Handicaps, disabilities, and dependency in French prisons

Handicaps, disabilities, and dependency in
French prisons
Lessons from a special survey*
National Prison Museum,
housed in the former remand prison (maison d’arrêt) of Fontainebleau
SICOM/Justice Ministry
In 1997, Maud Guillonneau and Annie
Kensey, two demographers at the
Prison Administration Directorate
of the French Ministry of Justice,
noted the shortage of information
on inmates’ health status. They
stressed the fact that “while the
handicapped are obviously a category
with specific needs, there are no
quantitative data on them.” This
finding led to the preparation of a
survey on handicaps, disabilities, and
dependency (Handicaps-IncapacitésDépendance: HID, an acronym used
in the rest of this article) in prisons.
The third HID survey
The HID-Prisons survey was
designed by the French Institute for
Demographic Studies (INED). It was
an extension of earlier surveys of
the same kind conducted by INSEE
among persons living in welfare and
healthcare institutions (1998) and in
private households (1999).
Disabilities were defined to include
those of physical or psychic origin
but also of cultural origin, such as
reading and writing impediments,
and language problems. The main
goal was to measure their prevalence
in the prison environment—which, as
some evidence suggested, could be
very high. To begin with, the prison
population has aged significantly.
There are two reasons for this trend:
(1) a change in legislation on sex
crimes and offenses that has led to
the jailing of older adults; (2) longer
sentences. Moreover, inmates often
come from lower-income groups
[Cassan, Kensey, and Toulemon,
2000]. As the HID-Households
survey had effectively demonstrated
[Mormiche and HID project group,
Virtual tour: http//www.justice.gouv.fr/musee/indexation
2000], the distribution of disabilities
is strongly characterized by social
inequality.
The presence of persons with
disabilities in prison naturally raises
the issue of their rehabilitation, as
well as of their living conditions. To
collect information on these aspects,
the survey includes questionnaire
modules on family environment,
education, employment, and income.
There are studies specifically
devoted to psychopathology in the
prison environment and on other
conditions and behaviors highly
prevalent among inmates such as
AIDS, hepatitis C, drug addiction,
and alcohol consumption. The value
of the new survey lies in its generalist
Courrier des statistiques, English series no. 11, 2005
approach and the opportunities for
comparison with earlier HID surveys
in welfare/healthcare institutions and
private households.1
A collective enterprise
INED formed a project group
to design the HID-Prisons survey
comprising representatives of the
Prison Administration Directorate of
the Ministry of Justice (Direction de
l’Administration Pénitentiaire: DAP),
the Directorate General for Health at
the Health Ministry (Direction Générale
* Originally published in Courrier des statistiques,
French ed., no. 107 (Sept. 2003), pp. 43-54.
23
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de la Santé: DGS), DREES,1 and
several research agencies such as
the National Institute for Health and
Medical Research (Institut National de
la Santé et de la Recherche Médicale:
INSERM) and National Center for
Scientific Research (Centre National
de la Recherche Scientifique: CNRS).
INSEE provided logistical support,
most notably its interviewer network:
the Institute had acquired a rich
experience from the HID-Institutions
and HID-Households surveys, as well
as the 1999 Family Survey [Cassan,
Héran, and Toulemon, 2000], whose
field had been extended to the
prison population. Funding came
from INSEE, DAP, DREES, and—of
course—INED.
Preparing the survey
protocol23 4 5
The initial plan was to submit the
HID-Prisons questionnaire directly
to a sample of about 700 inmates.
But, given the uncertainty over the
frequency of disability status in
prison, there was a risk of covering
an insufficient number of persons
effectively suffering from disability.
Should the administration of the
HID questionnaire be preceded by
a screening operation to identify
persons with disabilities—along the
1. The Directorate for Research, Studies,
Evaluation, and Statistics (Direction de la
Recherche, des Études, de l’Évaluation et des
Statistiques: DREES) was established in 1998
at the Ministry of Employment and Solidarity.
It is classified as the “ministerial statistical
office” (Service Statistique Ministériel: SSM) in
charge of the health and social-affairs sectors.
At the time of writing (2003), it reported to
two government departments: the Ministry
of Social Affairs, Labor, and Solidarity, and
the Ministry of Health, Family Affairs, and
Handicapped Persons.
2. In the 1999 population census, a specific
questionnaire on “everyday life and health” (Vie
Quotidienne et Santé: VQS) was distributed
by a sample of enumerators to about 400,000
people. See Mormiche 2000.
3. The prison population is highly mobile, with
a monthly turnover of about 15%. We thus
soon realized that the two operations should
not be conducted more than a month apart.
4. For the Family Survey in prison institutions,
a large majority of interviewers consisted of
persons with prison experience such as prison
visitors, former lawyers, and researchers
working on the prison population.
5. Administration of HID questionnaire to
anyone supplying a positive response to at
least one question in the VQS-Prisons survey.
24
Prison: an institution “almost” like any other
To allow comparability of results obtained for the prison population and the general
population, we took care to ensure that the HID-Prisons questionnaire was as similar
as possible to those used in the earlier HID surveys. In fact, it hardly differs from the
HID-Institutions questionnaire. Prison is “almost” an institution like any other—with
the obvious difference that inmates are not free to come or go as they please. We
therefore had to adapt the wording of questions on travel; other questions such as
those on purchases and vacations were, of course, eliminated.
lines of the procedure applied in the
HID-Households survey?2 And, if so,
how and when should the screening
questionnaire be administered?
It was decided to conduct an initial
test, whose results would give an idea
of the usefulness and feasibility of
prior screening via a self-administered
questionnaire called VQS-Prisons (in
French: Vie Quotidienne et Santé,
i.e. Everyday Life and Health).
The test was conducted in June
1999 in two penal institutions: the
detention center in Nantes and the
remand prison (maison d’arrêt) in
Osny. It yielded two main lessons.
First, the procedure was unsuitable:
the response rates were a very
disappointing 26% for Nantes and
32% for Osny. Second, disabilities
were far more prevalent among
inmates that in the total population.
As a result, we saw no way to avoid
a face-to-face administration of the
questionnaires. However, there were
three possible options:
• direct administration of HID
questionnaire: a very high prevalence
of disabilities would make the
screening operation pointless;
• face-to-face administration of a
screening questionnaire followed
three weeks later3 by the HID
questionnaire;
• face-to-face administration of a
screening questionnaire and HID
questionnaire in the same session.
We decided to test the third option.
By comparison with the second,
it admittedly had a drawback: we
needed to choose a screening
criterion that would be immediately
detectable by interviewers and would
thus have to be very simple. On the
other hand, and more decisively, the
third option offered many practical
advantages: shorter mobilization of
prison staff; no “losses” between
screening and HID questionnaire
administration; lower cost.
The operation was conducted
in January 2000 in three penal
institutions: the remand prisons in
Rouen and Amiens and the detention
center in Villenauxe-la-Grande.
Beyond the issue of the survey
protocol, the trial run was designed
to test the HID-Prisons questionnaire
and to determine whether INSEE
interviewers could conduct a survey in
a prison environment.4 The response
rates were fairly satisfactory: 76%
in Amiens, 75% in Villenauxe and
69% in Rouen. Once again, the
results showed an high prevalence of
disabilities in prisons: 51% in Amiens,
60% in Villenauxe, and 62% in Rouen
(admittedly, the screening criterion
was rather unselective5). The reader
will have noted that the locations with
the highest response rates are those
with the lowest apparent prevalence
of disabilities: this finding led us to
examine whether a selection bias was
at work. The comparison between
responses provided to the two
questionnaires in sequence—VQSPrisons and HID-Prisons—revealed
some discrepancies, confirming
the need to set up a large “control
sample.” As with the HID-Households
survey, the control sample served
a dual purpose: (1) to compare the
status of persons with disabilities
against that of other persons; (2) to
“recapture” false “negatives,” i.e.,
persons effectively suffering from
disabilities despite their not having
been identified as such at the
screening stage.
Handicaps, disabilities, and dependency in French prisons
The test also showed that INSEE
interviewers would be perfectly suited
to the task and that the average
completion time of 32 minutes6 for
the HID-Prisons questionnaire was
totally acceptable.
Final protocol
Despite the strong prevalence of
disabilities in the prison environment,
we decided to maintain the screening
operation, whose marginal cost
seemed relatively modest. The noscreening procedure would, in fact,
have required administering many
more “control questionnaires” to
obtain the same final number of
“positive” questionnaires. This would
inevitably have obliged interviewers
to perform more painstaking checks,
not to mention the probable impact
on response rates.
In practice, all inmates in the survey
sample were first given the VQSPrisons questionnaire. All those
responding positively to one of the
questions on presence of disabilities,
activity impediments, handicaps,
or need for aid linked to a health
problem (questions numbered 3-17:
see facsimile of questionnaire pp. 3133) were invited to respond to the
HID questionnaire. To construct the
control sample, one in three inmates
were also invited to participate
irrespective of their responses to the
VQS questionnaire.
As noted earlier, given the expected
failure rate, there was a major
risk that a selection effect could
significantly bias the results. Inmates
in good health might choose not
to participate on the grounds that
the survey did not concern them;
conversely, inmates in poor overall
health might be excluded because of
their difficulty in going to the visiting
room. To check this bias risk, we set up
a procedure for collecting additional
information. Doctors in participating
institutions agreed to conduct an
individual assessment of the general
health status of all inmates initially
selected, regardless of whether or
not they later responded to the VQS
questionnaire. The assessment used
a four-level scale (excellent / good /
poor / very poor) and was typically
performed by examining medical
records. The information gathered,
collated with the separately available
information on survey participation,
would allow a test of the hypothesis
of sample selection bias.
Two-stage sample
construction
Institutions were sampled on the
basis of the prison population
statistics at April 1, 2000. At
that date, there were 174 penal
institutions in metropolitan France
(mainland + Corsica), ranging in
size from only 15 inmates to over
3,000. To spare the UCSA7 doctors
an excessive work burden, it was
agreed that no more than a hundred
or so inmates should be surveyed in
each institution visited. Conversely,
given the desirability of assigning
at least two interviewers to each
institution, we would need to set a
minimum number of interviews to
be conducted in each institution.
We eventually opted for a sampling
of 50 or 100 inmates per institution.
We therefore excluded the nine
institutions with fewer than 50
inmates from the scope of the
survey. By contrast, we specified
the inclusion of the four institutions
with over 1,000 inmates: three in
the Paris area (Fresnes, La Santé,
and Fleury-Mérogis) and one in
Marseille (Les Baumettes). All
four prisons host a population
significantly different from the rest
of the prison population in many
ways: age distribution, structure by
socio-economic status, proportion
of aliens, type of offenses, etc. The
other institutions, insofar as they
were located in areas covered by
the nine INSEE Regional Offices
involved in conducting the survey,8
were distributed across six strata
by cross-tabulating two variables:
(1) number of inmates in the
institution (three categories: small
institutions with 50-149 inmates,
medium-sized institutions with 150349 inmates, and large institutions
with 350-999 inmates); (2) category
of institution (two categories:
Courrier des statistiques, English series no. 11, 2005
(a) maison d’arrêt [remand prison]
(b) centre de détention [detention
center] or maison centrale [highsecurity prison]). Next, we conducted
an equal-probability sampling in
each of the six strata thus defined.
This yielded 28 institutions, which
we added to the four very large
institutions mentioned earlier,
all of which are maisons d’arrêt.
The 28 institutions sampled at
random consisted of 21 maisons
d’arrêt (7 small, 8 medium-sized,
6 large) and 7 centres de détention
and maisons centrales (2 small,
1 medium-sized, 4 large).5678
The total number of inmates to be
surveyed in these 32 institutions
was set at 2,800, of whom 550 in
small institutions, 850 in mediumsized institutions, and 1,400 in
large/very large institutions. On
the Friday preceding the collection
week, the interviewers selected them
at random from the list of inmates
then present in the institution.9
Three categories were excluded
from the selection: (1) minors,
who could not be questioned
without parental authorization;
(2) inmates on day parole, who
could not have been reached at
the interviewers’ authorized visiting
hours; (3) hospitalized inmates, as
our purpose was to identify chronic
disabilities, and most disabilities
treated in hospital are temporary.
This choice was also consistent
with the one made for the generalpopulation survey, since the HIDInstitutions survey was restricted to
long-term-care wards.
6. The survey had to be carried out entirely
by means of paper questionnaires, except for
CAPI (computer-assisted personal interviewing)
arrangements. This is because it would have
been impossible to allow PCs to be brought
into prison institutions.
7. Primary-care units (in full: Unités de
Consultations et de Soins Ambulatoires).
8. The following Regional Offices were
involved: Alsace, Champagne-Ardenne,
Haute-Normandie, Île-de-France [Paris Area],
Limousin, Nord-Pas-de-Calais, Pays de la
Loire, Poitou-Charentes, and Provence-AlpesCôte d’Azur.
9. Naturally, all persons selected at random
were informed by letter that they had been
chosen to take part in the survey.
25
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Categories of French prisons
SICOM/Justice Ministry
Persons serving sentences of up to one year and persons on remand pending
final sentencing are placed in remand prisons (maisons d’arrêt). Detention
centers (centres de détention) receive persons sentenced to more than one year
in jail and with the best prospects of rehabilitation. The most difficult inmates are
held in higher-security prisons (maisons centrales). These various incarceration
arrangements may be applied in separate wards (quartiers) within the same penal
institution.
our control sample. In all, therefore,
1,314 persons were supposed to
respond to the HID questionnaire. At
this stage, we registered 30 failures,
of which 13 refusals to respond and
17 cases of inability to respond:
most of the latter consisted of
persons with inadequate command
of French.
General health status:
no significant difference
between respondents and
non-respondents...
We
naturally
examined
the
breakdown of VQS questionnaire
respondents and non-respondents
by general health status as assessed
by UCSA doctors and, conversely,
the distribution of persons whose
health status had been rated
excellent, good, poor, or very poor
according to whether they took part
in the survey or not. This examination
(see tables) revealed no significant
difference between respondents and
non-respondents.
...but wide variations
between institutions
La Santé prison in Paris,
built in 1867 by the architect Vaudremer
Collection results
The collection period ran from
Monday May 14 to Friday May 18,
2001. The work was carried out by
64 INSEE interviewers, in teams of
two per institution visited.910
Of the 2,800 persons in the initial
sample,10 2,031 (1,951 men and
80 women) actually responded to the
VQS questionnaire. The participation
rate averaged 72.5%, ranging from
47% to 96% in individual institutions.
Participation was generally higher in
small institutions, where it is easier
to mobilize staff and inmates: the
rate there was 82%, versus 70%
in institutions with more than
149 inmates. The refusal rate was
20.9% and the rate of non-response
for other motives11 was 6.6%.
Of the 2,031 VQS respondents, 950
responded positively to at least
one of questions 3-17 and were
therefore invited to respond to the
HID questionnaire. We also selected
an additional 364 persons to form
Chart 1 shows the survey participation
rate for each institution on the X-axis,
and the proportion of persons whose
general health status was rated poor
or very poor by UCSA doctors on
the Y-axis. The absence of linkage
between the two variables is clearly
visible, as is the very wide variation
between institutions (from 3% to
58%) of the proportion of inmates in
poor or very poor health.
A previous study on prison entrants
[Mouquet, 1999] revealed sharp
disparities between institutions. In
Number of institutions selected
and inmates surveyed by institution size
Institutions visited
10. I.e., a sampling rate of just over 6%. At
May 1, 2001, the prison population included in
the survey field totaled almost 44,000.
11. In most cases because the person had
just been released or transferred to another
facility (61 cases) or had been excluded in
advance because (s)he posed a security risk
(46 cases).
26
Inmates surveyed
550
Small institutions
9
Medium-sized
9
850
10
1,000
4
400
32
2,800
Large
Very large
Total
Handicaps, disabilities, and dependency in French prisons
Breakdown of participants and non-participants by health status
General health status
Excellent
Good
Poor
Very poor
Undetermined
Total
No
30.2%
41.5%
17.7%
1.4%
9.3%
100.0%
Yes
33.3%
44.4%
17.5%
2.2%
2.6%
100.0%
Total
32.5%
43.6%
17.5%
2.0%
4.4%
100.0%
Participation
Breakdown of inmates in each health-status category by participation/non-participation
General health status
Excellent
Good
Poor
Very poor
Undetermined
Total
No
24.9%
25.5%
27.1%
18.9%
56.3%
27.5%
Yes
75.1%
74.5%
72.9%
81.1%
43.7%
72.5%
Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
the present case, real differences
very likely explain only part of the
observed dispersion. Some of the
variation probably stems from the
procedure for assessing inmates’
general health status, which is more
or less optimistic depending on the
doctor. The 32 penal institutions
surveyed may be roughly divided
into three groups: a “median” group
comprising 11 institutions in which
more than three-quarters of inmates
were classified in the two central
categories (”good” and “poor”),
and two “outlier” groups where
the assessment scale appears to
have shifted toward “excellent” and
“very poor” respectively. It is easy to
understand the relativity of doctors’
assessments. In an institution where
most inmates are in good health,
the doctor’s criteria for regarding
an individual as being in very good
health are undoubtedly stricter.
These factors lead us to the following
conclusion: to test the hypothesis of
a selection effect, we cannot simply
compare the general health status
of survey participants and nonparticipants in the aggregate. We
need to make the comparison for
each institution.
vivid illustration. The X-axis shows
the proportion of inmates “screened”
by the VQS questionnaire; the Yaxis shows the proportion if all
inmates initially selected had
actually taken part in the survey.
We estimated the latter value as
follows. Let us assume that, in
a given institution, the proportion
of respondents screened by the
VQS questionnaire lies between
the proportions of inmates whose
general health status is assessed
by the doctor as being (1) very poor
and (2) poor or very poor. We can
then determine the coordinates of
the first proportion relative to the two
A closer look at the
sample
others (barycentric coordinates).
Assuming these coordinates are
valid for non-respondents as
well, we deduce (1) an estimated
proportion of “screened” nonrespondents and (2) the overall
result including respondents and
non-respondents. As we can see
on the chart, the points obtained
align almost perfectly on the
first diagonal. In each of the 32
institutions surveyed, therefore, the
inclusion of non-participants has
virtually no impact on the estimated
proportion of screened persons, so
the result of the VQS screening is
not biased by non-response.
Chart 1
General health status:
Poor/Very poor
Participation
The absence of a significant
difference between the general
health status of respondents
and non-respondents, which we
observed for the overall sample, is
also confirmed for each individual
institution. Chart 2 offers a fairly
Courrier des statistiques, English series no. 11, 2005
27
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% VQS+ estimated
Chart 2
% VQS+ (participants)
Chart 3
Assessing the assessment
For sake of completeness, we need
to make sure that the assessment
of inmates’ general health status
by UCSA doctors is a good proxy
for the presence of disabilities. The
information letter sent to prison
doctors did, of course, provide
guidelines for this, but they may not
have been easy to follow. Chart 3
cross-tabulates, for each institution,
the percentage of respondents
screened by the VQS questionnaire
(Y-axis) and the percentage of
inmates whose general health
status was assessed by the doctor
as poor or very poor (X-axis). The
fine linear relationship we hoped
to see is, alas, not perceptible.
But the non-correlation between
the two indicators observed is not
surprising if we accept that doctors
in different institutions produced
their assessments differently.
% VQS+
Specificity
of prison surveys
General health status: Poor/Very poor
Ensuring anonymity of information gathered
In each institution, a warden was put in charge of managing the list of persons
selected to take part in the survey (see facsimile p. 30). The warden summoned the
inmates to the lawyers’ visiting room—the locale where the interview would take
place. If the inmate refused or was unable to participate, the warden would check the
appropriate box in the right-hand columns on the list. Because of this arrangement,
the interviewer was unaware of the respondent’s identity, unless, of course, the
respondent had voluntarily introduced himself/herself. The interviewer did not retrieve
the list until the end of the final interview, in order to make sure that the list and the
collection process were complete. After these checks, the interviewer was supposed
to detach the right-hand part of the list concerning survey participation and send it to
INED. The left-hand part was given to the UCSA chief physician who, after performing
his or her assessment, destroyed the nominal data and sent the rest of the form
to INED. The information on overall health status and on survey participation was
matched by means of the bar code preprinted on the form.
28
The crucial point, no doubt, is inmate
participation. As we saw, it can vary
quite widely with the choice of survey
protocol and with the institution. While
we are indeed dealing with a captive
population, that does not mean it is
docile. Moreover, it is a population with
a very fast turnover (see footnote 3).
Lastly, given the various activities in
which inmates participate (workshops,
sports, walks, etc.), “obtaining”
an interview sometimes requires
perseverance. Optimal cooperation
by prison staff is thus a vital necessity.
In this respect, the organization of
the HID-Prisons survey—despite its
broadly very satisfactory outcome—
would no doubt have been even more
successful if contacts with selected
institutions had been made earlier and
the stakes of the operation had been
more fully articulated.
Another important issue is, of course,
security, which encompasses not
only the interviewers’security but
also organizational problems due
Handicaps, disabilities, and dependency in French prisons
to prison security constraints. In
practice, everything went as well
as could be, including in the highsecurity prison (maison centrale)
that we were able to include in
the survey sample thanks to the
excellent cooperation established
with the Prison Administration
Directorate (DAP). Our regret—which
is also a lesson for future prison
surveys—is that we did not plan more
interviews in that type of institution,
or at least a sufficient number to
allow specific post-survey analyses.
Inmates of high-security prisons form
a population with very distinctive
characteristics, both in penal and
socio-demographic terms.
confirmed their strong motivation and
wide-ranging talent.11
In conclusion, we would like to pay
tribute to INSEE interviewers. They
had already undertaken two highly
challenging operations—the HIDInstitutions survey and the Survey
of Users of Shelters and Soup
Kitchens12—on “tough” subjects,
in unconventional environments,
and using novel collection methods.
The HID-Prisons survey brilliantly
Institut National
d’Études Démographiques (INED)
Aline Désesquelles
12. See Cécile Brousse, Bernadette de la
Rochère, and Emmanuel Massé, “The INSEE
survey of users of shelters and soup kitchens:
an original methodology for studying the
homeless,” Courrier des statistiques, English
series, no. 9 (2003).
References
Cassan F., Héran F. and Toulemon L., 2000, “Study of family history: France’s 1999 Family Survey,” Courrier des statistiques,
English ed., no. 6, pp. 7-19.
Cassan F., Kensey A., and Toulemon L., 2000, “L’histoire familiale des détenus,” INSEE Première, no. 706, April 2000.
Désesquelles A. and HID-Prisons Project Group, 2002, “Le handicap est plus fréquent en prisons qu’à l’extérieur,” INSEE
Première, no. 854, June 2002.
Désesquelles A., (2005), “Disability in French Prisons: How Does the Situation Differ from that of the General Population?”
Population-E, 60(1-2), 2005.
Guillonneau M. and Kensey A., 1997, “La santé en milieu carcéral – Éléments d’analyse démographique,” Revue française des
affaires sociales, no. 1, Jan.-March 1997, pp. 41-60.
Mormiche P., 2000, “The INSEE survey on handicaps, disabilities, and dependency: aims and organization,” Courrier des
statistiques, English ed., no. 6, pp. 21-32. [originally published in French in 1998].
Mormiche P. and HID Project Group, 2000, “Le handicap se conjugue au pluriel,” INSEE Première, no. 742, October 2000.
Mouquet M.-C., 1999, “La santé à l’entrée en prison en 1997: un cumul des facteurs de risque,” DREES-Études et résultats,
no. 4, January 1999.
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Handicaps, disabilities, and dependency in French prisons
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Handicaps, disabilities, and dependency in French prisons
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