key: cord-1037928-9erqm5dt
authors: Ako, T.; Plugge, E.; Mhlanga-Gunda, R.; Van Hout, M.C.
title: Ethical guidance for health research in prisons in low- and middle-income countries: a scoping review
date: 2020-08-27
journal: Public Health
DOI: 10.1016/j.puhe.2020.07.008
sha: 6ec3907a056035923b4bbc4f3844db4199eccdf8
doc_id: 1037928
cord_uid: 9erqm5dt

OBJECTIVES: This study examined the extent, range and nature of the published literature, prison policies and technical guidance relating to the ethical conduct of health research in prisons in low- and middle-income countries (LMICs). STUDY DESIGN: Scoping Review. METHODS: We adhered to the five stages of the scoping review iterative process: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing and content analysis of polices. Disagreements around allocation of content were resolved through team discussion. We also appraised the quality of the included articles. RESULTS: We included nine records that examined the ethical aspects of the conduct of health research in prisons in LMICs; eight of these were peer-reviewed publications, and one was a toolkit. Despite the unique vulnerabilities of this group, we could find no comprehensive guidelines on the ethical conduct of health research in prisons in LMICs. CONCLUSIONS: The majority of the world's imprisoned populations are in LMICs, and they have considerable health needs. Research plays an important role in addressing these needs and in so doing, will contribute to the achievement of the Sustainable Development Goals. With regards to health research, imprisoned people in LMICs are ‘left behind’; there is a lack of clear, prison-focused guidance and oversight to ensure high quality ethical health research so necessary in LMICs. There is an urgent need for prison health experts to work with health research ethics experts and custodial practitioners for procedural issues in the development of prison-specific ethical guidance for health research in LMICs aligned with international standards.

The health of people in prison and inequities in health research across the world are two distinct but linked issues of international public health importance. The global prison population continues to enlarge with approximately 11 million people in prison at any given time and an estimated 30 million people cycling through the system each year. 1 Those in contact with the criminal justice and prison systems are likely to be the most marginalized and poorest members of society, and when imprisoned, may have their basic health needs neglected. 2 Tackling health inequalities by addressing the health needs of these vulnerable populations is an essential component of contributing to the achievement of the Sustainable Development Goals (SDGs), specifically to "reduce inequality within and among countries" and "leaving no one behind". However, effective health care delivery in prisons, an important aspect of prison life, is particularly challenging, in part because of the huge burden of disease in this population, and insufficient government resource allocation to prison healthcare. People in prison have higher rates of substance abuse and dependence, psychiatric illness, infectious and non-communicable diseases, and experience of violence compared to the general population, and poorer pregnancy outcomes in women are observed. 2e8 Despite their many health concerns, people in prison remain significantly under-represented in health research, and this inequity mirrors global inequities in health research more broadly. 9, 10 Compared to high income countries such as Australia, Canada, the United Kingdom and the United States of America, there are few studies from countries in low and middle-income countries (LMICs) despite the fact that the prison population in LMICs is estimated to be 7.58 million, that is, 71% of the global prison population estimate. 1 This deficit is important because research into the health of people in prison is crucial to improving this population's health, reducing health inequalities, creating a better understanding of their complex health needs, and in a gender and culturally sensitive manner, empowering and advocating for people in prison, and ultimately informing the development of prison health and social care policies and services, and wider prison reform and procedural changes. 9 It is important to address this inequity and initiatives such as the WorldwidE Prison Health Research and Engagement Network (www. wephren.org) have been established with the specific aim of reducing global inequities in prison health research and building capacity in LMICs to do this. 9 As initiatives to develop health research in prison in LMICs gain momentum in the coming years, and more LMIC academics are interested to engage in such research, it will be essential to ensure that any health research conducted is carried out to the highest standards and done so within a robust ethical framework.

Prison health research however has a controversial history, and it has been well documented that prisoners have been used unethically as populations of convenience. 11 The ethical conduct of research in prisons is an important issue; as prisons are essentially a coercive environment, with power differentials and structural obstacles to voluntariness, pressures on people in prison as vulnerable populations to participate in research must be considered very carefully. 12e14 There are international guidelines that govern the conduct of health research, such as The Declaration of Helsinki 15 and the International Ethical Guidelines for Biomedical Research involving Human Subjects 16 and the CIOMS guidelines for epidemiological studies. 17 However, despite the growing body of literature regarding people in prison, few publications have provided guidance regarding the specific ethical complexities, challenges and strategies of conducting health research in prisons and other closed settings. 11,18e22 There is broad acknowledgement that 'All vulnerable groups and individuals should receive specifically considered protection'. 15 Hence, principles of informed consent, autonomy, balancing the potential for direct benefit with the risk for harm, confidentiality and voluntary participation must be fundamental ingredients of ethical research in prisons.

Prison health research applications certainly undergo increased scrutiny from university ethics review and correctional services review boards in many countries in the world. 23e26 In high income countries, there has been a considerable increase in research in prisons, but this has not been mirrored in LMICs, creating yet another inequity in health research outputs between rich and poor countries. For example in the UK, where health research is closely regulated and there has been a significant increase in health research conducted in prison in recent decades, there are guidelines that must be adhered to and approvals sought from both health and prison service authorities prior to the conduct of any health research in prison. However, it is not clear what regulations are in place in LMICs where little prison health research has been conducted and where regulatory frameworks may not be so robust. There have been a number of initiatives to increase research and research capacity in LMICs (for example the Worldwide Prison Health Research and Engagement Network www.wephren.org).

Therefore, this study aims to examine the extent, range and nature of the published literature, prison policies and technical guidance relating to the ethical conduct of health research in prisons in LMICs. Our rationale for undertaking the review was that there is a huge gap in the evidence to inform effective health care and health promotion in prisons in LMICs. In parallel with efforts to increase research, it is important to ensure that any research conducted in prisons conforms to the highest ethical standards in this vulnerable population. We sought to establish what existing guidelines there were to inform good practice in LMICs. Frameworks and guidelines are key to monitoring ethical research practice within prisons, and these are very important in informing the development of standard operating guidelines for researchers' practice, and ensuring researcher and gatekeeper accountability.

Scoping reviews are a form of research synthesis that maps and describes literature on a particular topic or research area and are increasingly used within health research to identify key concepts; types and sources of evidence to inform practice, policy-making and research, including gaps in research. 27e29 We adhered to the five stages of the scoping review iterative process. 29 This consisted of (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing and content analysis of policies.

We established an author team with expertise in public health, prison health, research and health rights in LMICs. The research question for this scoping exercise was; 'What is known in the literature about prison policies and applicable technical guidance around ethical health research conducted in contemporary prisons in LMICs?' The term 'prison' was adopted as representing detention facilities housing both on-remand and convicted people. These settings included prisons, police holding cells, pretrial detention, closed youth institutions, and camps where drug users are forced into mandatory labour as means of rehabilitation.

We searched electronic databases and the websites of relevant organizationss, namely the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Bank, the United Nations International Children Emergency Fund (UNICEF), the United Nations Office on Drugs and Crime (UNODC) and the International Committee of the Red Cross (ICRC). We also searched the reference list of included articles.

The general search strategy for electronic databases using Medical Subject Heading (MeSH) terms is illustrated in Table 1 . These searches were conducted on 10 databases accessed through the London School of Hygiene and Tropical Medicine (LSHTM) library and the University of Zimbabwe Library catalogs. The databases were EBSCO, EMBASE, Medline, CINAHL Plus, Global Health, PubMed, Cochrane, PsycINFO, PsychExtra and ScienceDirect. Publications of interest were restricted to the time period between 1999 and 2019.

All articles examining any aspect of ethical conduct or guidance for health research in prisons in LMICs were included; these comprised editorials, commentaries, case reports and studies presenting empirical evidence. We included all age groups of people in prison, from juveniles to adults. There were no limits on language.

All records were managed using EndNote. The title and abstract of each record were initially screened by the second author, with all authors independently reviewing a portion of included and excluded records to determine inclusion status. All records warranting assessment of inclusion by the team were obtained for full text review. Where required, records were translated into English. A second screen of the full-text of each record was conducted in consultation. Studies were excluded at this stage if found not to meet the eligibility criteria. Fig. 1 summarizes this process.

Included papers were charted, summarized and with the prison health research policy content analyzed, as per scoping review protocols. This involved the creation of a charting spreadsheet. Charting involved collecting and sorting key pieces of information from each record. The team conducted a trial charting exercise of five records as recommended by Levac and colleagues 28 in order to maintain alignment with the scoping preview parameters. Disagreements around allocation of content were resolved through team discussion.

We also appraised the quality of the included articles. Given the diversity in the type of publications, different appraisal tools were used. The majority of included articles were expert opinion commentaries and we used Burrows & Walker's appraisal tool for these studies. 30 

Our search revealed nine records that examine in some way the ethical aspects of the conduct of health research in prisons in LMICs; eight of these were peer-reviewed publications 31e38 and one being United Nations Office on Drugs and Crime (UNODC) toolkit. 39 Despite the unique vulnerabilities of this group, we could find no comprehensive guidelines on the ethical conduct of health research in prisons in LMICs. The included articles largely comprised historical or contemporary case studies and commentaries ( Table 2) of generally high quality (Table 3) .

They outlined the many historical human rights breaches and abuses in prison research where the most fundamental of ethical 

Case study.

By examining a particular research study involving forensic psychiatric patients in a maximumsecurity prison, the author outlines an ethical 'conundrum' and considers in detail the ethical issues raised. The aim of the article is to identify key problems and offer a sensible way to conduct ethically sound applied psychological research among vulnerable or marginalized groups in Africa.

Case study

The authors examine two research studies, identifying the key ethical challenges in their conduct, discussing these and how they were managed.

Ethical clearance to conduct the study was obtained. Permission was sought from the National Drug Law Enforcement Agencies (NDLEA) in Nigeria in order to gain interview access to drug offenders in their custody.

Voluntary participation & informed consent: During the questionnaire distribution, the participants were informed that their participation was voluntary and anonymous. The researcher explained the research's purpose and aims and ensured that potential participants understood the study had no bearing on the outcome of their cases. Voluntary participation was stressed. In addition, they were told that they could get more information about the study at any time during the data collection; ask questions about the study even after they had completed and returned the questionnaires; leave out questions on the questionnaire they did not feel comfortable completing and the return of a completed questionnaire was their way of consenting to participation in the study, as is common practice elsewhere Risk: Exclusion criteria used included Inmates who might be unfit for an interview due to mental illness, high risk inmates such as those considered to be potentially violent or dangerous, or had previous records of planning/ preparing/attempting to abscond or escape, and those deemed ineligible for other reasons at the discretion of the gaoler Anonymity, was ensured through ensuring that no names or other, marks likely to identify the participant appeared on the self-administered questionnaire. A high number of prison inmates who participated in the study were awaiting trial and were reluctant to sign the consent form because of the fear that it would be used to implicate them in their trial Reimbursement: payment or reimbursement in money or in kind is not a problem per se. However, if participants are from financially disadvantaged groups, this could be potentially construed as a form of coercive consent because of their monetary needs: is consent "freely given" if payment is involved? Ethical standards for participation in research demand that the participants should not be coerced and/or unduly influenced by financial, psychological, or other pressures. -Pro-active role of ethics in research committees. The prison setting is unique but there is no prison specific guidance. This is problematic as 'Merely invoking traditional variables, such as mental competence and the absence of coercion, is insufficient.' Compensation for Bearing in mind the vulnerability of prisoners, deprived of a portion of their autonomy and free will, as well as the fact that they live in an environment that fosters abuse, the ERC should carefully evaluate the following aspects: -the scientific validity of the project; -the qualifications of the researchers;

(continued on next page) This data was revealed in 2010 after being hidden for more than 60 years. The studies used many groups who are considered to be vulnerable populations: people in prison, people with mental illness, people with limited literacy and cognition, and commercial sex workers.

The key ethical principles that were flouted in these studies include: 1. a lack of respect for individuals' autonomy, justice, respect for persons, and non-malfeasance. 2. no consent was obtained, either direct or implied, for any of the studies. 3 . the studies put the participants' health at unreasonable risk. 4 . the studies' design and documentation were often faulty. 5. the lack of recognition of participants' vulnerability.

The vulnerability of groups such as people in prison was not acknowledged by researchers at the time. Many ethical principles now accepted as key in the conduct of research were not adhered to. Although not specific to SSA the presence of UNODC in some SSA and needs assessments for the prevention and treatment of HIV infection and tuberculosis (TB) in prisons -All assessments and research involving human participants must be conducted in an ethical manner respecting the dignity, safety and rights of participants, and recognising the safety, security and responsibilities of assessment team members -Guiding ethical consideration in serological and behavioural situation and needs assessments should ensure that the basic human rights of individuals are not violated in the course of the assessment -Explain to respondents the objectives of the assessment; method of assessment; any possible risks of participation; the benefits of participation to themselves, the community and science; and how confidentiality will be maintained. -Participation in the assessment should be completely voluntary, without coercion -The participant's right to give or withhold consent at any stage of the assessment should be explained to the participants prior to study beginning and during the consenting process -No false expectations should be raised throughout the assessment, -For all KABP survey and focus groups a signed informed consent form is required -Anonymity and confidentiality should be maintained -Anonymity should be maintained and, arrangements should be made to ensure that respondents are not endangered in any way by disclosure of information. -Field worker safety should also be taken into account, considering the particular setting. -All members of the assessment team should sign a confidentiality agreement -The anonymity of serological and behavioural surveys, test results will not be provided to individual participants who might be interested in their results -If participating prisoners want to know their HIV/TB/HBV/HBC serological status, they should be offered an independent and nominative (nonanonymous) test. -A voluntary testing and counselling programme can be linked to the assessment activities in participating prisons. Principal Investigators should consider integrating VCT activity into their assessment protocol.

country prisons and its focus on HIV&AIDS and TB prevention, treatment care and support including commissioning and funding research in these conditions dictate that all researchers have to abide by these principles when conducting research in prisons guidelines were not respected. A number of authors also highlighted the fact that the subsequent institutional reaction to these abuses e that health research was no longer conducted in prisons e was also damaging, preventing people in prison from benefitting from research. Authors argued for 'balance' to ensure that people in prison are not excluded from participation in research that may be beneficial to them or their peers but are also protected from exploitation during the research process. Salaam and Brown identify how difficult this balance can be with prisons, a unique environment demanding careful consideration of each aspect of ethical research practice not a wholesale importation of practices seen in the community. 35 They write, 'it is important to strike a balance between the safety of individuals (both of the researcher and the researched), cultural sensitivities, the socio-economic realities, and optimal research designs.' They reflect on such aspects of research practice as the use of incentives/compensation in research in prison, arguing that this needs to be considered very carefully because, given the unique prison environment, what might seem a small recompense in the community might be a huge incentive in prison. They question whether voluntary informed consent is ever truly possible in prison which is essentially a coercive environment. Research in prisons in LMICs throws up further serious issues: Tangwa describes the 'Triple vulnerability' of many in LMICsvulnerable because they are economically disadvantaged; vulnerable as members of medically disadvantaged groups, bearing a heavy burden of disease; and vulnerable because they are imprisoned. 37 Taborda et al. suggest that ethical review committees need to consider these issues carefully along with the suitability of the specific researchers (their experience, qualifications, conflicts of interest) and proactively monitor studies in the prison environment, making a case for unannounced visits in prisons by ethical committee representatives. 36 They argue cogently for prisonspecific guidance for the conduct of ethical research: this unique environment with its vulnerable participants merits a different approach.

Further to this, there are ethical dilemmas pertaining to the control of prison authorities over research findings, whereby inadvertent coercion takes place, and those partaking are selected specifically and prepped on what to say to researchers on the day of data collection. Often this is followed by instances whereby findings not reflecting positively on the prison system are blocked from publication and dissemination by authorities. Actual findings are impeded from communication to those who have the ability to intervene and improve conditions, stifles the voices of people in prison, and ultimately disincentivises LMIC academics from attempting to conduct prison health research.

Successful prison research is underpinned by a collaborative approach and strict adherence to rigorous research standards, 24, 40 regarding people in prison as a vulnerable group. 17 Given the distinct sociocultural aspects, the often 'triple' vulnerabilities of imprisoned people in many LMICs (poor, heavy burden of ill health, incarcerated, women/minority grouping) and the prioritization of punishment as the dominant discourse in many LMICs, we sought to investigate what existing guidelines there were to inform good research practice. The scoping study represents a unique and first step toward gathering and mapping available literature on prison policies and technical guidance around ethical health research conducted in prisons in LMICs. It is disappointing to find that despite the many vulnerabilities of this group, we could find no comprehensive guidelines on the ethical conduct of health research in prisons in LMICs.

To the best of our knowledge, this is the first comprehensive review which has examined the extent, range and nature of the published literature, prison policies and technical guidance relating to the ethical conduct of health research in prisons in LMICs. The review was thorough in terms of adhering to the scoping review method, 27e29 and its multilayered strategies to locate information but yielded a small number of records (n ¼ 9) which examined the ethical considerations, protocols and polices for oversight for conducting ethical prison health research in these countries. When charted thematically, the historical dimension was included, and illustrates the progression in frameworks and regulations governing the use of human subjects in research including prisons. Several of these records (n ¼ 4) took a historical perspective, detailing the misdemeanors of the past, many of which had profound adverse consequences for vulnerable groups who were subjected to unethical research practices. These studies serve to reinforce the importance of robust frameworks which are clearly regulated and universally applied. The included studies scored well with respect to quality according to Burrows and Walker's criteria. 30 However, it should be noted that most were case studies/commentaries/editorials, generally considered to provide a poor level of evidence. Furthermore, the included studies examined issues in-depth in six countries only (Brazil, Guatemala, Nigeria, Papua New Guinea, Philippines and Zimbabwe) although authors did consider issues relating to LMICs more generally. We note that aside of development status (for example in historic periods when the USA was in power in the Philippines/Guatemala), the cultural and contextual sensitivities around prison research remain in LMICs, and underscore the need to understand the context, the political dimensions, and the need for clear, prison-focused guidance and oversight to ensure high quality ethical health research and protection of participants so necessary in LMICs. Notwithstanding this diversity in discipline, and publication type, the overall finding remains the same, that there is a lack of clear, prison-focused guidance and oversight to ensure high quality ethical health research so necessary in LMICs.

Despite our rigorous search approach, only eight peer-reviewed publications (five commentaries, two case studies, and one review) and one toolkit emerged. We analyzed these thematically as per the scoping review method, 27e29 and we recognize that the included records represent a broad and diverse range of different disciplines, and publication type (review, case study, commentary, toolkit). Many of the included documents, whether taking a historical or contemporary perspective, emphasized the importance of access based on ethical clearance, permission with the relevant and senior correctional authorities, exclusion criteria where inmates might be considered high risk, ethical premises based on full explanation of the research aims, benefits and risks to participants, assurances around voluntary and anonymous participation with no bearing on the outcome of pending cases, and inmate ability to ask questions throughout and after the study. Health research should be conducted in an ethical manner, respecting the dignity, safety and rights of participants, recognizingthe safety, security and responsibilities of researchers, and the importance of ensuring that the basic human rights of individuals are not violated in the course of the research, and that no false expectations are raised. The documents highlighted the importance of voluntary participation but referred to the complexities around perceived coercion pertaining to selection of suitable participants, and the coercion of academics engaged in this research. This may be because the autonomy of imprisoned people is limited in many ways but it is important for them to understand that their participation in research is a decision they can make freely. This was also highlighted in the 2009 International Ethical Guidelines for Epidemiological Studies which specifically but briefly mentioned the lack of autonomy of prisoners. 17 However, the included documents also considered the issues raised by payment for participation of this marginalized and vulnerable group.

Hence, our scoping review underscores the justification for contextually appropriate ethical frameworks in LMICs distinct from that of a non-LMIC country. Prison health research is traditionally low priority and there is a lack of engagement in routine prison health enquiry and academic prison health research in many LMICs, due in part due to the focus in these countries on security and punishment, prejudices and the devaluation of prisoners as citizens, the lack of political commitment and domestic resources to improve health standards and the presence of significant barriers to access to those outside the system seeking to investigate. 10 There are potentially a myriad of substantial ethical concerns in terms of prison officials influencing research data, structural obstacles to voluntariness, lack of voluntariness and the coercion of imprisoned people and prison staff, and embargoing of academic publications at country levels. This creates a dearth of published literature which directly addresses the assurance of health rights of both imprisoned people (and prison staff) coupled with a distinct lack of clear prison focused guidance and oversight in line with international standards to ensure ethical and robust prison health research.

Growth of prison health research activity in LMICs is therefore dependent upon an adequate, culturally sensitive and contextually appropriate ethical framework to protect imprisoned people and prison staff as research participants. Research efforts underpinned by robust ethical guidelines and frameworks are an imperative to generate evidence to inform rights-based programming and policy formulation to improve imprisoned people's welfare in LMICs. Ethical guidelines appropriate to the LMIC context, and aligned with international guidelines will safeguard the rights of research participants in prisons. Health research in these prisons is important to inform the development of appropriate and effective evidence based health education and promotion interventions, healthcare services both within prison settings, and also connecting to the continuum of care for those on release. 41, 42 It is clear that people transitioning from prison to the community are at particularly high risk for adverse health outcomes. 43e45 However, if research interest and activity is to expand here, it is important to establish what ethical safeguards should be in place to protect this vulnerable population, and support those academics engaging in this challenging form of health research. The review whilst yielding a low number of records, underscores that health-related research with prison populations in LMICs is important but that healthrelated research in these settings is scant; growth of healthrelated research is dependent upon an adequate ethical framework to protect prisoners as research participants, and encourage greater academic interest in this neglected health environment. There is little published literature or grey literature that directly addresses prisoner protections in health research and that these protections need to be put into place. Ethics bodies in different LMICs do exist to regulate research in the respective countries and researchers within these respective countries wishing to undertake research in correctional facilities (prisons and other closed settings) would follow the ethical requirements as stipulated by the ethical review bodies. We assume that health researchers would obtain relevant institutional ethical clearance prior to gaining access to prisons and potential participants. It is vital for prisons and correctional services and other relevant bodies adhere to ethical protocols, based on international guidelines of ethical research conduct. Countries need to address this deficit by developing a regulatory framework for the ethical conduct of research involving imprisoned persons in line with international guidelines as prerequisite for permission of such research. Further investigation of prison policies is warranted in each country to ensure standards are met, and in approving research access to prison populations. Lastly, the 'bridge of prison health and public health' cannot be underestimated. Prisons by their nature have long been associated with rapid transmission of disease, become high risk breeding environments of transmission, vehicles and bridge of onward transmission in the general population. Often the connectivity between prison and community occurs via the prison staff, their families, visitors to the prisons and the revolving door of incarceration. Those imprisoned generally suffer high burden of disease, great health disparity and poor health outcomes. It is through research underpinned by ethical guidelines and frameworks that evidence can be generated in LMICs to protect researchers, and research participants, inform interventions, encourage positive prison health reform, gender sensitive programming, and robust contagious and infectious disease prevention, ultimately resulting in protection of public health. This is now an imperative given the COVID-19 crisis, and also the impact of Multi-drug resistant tuberculosis (MDRTB)/Extensively drug resistant tuberculosis (EDRTB). Continued neglect of prison health research in the absence of robust contextually appropriate ethical frameworks for health research in prisons therefore has huge implications on mortality, morbidity, and disease prevention, the right to health of imprisoned people and right to a safe healthy working environment for those who work in prisons, and overall impact on general population health. Further, clear ethical principles and greater academic activity within prisons in LMICs can incur great impact in raising awareness, political sensitization and human rights advocacy.

The majority of the world's imprisoned population, almost eight million people, are in LMICs. Prison populations have considerable unmet health needs and ethical health research can play an important role in addressing these needs and in so doing, countries will be contributing to the achievement of the SDGs. However, it is clear that with regards to health research, people in prison in LMICs are 'left behind' and there remains a need for high quality, ethical and robust health research. Ensuring that people in prison have similar access to participate in research as those in the community should be regarded as an ethical imperative by health researchers, practitioners, and policymakers. 11 Tangwa's assertion of the 'triple vulnerability' of people in prison, emphasizes the need for such research to be conducted to the highest ethical standards. 37 Our study highlights that currently there is a lack of clear, prison-focused guidance and oversight to ensure this in LMICs and underscores the urgent need for prison health experts to work with health research ethics experts and custodial practitioners for procedural issues in the development of prison-specific ethical guidance for health research in LMICs aligned with international standards. This will encourage greater academic interest, engagement and commitment to conducting health search in prison environments, and in so doing inform policy and practice reform, and the improvement of health standards for people in prison.

Ethical approval was not required as this is a scoping review of extant literature. 

World prison population list. 12th ed. Institute for Criminal Policy Research

London: Penal Reform International

Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis

Substance use disorders in prisoners: an updated systematic review and meta-regression analysis in recently incarcerated men and women

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

Smoking in correctional settings worldwide: prevalence, bans, and interventions

Prevalence of risk factors for noncommunicable diseases in prison populations worldwide: a systematic review

Perinatal health care services for imprisoned pregnant women and associated outcomes: a systematic review

WEPHREN: a global prison health research network

Challenges in ensuring robust research and reporting of health outcomes in sub-Saharan African prisons

Balancing the rights to protection and participation: a call for expanded access to ethically conducted correctional health research

Coercion in research: are prisoners the only vulnerable population?

Ethical monitoring: conducting research in a prison setting

Coercion and informed consent in research involving prisoners

Declaration of Helsinki -ethical principles for medical research involving human subjects. WMA

In: International ethical guidelines for health-related research involving humans

Council for International Organizations of Medical Sciences (CIOMS)

Conducting research as a visiting scientist in a women's prison

Multivariate comparison of male and female adolescent substance abusers with accompanying legal problems

Factors and conditions influencing the use of research by the criminal justice system

Through the bullet-proof glass: conducting research in prison settings

Conducting research in corrections: challenges and solutions

Clinical and epidemiologic research on HIV infection and AIDS among correctional inmates: regulations, ethics, and procedures clinical and epidemiologic research on HIV infection and AIDS among correctional inmates

Conducting ethics research in prison: why, who, and what?

Ethics in research involving prisoners

Ethical challenges in conducting psychiatric or mental health research in correctional settings

Enhancing the scoping study methodology: a large, inter-professional team's experience with Arksey and O'Malley's framework

Scoping studies: advancing the methodology

Scoping studies: towards a methodological framework

Developing a critiquing tool for expert opinion

Trends in health research ethics in the Philippines during the American Colonial Period (1898-1946)

Navigating the libido dominandi: intricate realities of forensic psychiatry research ethics in Zimbabwe

Research in prisons: an eye for equity

History, ethics and the presidential commission on research in Guatemala

Ethical dilemmas in psychological research with vulnerable groups in africa

Forensic psychiatry ethics: expert and clinical practices and research on prisoners

Research with vulnerable human beings

The Guatemala sexually transmitted disease studies: what happened

HIV in prisons Situation and needs assessment toolkit

Challenges and solutions for conducting research in correctional settings: the U.S. experience

Contemporary women prisoners health experiences, unique prison health care needs and health care outcomes in sub Saharan Africa: a scoping review of extant literature

Mankind owes to the child the best that it has to give': prison conditions and the health situation and rights of children incarcerated with their mothers in sub-Saharan African prisons

Barriers and facilitators to hepatitis C (HCV) screening and treatment-a description of prisoners' perspective

Risk of reincarceration among prisoners with co-occurring severe mental illness and substance use disorders

Health outcomes and retention in care following release from prison for patients of an urban post-incarceration transitions clinic

We have no conflicts of interest to declare.