Mixed-methods investigation into the prevalence, patterns and determinants of prisoner self-harm during the COVID-19 pandemic in England and Wales compared with prepandemic self-harm (COPE).

Introduction: COPE investigated the prevalence, patterns and determinants of prisoner self-harm during the COVID-19 pandemic, compared with pre-pandemic. The project used the natural experiment of the pandemic to understand effects of prison environments on self-harm. Methods: COPE was a mixed-methods study involving all prisons within England and Wales. Participants included 80 437 prisoners identified from routine data sources, 71 (ex)prisoners consulted and 89 staff interviewed (average experience: 18.5 years). The main outcome measure was the rate of self-harm incidents reported. Secondary measures included qualitative assessments of prisoner and staff experiences related to self-harm during the pandemic. Qualitative outcomes were derived from thematic grouping of inmate consultation responses and framework analysis of staff responses. The exposure was the pandemic period from March 2020 to December 2021. Results: There were gender differences in prisoner self-harm rates during the pandemic. In women's prisons, the pandemic was associated with a 7% overall increase in self-harm (95% CI 2% to 13%) and a 43% increase in self-harm requiring hospitalisation (11% to 83%). Conversely, men's prisons saw an 8% self-harm decrease (6% to 11%) and a 21% decrease in self-harm hospitalisation. Policy interventions, for example, in-cell telephones and additional phone credit were linked to reduced self-harm in men's prisons. Introducing video visits was associated with an increase in self-harm in women's and men's prisons. Qualitative analysis revealed a complex interplay of factors influencing these outcomes, including tension between the risk of mental health deterioration because of greater isolation and the perceived safety benefits of a restricted regime. Conclusions: The pandemic, and policy changes, were associated with changes in prisoner self-harm. Distinct patterns emerged between genders underscoring the need for gender-specific prison policies, especially during crisis management. Furthermore, the complex relationship between policy implementation and self-harm highlighted the importance of tailoring prison environments to effectively address the population's diverse needs.