether participants were referring to primary or secondary healthcare. Primary healthcare represents the first point of contact in the healthcare system, focusing on preventative care and managing common illnesses. Secondary healthcare is the provision of specialised medical services, diagnosing and treating patients with more severe or chronic conditions, typically referred to by a doctor in primary healthcare service. This study is thus not limited to addressing either the primary or secondary healthcare systems exclusively, partly because they are difficult to separate in participants’ accounts, and partly because participants’ perceptions of one system are likely to influence perceptions of the other. However, considering the dominant presence of primary healthcare in prison, it is, in the majority of cases safe to assume participants are referring to primary healthcare services.

It is important to emphasise that these results are specific to this cohort and may not be applicable to other prison populations. However, given the variety of prisons participants had experienced and the consistency in their opinions on prison healthcare services, these sentiments are likely somewhat representative of broader trends within the Norwegian prison system. The study is based on narratives and viewpoints from four Norwegian prisons between 2021 and 2022. While the global COVID-19 pandemic may have influenced these narratives, with healthcare professionals encountering heightened workload pressures and challenges in delivering optimal care (Helsedirektoratet, 2022), the comparatively limited impact of COVID-19 on Norwegian prisons and the infrequent mention of COVID-related incidents in my data suggest that data collected in a pre-pandemic context would likely give comparable or somewhat similar outcomes. Due to my close involvement with the participants, there is a potential risk of researcher bias. However, although this article relies solely on fieldnotes and interview data from incarcerated individuals, I also conducted interviews with prison staff and healthcare professionals as part of the larger project, which may help mitigate this bias.

As sensitive data were involved, necessary approvals were obtained from the Norwegian Centre for Research Data. Written informed consent was obtained before conducting the interviews. In addition, information posters were displayed in several places throughout the prisons, and verbal information was given when larger groups of people were gathered, such as during formal counting or lunch, and repeated numerous times during informal interactions throughout my fieldwork. This information emphasised the voluntary and anonymous nature of the study. The interview guide was semi-structured and included open-ended questions about health background and experiences with prison healthcare services. It was entirely up to the participants how much they wanted to share, and no specific questions were asked regarding their criminal history. Interviews were recorded and transcribed verbatim, and both fieldnotes and interview transcriptions were thematically coded (Braun and Clarke, 2006). The coding scheme was continuously refined through ongoing reflections and revisions. Codes addressing healthcare services from the incarcerated individuals’ perspectives included ‘quality’, ‘availability’ and ‘interactions with healthcare professionals’, along with more practical categories such as ‘medicines’, ‘resources, equipment and rooms’ and ‘systems and routines’. The thematic coding scheme was discussed and refined with peers to ensure validity. The data was collected and analysed by a sole researcher, with partial assistance for transcription. After coding, all relevant categories were grouped and broader themes were identified, such as a perceived health equality, lack of health autonomy and patient-centred care.

Findings

During the ethnographic fieldwork, narratives focussing on the flaws and shortcomings of the prison healthcare services were predominant. Although the data includes some positive accounts of prison healthcare services, the primary focus of this study is on the stories depicting these shortcomings. The emphasis on negative perceptions is not arbitrary; rather, it stems from their prevalence within the data material. Phrases like ‘the health department here is not good’ and ‘everything is good here except for the healthcare services’ were frequently mentioned, unsolicited, during fieldwork. When these viewpoints were discussed with prison staff or healthcare professionals, none expressed surprise. The interview data also revealed that a majority of interview participants − 30 out of 52 – held clear negative views regarding prison healthcare services. It is important to clarify that this study refrains from offering a systematic study of the tangible outcomes of prison healthcare services, as the interview data does not allow for evaluating the healthcare service delivery in Norwegian prisons in full. Rather than providing a representative or typical account of individuals’ experiences with the healthcare system, the study focuses on examining the inherent tensions between punishment and healthcare delivery in the prison system. From this perspective, the negative accounts are particularly relevant for analytical purposes.

In some interviews, the difference between the prison system and healthcare services almost entirely disappeared. In some cases, it seemed like participants were talking about the correctional services when we were, strictly and formally speaking, discussing the available healthcare services. The physical placement of the health services within prison and incorporation of security elements exacerbated, for many, the association between the two different governmental agencies, as exemplified in the following quote by Axel ² :

No, you shouldn’t get sick in prison. You don't receive the help you need. […] Yeah, it's like everything is supposed to be so difficult and slow, you know. Unfortunately, the entire correctional system is like that. [own emphasis].

In a similar vein, Simon praised a new doctor who many considered to be one of the exceptions within the otherwise ill-functioning healthcare service. The former doctor had, according to several participants, been there too long, leading to him ‘becoming a part of the prison system’ (fieldnotes). The general impression among participants was that healthcare staff had either partly or wholly merged with the rest of the prison system. This reflects the existence of an ‘us versus them’-attitude among the participants – similar to the oppositional relationship between people in prison and prison officers – rather than perceiving healthcare professionals as having patient care as their main priority.

When identifying broader themes in my data, it became evident that participants often had specific expectations upon contacting the healthcare department, which were frequently unmet. These expectations included (a) receiving healthcare services of similar quality as the general society (health equality), (b) being able to maintain one's health autonomy and (c) encountering compassionate and patient-centred treatment. When these expectations were not met, participants were more likely to have negative experiences and develop unfavourable perceptions, or have their pre-existing negative views of the prison healthcare system reinforced.

Health equality

Health equality describes the idea that everyone should have the same opportunity to attain optimal health, regardless of socially defined circumstances. This includes a fair distribution of healthcare resources, opportunities, and outcomes (Braveman and Gruskin, 2003). The Norwegian public healthcare system is firmly rooted in the principle of providing equal access for all residents, regardless of social or economic standing and geographical location (Saunes et al., 2020). This implies that the healthcare system, as well as the correctional services through the principles of the import model, strive to give every incarcerated person equal access to the same healthcare services as the general population. However, the experiences of many participants do not align with this ideal. Medical negligence and human errors are not unique to a prison setting, but the consensus among people in prisons is that such instances are far more common. Issues frequently mentioned by the participants of this study include access to medication, communication with healthcare professionals, and health information privacy.

One aspect frequently mentioned is the availability of prescription drugs. The Norwegian healthcare system categorises prescribed medications into three groups: group A for highly addictive medications, such as morphine and other opiates; group B for other potentially addictive medications; and group C for other minimally addictive medications that still require a prescription (Nylenna, 2018). Prison healthcare services are restricted in their provision of medicines to patients. These restrictions intend to minimise the usage of dependence-inducing medication classified as groups A and B. Hence, patients in prison will often receive alternatives that carry a lower risk of addiction to avoid attempts to «score drugs,» either for illicit personal use or trade (Mjåland, 2014). Such medical decisions frequently give rise to conflict or disagreements between patients and healthcare staff in a prison setting. In the following interview quote, Adrian related losing access to prescribed medication, even though imprisonment exacerbated his need for it:

I was deprived of the sedatives I had been taking for many years on the outside; I lost those the second I entered the gates. And it's probably when you come into prison that you really need those poor, few pills.

Adrian's experience illustrates a shared experience of losing access to medication. A study examining prescribed psychotropic drugs among people in Norwegian prisons concluded that they use more prescribed medication than the general population, which is expected considering the challenges of the prison population (Lindstad et al., 2021). However, the study also revealed that people in prisons use less pain medication. The authors of the study proposed two possible explanations: either there is an increased use of un-prescribed medicines, or it is related to the prison healthcare departments’ focus on reducing the misuse of dependence-inducing medication. Several participants, including Magnus, doubted the health department's motives for restricting access to medications: ‘It seems like they want nice papers to show that “in this prison, we barely use any strong medications”’. This statement exemplifies the participants’ view that the healthcare service had incorrect priorities, in this case, keeping the number of habit-forming medications low rather than focusing on patients’ needs.

Another factor that may contribute to the experience of health inequality is the waiting time for medical appointments, which is seen as prolonged by many participants. Difficulties with long waiting times and the appointment-making process are also experienced in general healthcare services, especially when accessing specialist doctors (Schein et al., 2019). However, due to security reasons, Norwegian prisons are unable to integrate the digital system used by the national healthcare system. This system allows for e-consultations, online booking of appointments and automatic confirmations via SMS, which is considered helpful and efficient compared to conventional approaches (Zanaboni and Fagerlund, 2020). Most Norwegian prisons rely instead on a manual system of hand-written notes. During fieldwork, when I asked Mikkel about this system, he replied by telling a story about having asked the staff in one of the prisons if ‘they had a paper shredder under each mailbox because it seems like a lot disappears on the journey’. This was one of the causes of distress or annoyance mentioned most often by participants and healthcare professionals alike due to never-ending claims of missing notes and a lack of transparency around the appointment-making process. Practical approaches to this old-fashioned pen-and-paper communication system varied between prisons. In some prisons, using sealed envelopes when delivering notes was not customary, leaving sensitive medical information accessible to prison staff. This can lead people in prison to avoid contact with healthcare services altogether in fear of exposing private health information to the prison staff. Even with sealed envelopes, the act of sending a note to the healthcare department in itself also reveals people in prisons’ need for care or treatment.

Health autonomy

Health autonomy refers to the ethical principle of enabling patients to make informed decisions about healthcare interventions that concern themselves (Entwistle et al., 2010). Highlighting individuals’ rights to self-determination is increasingly a priority in healthcare. However, patient autonomy is particularly challenging in an environment where individuals have been deprived of their general autonomy. For instance, people in prison cannot choose their healthcare service providers, as opposed to the general population. In Norway, all citizens registered in the National Population Register are entitled to a regular general practitioner (GP) (Saunes et al., 2020). When someone is incarcerated, the prison doctor automatically takes on this role, regardless of what the person in question might prefer. In the wider Norwegian society, dissatisfaction with healthcare treatment or healthcare professionals has been shown to be strongly linked to changing their GP (Baron-Epel, 2001), and patients can change their GP up to twice a year provided there are available spaces. This is rarely possible in prisons, seeing as most prisons have only a small number – in many cases, only one – prison doctor(s) available. Participants mentioned how losing access to their regular GP feels like a significant disruption, as expressed by Alex:

That's what I think; as soon as I walk out of here and get to my own GP, I never have to dread seeing him [the prison doctor]. I know that he listens to me. […] My GP, who has known me for 15–16 years, has no influence or anything he can say about my health in here, and it's fucking terrifying.

All people in prison will, to different degrees, experience a lack of autonomy as a consequence of imprisonment. Deprivation of autonomy was one of the five pains of imprisonment originally described by Sykes (1958). Therefore, further loss of autonomy might feel more radical and disruptive in prison than in other situations. In Alex's case, this disruption resulted in a sense of lost autonomy, as well as the loss of a familiar and trustworthy ally within a system often experienced as demeaning and judgmental.

Health autonomy is not just about having options but also about being heard when voicing what you believe to be best for your own health. The following fieldnote excerpt illustrates how Ronnie felt disregarded by a nurse regarding his medication needs:

Ronnie told me about an injection he had to take regularly […]. According to him, this nurse had decided that the injection should be given once a month on a set date, even though it should be given every four weeks, which is not the same. The nurse wants to give the injection seven days late this time in order to give it on the fixed date. So, every month, Ronnie has to argue about it.

Consequently, the nurse's decision went against Ronnie's autonomy, decreasing trust in their patient-caregiver relationship. Similar disagreements between healthcare professionals and patients can also occur outside of prison; however, the prison context adds another dimension to patients’ interpretation of these conflicts. Ronnie interpreted this situation as a deliberate abuse of power, which is evident by his succeeding statement that the nurse ‘probably had a dream of being a uniformed prison officer’.

Because of what was considered unfair or insufficient treatment, and as an effort to regain autonomy, many participants expressed a feeling of being forced to ‘put up a fight’. Several told stories of ‘struggle’ from when they had fought and succeeded, and as a result, experienced better treatment from the health services or gained access to medication. Different ways of ‘putting up a fight’ included nagging, debating, arguing, showing aggression, or, when possible, recruiting third parties to one's cause. Third parties could be an official agency that received complaints, such as the National Ombudsman for Public Administration or a media outlet. It could even be, as in the case of the following quote from Avery, a prison officer:

And then I took [prison officer] with me to the doctor; she sat with me at the doctor's office and heard every word he said. Because then I think he [the doctor] is more careful with what he says, because I brought an officer along.

Others admitted to a level of resignation where they did not bother or lacked the energy necessary to ‘fight’ the healthcare professionals. The following quote illustrates how Alex felt after several months of struggling for the healthcare considered necessary:

After three months, he took me to the doctor there. Three months where I wrote letters to him every week about how fucked I was, and if I really had to… if I really… I mean, it was really… And then I became really desperate, and… It was absolutely terrible. And that's like. The powerlessness you feel, you just, you have no control.

Alex described the sense of an uphill battle, similar to that experienced by several other participants. Lack of trust has especially negative consequences for people with severe or chronic diseases, as it may lead to delays in treatment or check-ups. Those who experienced being moved frequently between prisons were at a further disadvantage as they had to earn the trust of healthcare professionals at every new prison. Many felt their expectations of patient autonomy and reciprocal trust were broken when moving between prison and care settings, resulting in a sense of being treated more as a prisoner than a patient.

Patient-centred compassion

A third expectation participants often have when soliciting help from the prison healthcare system is that their needs will be given priority over the needs of the prison and that they will be treated with compassion. Compassionate healthcare services should be patient-centred, focusing on individualisation, dignity and choice (Berwick, 2009). Patient-centred care is thus characterised by respect and responsiveness to patients’ individual preferences, needs, and values (Frampton et al., 2013). This is closely intertwined with the need for health autonomy, as both concepts are related to empowering patients to become active participants in their own healthcare. As the following quote by Alex illustrates, these ideals do not always align with the participants’ experiences:

For them, I'm just a name. A number. They haven't met me, right? They're used to a bunch of crazies who get high. And then they tar everyone with the same brush.

The lack of individualisation and the unmet expectation of being treated with compassion can function as reminders of one's imprisonment and one's status as a prisoner. The conceptualisation of stigma offered by Link and Phelan (2001) argues that ‘people are stigmatised when the fact that they are labelled, set apart, and linked to undesirable characteristics leads them to experience status loss and discrimination’. This aligns with both the general sentiments expressed by the prison community regarding the prison healthcare services and, more specifically, the claim of being labelled as untrustworthy by healthcare professionals. Patrick shared one example of being labelled by healthcare professionals:

They have such an attitude, which is at least what I have felt and what I hear others say, too. That you are there to deceive them, they think that either you’re lazy and don't want to work or that you’re drug-seeking.

Many shared this experience of being framed as a criminal who was not to be trusted, which affected their patient experience. The majority of participants related this lack of trust to the problems around habit-forming medications. 30 out of the 53 participants talked about negative experiences with the prison healthcare services during the interviews. In contrast, 13 participants talked about favourable experiences, and among these 13, almost none had pre-existing health problems or a known history of illegal drug use. This indicates that people with stigmatised health conditions are more likely to have negative experiences and perceptions of healthcare services. This also aligns with previous research on how people with drug issues experience stigma and have poor overall experiences with healthcare services (Biancarelli et al., 2019; Muncan et al., 2020), and how healthcare professionals generally have a more negative attitude towards patients with substance use disorders (van Boekel et al., 2013). This is reflected in my data, where several healthcare professionals expressed reduced trust after encountering people in prison who lied to gain privileges, often related to accessing medications. This excerpt from an interview with George illustrates an example of the type of behaviour which contributed to mistrust from healthcare professionals: Interviewer:

Have you used the healthcare department in other prisons?

George:

Yes, I did. But that was to score drugs. But I can't be bothered to do that here.

Interviewer:

How did you manage it in the other prisons?

George:

Well, it's just a matter of whining long enough, and then you get what you want.

This reflects what participants in the study by Condon et al. (2007) described as ‘non-legitimate’ patients who feigned illness in order to obtain medication or avoid work, causing the healthcare services to become stricter. Distrust of patients among healthcare professionals was confirmed in my data as well, such as in a situation described in the following excerpt from my fieldnotes:

A healthcare professional showed me the view from their staff room and expressed how practical it was to be able to see the prison yard – ‘because then they could see if anyone was lying about having a hurt foot or something’.

This excerpt seems like a valid example of a healthcare professional with a security-oriented care perspective (Fredwall and Larsen, 2020). The lack of trust was often reciprocal, as the following quote by Christian shows: ‘I have chosen not to have much to do with the healthcare services here. I don't have faith in them’. A significant amount of the participants felt similarly, something I was told about repeatedly during fieldwork, with matching sentiments as expressed in the following quote by Einar: ‘I don’t bother. Every time I go there, I just feel like an idiot when I leave. […]. It is just like they don’t believe me when I come up there with an issue’. Participants often felt that their legitimate health needs were dismissed, as healthcare professionals, influenced by a general distrust, prioritised security concerns over patient-centred care. This dynamic can easily alienate people in prison, reinforcing a cycle of mistrust that is further exacerbated by their pre-existing frustration and suspicion of authority figures. The power imbalance thus undermines patient-centred compassion by limiting trust, open communication, and collaboration. As a consequence of these negative experiences, people in prison might also be likely to hesitate when in need of non-urgent care.

Discussion: feeling like a patient, being treated as a prisoner

The analysis showed that many participants’ expectations revolved around the need for equality and to be treated like a regular patient. The ideal-type patient is someone with a health problem, in need of care or treatment, with the primary aim to cure or treat said problem. The archetypal prisoner, on the other hand, is someone who has broken the law, thereby making punishment in a controlled environment necessary. Notably, to receive the label ‘criminal’, you only need to commit a single criminal offence (Becker, 1963). This label makes others view you differently, as someone liable to commit another offence, seeing as you have already been shown to be a person without ‘respect for the law’ (Becker, 1963: 33). Additionally, the prison is an institution based on distrust and the need for control (Ugelvik, 2014). It confirms, by its very design, that the people inhabiting it pose a risk. When someone seeks the help of healthcare service professionals, they are, in a sense, asking to be seen as and treated as a ‘patient’. When someone in prison, however, asks for help from the prison healthcare services, they are positioned as both ‘prisoner’ and ‘patient’ at the same time. It is likely that healthcare professionals often intend to treat those in their care as patients; at the very least, they are bound by their professional ethics to do so. However, different factors influence healthcare professionals’ consideration of security concerns when working in prison, either due to the security regime within the prison itself or their own perception of personal safety. People using prison healthcare services, on the other hand, are likely to notice their placement on the prisoner–patient continuum. Much like the participants in the study by Condon et al. (2007), who identified a distinction between being treated as a ‘legitimate’ versus a ‘non-legitimate’ patient. In my study, however, it seems clear that even when someone is seen as a legitimate patient, they may simultaneously be seen as a ‘prisoner’, with all this entails.

Although stories about negative healthcare experiences are not unique to prisons, there is little doubt that many of these grievances are either caused or exacerbated by the context of incarceration. This study suggests that people in prison expect the same healthcare standards as those available in the broader society, which aligns with the proclaimed official objectives of the Norwegian Healthcare system. In a way, people in prison also appear to have ‘bought into’ the official description of imported welfare services, expecting healthcare services to be on par with the standards they have experienced or imagined within the broader society. With Crewe et al. (2014) in mind, one could argue that people in prison expected the prison healthcare department to be a zone in the emotional landscape that harboured a different ‘emotional climate’ – a bubble of welfare orientation within a prison otherwise preoccupied with punishment and control. This alternative emotional climate would ideally offer a break from prison life's daily routines and security procedures and a window into the normality of not being a prisoner. When unmet, this expectation exacerbated the feeling of stigma and being wrongly identified. In stark contrast to healthcare facilities in general society, with an increasing focus on patient autonomy, prisons are frequently characterised by a trust deficit (Ugelvik, 2022). This distrust is noticeable in almost all aspects of prison life, from the daily imposition of security measures in the daily routines to the architectural layout of the prison. Even though the import model implies that healthcare professionals maintain full autonomy to provide their services and conduct their jobs as they would have done in any other healthcare facility, the provision of healthcare services remains, at least partially, provided by the prison or at least dependent on the prison system. The correctional system is responsible for the physical facilities that house the healthcare services, the security routines that healthcare professionals must adhere to, and for accompanying patients to specialist appointments outside the prison. In cases where healthcare needs clash with security responsibility, it becomes challenging for either party to assume full accountability. The prisons prioritise security first and rely on the healthcare department to be in charge when it is a question of health issues, while the healthcare department lacks absolute authority when security is involved. An anticipated advantage of the import model was that healthcare professionals would not get too acclimatised to prisons or adopt different standards than with the remaining population (Christie, 1970). However, as this study suggests, the intention of the model does not align with the current perception of people in prison. Many participants felt they were treated as prisoners and seen through a security or control lens, first and foremost, even when visiting the healthcare department. The prevailing trust in the import model may have contributed to complacency, leading to the assumption that people in prison receive adequate healthcare without fully considering the ramifications of placing a health-oriented service within a security-oriented system. This study highlights the pressing need for a discussion of the quality of healthcare services in prison, including both the measurable and objective, as well as the more subjective and experiential aspects.

This brings us to a two-fold explanation for why large parts of the prison population share these negative perceptions of prison healthcare services. The first explanation aligns with the narrative's fundamental message: that there are lacks and flaws in the healthcare services provided within prisons, compared to what is available outside of prison. The nature of imprisonment and the ways the prison context inevitably shapes almost all aspects of everyday life in prison suggest that there probably are significant disparities in the quality of and access to healthcare services, including aspects such as restrictions on medications; the paper communication system; the low level of trust between patients and professionals; and the experience of decreased health autonomy. It is important to recognise that these discrepancies are not necessarily indicative of intentional mistreatment of people in prison, as this study is not equipped to make such determinations. Rather, these flaws highlight the broader challenges of delivering healthcare in a prison environment primarily focused on security and control.

The second explanation relates to the participants’ subjective experiences. All patients carry certain expectations when seeking healthcare services. This is also true of incarcerated patients entering prison healthcare departments. In this study, some of these expectations were shown to include (a) obtaining equal access and quality to healthcare as other citizens outside the prison walls, (b) maintaining the same level of health autonomy as patients outside of prison and (c) receiving compassionate treatment. When these expectations were not met, participants were more likely to focus on negative qualities and perceive healthcare services unfavourably. These findings confirm those of earlier studies examining the connection between patient satisfaction and expectations (Bjertnaes et al., 2012), affirming that meeting positive expectations is one of the most important predictors of overall patient satisfaction. Put differently, in addition to the objective changes to and shortcomings of the services provided, participants’ experiences were often shown to be overlaid with a negatively loaded narrative filter. The first layer of explanation can be envisaged as a photograph of concrete faults within the system. The second layer of explanation then acts as a filter over this photograph, shaped by the unmet expectations, the association with imprisonment and security measures, and the negative experiences of being stigmatised and labelled as a prisoner. This filter likely adds a grey, murky lens through which healthcare services are interpreted. As a result, even everyday mistakes, slip-ups, or poorly worded phrases could be interpreted through this filter as something revealing a gross lack of competence and compassion. This demonstrates how our experiences are framed by our expectations and how we believe we should be treated. Just as negative narratives might affect the perceived quality of patient treatment in broader society (Greenhalgh and Hurwitz, 1999), negative views among the prison population may similarly influence how prison healthcare services are perceived. This is not to suggest that people in prison are simply ‘expecting too much’; rather, it underscores the importance of treating individuals primarily as patients. Whether the objective shortcomings or participants’ subjective evaluations weigh more is impossible to conclude as they are closely intertwined. The common factor across both explanations is the pervasive role of security. Security permeates nearly every aspect of prison life, including the delivery of healthcare services and interactions between patients and healthcare professionals.

The perceptions held of healthcare services in prison are a problem that demands more attention. The evident negative opinion of prison healthcare services causes dissatisfaction. Patient satisfaction, in turn, affects how patients seek care, follow medical recommendations, and interact with healthcare providers (Hsieh and Kagle, 1991). Experiencing stigma in healthcare settings is proven to impact healthcare-seeking behaviour in the future (Muncan et al., 2020). Furthermore, experiencing illness and imprisonment simultaneously is likely to increase the experience of the pains and disruptions of imprisonment, which may intensify the punitive dimensions of imprisonment (Ugelvik et al., 2022). Given that people in prison already constitute a vulnerable population compared to the general population, it is imperative to take their healthcare experiences seriously. From this discussion, one can argue that a clear separation between care and control would likely improve the quality of healthcare services in prison. However, separating care and control may not be entirely feasible or even desirable, necessitating a focus on improving patient experiences within the existing context. Increased awareness of patients’ expectations of the delivery of healthcare services and of the negative effect of being mislabelled can potentially alleviate dissatisfaction, provided healthcare professionals have the sufficient means and time to communicate and connect during appointments. Additionally, the study underscores the importance of acknowledging and addressing the limitations of the import model and its implementation in practice.