Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 1 POLICY BRIEF Policy Recommendations to Improve Mental Health in Polish Prisons Juan Roman Mora Barrios1,2*, Anne van den Broek1*, Riccardo Buttarelli1, Han Reuvers1, Wiktoria Sobotka1, Martina Paric1 1Department of International Health, Governance and Leadership in European Public Health Master, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands; 2 Europubhealth+ Joint Diploma Master in European Public Health, Rennes, France. * These authors contributed equally. Corresponding author: Juan Román Mora Barrios Address: Duboisdomein 30, 6229 GT Maastricht; Postbus 616, 6200 MD Maastricht Email: juanro.barrios@gmail.com mailto:juanro.barrios@gmail.com Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 2 Abstract Context: Mental health is a central aspect of public health and social development, as such it corresponds to target 3.4 of the Sustainable Development Goals. This target aims to promote mental health and well-being, making it especially necessary to address this matter in environments such as prisons where exposure to risk factors is high. Incarceration itself is a cause of mental illness. Central and Eastern European countries hold some of the highest prison populations in the region and Poland numbers in this regard are 50% higher than the average in the European Union (EU) (about 179 inmates per 100,000 inhabitants). In Polish prisons, the chance of receiving adequate psychiatric and psychological care is limited due to a shortage of trained personnel and scarce infrastructure. However, data on mental health in Polish prisons is not routinely reported from official sources. Article 150 of the Polish Penal Code attempts to protect the mental health of inmates; yet, in reality, there is no legal enforcement to apply these measures, a feature shared with most of its neighbouring countries. The aim of this policy brief is to offer recommendations to lower recidivism rates, up-scale prison staff and create spill-over effects on (mental) healthcare and security in Polish prisons. Policy Options: The World Health Organization (WHO) European Framework for Action on Mental Health 2021-2025 should be adapted to the Polish Prison System. Best practices focus on a collaborative approach centred on healthcare services, labour policies, well-being and rehabilitation. Ideally, incarceration provides inmates with the possibility to be included and active, to see their relatives, to vote, to be engaged and maintain contact with the outside society. These best practices statistically reduce mental illnesses, lower recidivism and promote inclusion and rehabilitation. Recommendations: To tackle mental health challenges that prisoners in Poland experience, it is recommended to adapt a new approach with the following components: improving methodological quality of data collection as well as routine reporting to enable good governance structures, promoting collaborative efforts among stakeholders, and strengthening existing resources through capacity building which has been convincingly demonstrated as the most cost-effective type of interventions. Keywords: mental health, Poland, policy brief, health in prisons, prison health systems, health services. Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 1 Introduction More than 10.77 million people worldwide are imprisoned, but this number might exceed 11.5 million if we consider the unreported data (1). In the European Union (EU), 104 in every 100,000 inhabitants were imprisoned in 2020, this equals a total of 463,700 individuals (2). When the focus is placed on the Central and Eastern European countries, prison population figures are located among the second highest in the region, ranging from 150 to 200 prisoners per 100,000 inhabitants (See Appendix 1) (3). 10.2% of the male prisoners and 14.1% of the female prisoners suffer from a major depressive disorder, while in the general population the age-standardised prevalence is at 2.81 (4,5). Prisoners are part of the population that is already at a higher risk for mental health problems and substance abuse (6). See Box 1. The prevalence of self-harm in prisoners is estimated to be 5%-6% in men and 20%-24% in women, which is much higher compared to the general population, where this number does not exceed 1% (0.24% age- standardised) (7,8). Prisoners that face self- harming behaviours are 6 to 8 times more likely to die by suicide, which is why self- harm is also considered a risk factor for suicide among inmates, including the after- release period (7). In 2016, the standardised suicide rate in prisoners in the EU was 4.4 times higher when compared to the general standardised suicide rate in the EU (1.41 per 10,000 inhabitants) (9). Mental health is a central aspect of public health and it is therefore an EU wide task to safeguard it through incisive programmes. Implementation of said programmes must be considered in prison settings, a context with underserved populations that are at increased risk for mental health illness. In 2021, during the 74th World Health Assembly, the Comprehensive Mental Health Action Plan 2013-2030 was endorsed recognising mental health as a public health priority and an essential action point towards the achievement of Sustainable Development Goal (SDG) 3, which explicitly mentions mental health in target 3.4 (10,11). Box 1. Risk factors for increased mental health disorders in prison settings (6): • Limited contact with family/outside community • Overcrowded facilities • Higher of violence • Partial or complete deficit in privacy • Loss of autonomy Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 2 Aligned with this, Mental Health in All Policies (MHiAP) comprises an approach that aims to promote population mental health and well-being by impacting actions and development of public policies other than health that posit an effect on mental health determinants (12). In the case of prison systems, they can be considered units of measurement used to assess the status of progress of social rights of citizens in the EU, as well as the level of inclusion and solidarity procured in their Member State. To date, healthcare in prison settings is still an unsolved issue in most countries, and mental health in prisons is a topic that has its own recent and unstructured development (6,13,14). In previous research, it is highlighted that ex- prisoners face difficulties securing employment upon release (15). Former prisoners with a mental illness are also more likely to be excluded from services targeting employment due to their difficulties and low expectations concerning their ability to work (15). This inability to fulfil a job in society is a high burden on the economy as less productivity is perceived. In addition, it is likely that there is a large reduction in personal earnings as a result of employment penalties after incarceration (16). Furthermore, procuring a labour situation in which prisoners and prison staff possess the same labour rights, and contribute to the economic system in the same magnitude, makes it possible to overcome some of the confrontation and violence that occurs in prisons with obvious positive results for all (14). Poland is currently facing challenges in ensuring a fair and effective political, social and economic system in which all individuals and social groups have equal access to resources and opportunities. These challenges include implementing judicial reforms, imposing restrictions on freedom of expression, and controlling the media (17). The mental health situation in Polish prisons is especially alarming. In 2017, more than 72,000 psychiatric consultations were conducted and as many as 1,164 patients were treated in psychiatric wards in prison hospitals (18). Poland lacks comprehensive statistical data showing the scale of the problem of mental health in prisons. Reports by the European Prison Observatory reveals similar situations regarding healthcare in prisons in Latvia (9). Although the Ministry Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 3 of Justice is responsible for data collection, they do not have a clearly developed system for it (19). Databases reveal lack of comprehensive data regarding prison population portraying consistent deficits of national data collection structures in this concern throughout other Central and Eastern Europe countries (19). In general, it is estimated that mental health issues cost 3% of GDP in Poland (13). The mental health of prisoners has been proven to be poorer in comparison with the general population (20). When looking at the incarceration of adults, mental illnesses have an extraordinarily high cost to the economy. There are direct costs such as the involvement in the criminal justice system, while indirect costs include lost productivity resulting from untreated and underrated mental illness (15,16). The European Commission has already issued recommendations for the Polish prison healthcare system (14). The involvement of Ombudsman, the Helsinki Committee, Amnesty International, the Legal Intervention Association in Poland and other local stakeholders is required for improving mental health in Polish prisons following the recommendations provided in this policy brief. Context It is acknowledged that country contexts, and prison and health structures vary significantly among Member States, however the core concept of imprisonment lays upon the protection of society against crime and the reduction of recidivism. This principle is detailed in The United Nations Standard Minimum Rules for the Treatment of Prisoners, a document that also observes that applicability in full extent in all places and at all times is not possible (21,22). See Box 2. Health services are inherently destined to be framed in a person-centred approach and so are prison health systems. Along with this, continuity of care should also be guaranteed for these settings (23–25). Data from the 2021 SPACE I report on Prisons and Prisoners in Europe shows that the landscape is not portraying these principles. Poland held prison population rates 3.2 times higher by January 2021 than the ones encountered in Norway, and suicide rates per 10,000 inmates ranging from 4 to 6.6 in said nations (2020) (3). See Figure 1. Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 4 This makes the economy suffer as a whole, making the cost of the effect of mental health problems during and after incarceration significant to a nation’s economy. When incarceration ends, ex-inmates have difficulty finding employment which carries a direct and indirect significant cost as a personal and socioeconomic burden (15,16). Another indirect cost to the economy covers the involvement of family members and associates of former inmates with mental health issues. It is not only the former inmates who experience a loss of productivity, it is also a reality for family members who provide unpaid care for the person with mental illness (26). This represents an additional burden to the economy. What is happening in Poland? As of November 4, 2022, the population in prisons and detention centres in Poland covered 87.7% of capacity nationwide. There are currently 87 prisons, as well as 37 external wards subordinated to them. Sixty- seven pre-trial detention centres are also used to carry out prison sentences (27). Medical care in the Polish prison system Providing inmates with proper medical care is one of the basic duties of the state. The right of prisoners to medical and sanitary care is indicated primarily by Article 102 paragraph 1 of the Executive Penal Code (28). See Box 3. Box 2. The United Nations Standard Minimum Rules for the Treatment of Prisoners – the Nelson Mandela Rules (21): 4.1. The purposes of a sentence of imprisonment or similar measures deprivative of a person’s liberty are primarily to protect society against crime and to reduce recidivism. Those purposes can be achieved only if the period of imprisonment is used to ensure, so far as possible, the reintegration of such persons into society upon release so that they can lead a law-abiding and self-supporting life. 5.1. The prison regime should seek to minimize any differences between prison life and life at liberty that tend to lessen the responsibility of the prisoners or the respect due to their dignity as human beings. 5.2. Prison administrations shall make all reasonable accommodation and adjustments to ensure that prisoners with physical, mental or other disabilities have full and effective access to prison life on an equitable basis. Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 5 Respect for the human dignity of the convict is also mandated by Article 4 par. 1, which prohibits torture and degrading treatment of prisoners. According to Article 115, detainees are provided with free health services, medicines and sanitary supplies, provided primarily by medical providers (28). Health services for persons deprived of liberty are provided by Treatment Entities established in detention centres and prisons (27,28). These entities are under the authority of the Ministry of Justice. They provide health services to prisoners in the following areas: medical examinations and advice, medical treatment, psychological examinations and therapy, rehabilitation, Box 3. Article 102- Executive Penal Code of the Republic of Poland (28) In particular, a convict has the right to: (1) food, clothing, living conditions, accommodation, as well as health services and adequate hygienic conditions appropriate for the preservation of health; Figure 1. Prison population in Europe, 2021. Source: Aebi MF, Cocco E, Molnar L, Tiago MM. Prisons and Prisoners in Europe 2021: Key Findings of the SPACE I report. 2022 Apr. Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 6 diagnostic tests, care of the sick and disabled, prevention of injuries and diseases through preventive measures and mandatory vaccinations (28). If health services cannot be delivered to inmates, it is necessary to grant them a temporary pass to receive these services in a non-prison medical entity, such as public hospitals. Under these circumstances, healthcare services are delivered by providers regulated by the Ministry of Health rather than the Ministry of Justice, as it is the norm (27,28). Norwegian prison system Contrasting the Polish prison system with the Norwegian prison system (Kriminalomsorgen) serves as a best practice locator methodology more than a comparison between them. In Norway the punishment for the crimes committed comprises only the restriction of freedom within the community. However, inmates preserve their right to vote, study, and interact with the external world to facilitate reintegration after release. Norwegian prisons are characterised by structured active participation, a real possibility for redemption and rehabilitation into the society based on labour (29). The healthcare system in prisons is regulated by the Ministry of Health and allows the inmates to be personally followed during their incarceration, focusing on their mental rehabilitation (19,29). See Box 4. This approach leads to lower criminality levels; for instance, the murder rate in Norway is 0.6 per 100,000 people, as one of the top lowest murder rates worldwide, and the total number of crimes in Norway is about 330,000 per year (30). Even the number of inmates has decreased progressively, and to date, the population in Norwegian prisons remains stable at around 3,000 individuals (31,32). For these reasons, the system is not systematically comparable to the Polish, but these best practices could suggest a different efficient approach. Box 4. Norway: an import model (29). Crucial services for reintegration are delivered to the prison by local and municipal service providers. These are imported from the community. Advantages: • A better continuity in the deliverance of services – the offender will already have established contact during his time in prison; • Involvement from the community with the prison system – more and better cross-connections. Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 7 Is this difference determined by the type of facility or the governing structure? Data collected in the Health in Prisons European Database (HIPED) last reviewed in 2019, shows a difference in the authority in charge of prison healthcare, its funding and the budget administration. Whilst in Norway, guidelines follow the Helsinki Recommendations aligned with the Nelson Mandela Rules and the United Nations Bangkok Rules entitling the Ministry of Health to the management and provision of healthcare services in prisons and secure settings, the Polish prison healthcare system relies solely on the Ministry of Justice for this role (19). Mental health in prison settings Notions of psychiatric care in prisons and secure settings date from 1993, and according to this, mentally distressed prisoners should be “kept and cared for in a hospital facility which is adequately equipped” (33). Mental health in prisons also attains and maintains the well-being of prisoners as much as it would in the outside community. The European Mental Health Action Plan 2013-2020 portrayed a diagram representing the cycle of mental well-being (See Appendix 2) underlying the modifiable and non- modifiable inputs to achieve well-being for all individuals regardless of their freedom status (34). Another area that is overlooked by healthcare services is prisoners’ contact with the outside world as a means of mental health promotion and well-being; in Norway, for example, most prisoners are engaged in purposeful activities which promote a sense of normality and allow for meaningful human contact to be established (35). Mental health in Polish prisons A study shows that a mentally ill person in a Polish prison has a limited chance of receiving adequate psychiatric care (36). There is a shortage of prison hospital wards providing round-the-clock care. Those that do exist tend to have inadequate conditions for the rehabilitation and treatment of mentally ill patients, as they are mainly for observation and assessment of sanitary conditions (37). Patients there often have no access to any form of treatment other than medication. Today, only one psychiatric hospital, at the Detention Centre in Szczecin, provides mentally ill inmates not only with pharmacotherapy, but also with rehabilitation activities (psychological assistance sessions, particularly in the form of individual, group Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 8 or family psychotherapy; education and psycho-education; occupational therapy; social skills training; art therapy; physical therapy) (38). Most inmates with mental illness who do not require hospital treatment are placed in one of the 23 therapeutic wards with a total of 1,780 available places, where convicts serve their sentences in the therapeutic system (27). Those in the worst situation are those whose mental illness manifested itself after conviction and incarceration. According to Article 150 of the Penal Code, it is then mandatory to postpone imprisonment until the "cessation of the obstacle", and thus allow the convict to receive treatment (28). The problem is that there is no legal basis for applying protective measures to such a person, such as placement in a psychiatric facility or control at large (27). The Ombudsman, who is positioned to objectively resolve the dispute between the citizen and the state, has repeatedly argued in Poland that such people in whom a psychiatric disorder has appeared while serving a sentence should not be placed in prisons or prison psychiatric hospitals, as this does not give them a chance for effective therapy (39). However, a legal loophole stands in the way of this, the Ombudsman warns (39). Due to loopholes in the law, there are no designated facilities to which convicts who develop mental illness in prison can be sent to (40). Policy Options The cycle of mental well-being (Appendix 2) is a model proposed by WHO and can be used to identify all the intersecting inputs and action points for the prevention and treatment of mental illness (34). Under the aforementioned contexts, the following policy options have been identified: The WHO European Framework for Action on Mental Health 2021-2025 can be adapted to the Polish Prison System. With this adaptation, a Mental Health in All Policies (MHiAP) approach could reduce the impact that mental health inequalities have on the Polish health, social and economic structure (10,12,41). Individuals in Polish prisons and secure settings need to be integrated as part of the vulnerable and discriminated population that encounter impeded access to mental health services (12). Evidence shows that setting a standardised mental health care pathway, along with active labour policies aimed at the reintegration of Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 9 inmates into society, have positive repercussions on the data concerning drug consumption, suicide, and self-harm rates, as well as psychological disorders (15,42,43). The following recommendations can help to foster preventative mental health services in prisons and secure settings. Recommendations Recommendations are intended to achieve a comprehensive response to the challenges that inmates in secure settings face daily in Poland, especially those of mental health nature. The following strategies can lead to the desired outcomes: 1) Data collection for good governance - Align with the WHO European Framework for Action on Mental Health 2021-2025 to develop a mental health data platform that enables routine data collection from prison systems in Poland to foster adequate planning, budgeting, and coordination of service delivery and evaluation (10). This would improve data collection and reporting strategies, transparency and accountability as markers of a strong governance structure (44,45). - Facilitate the development of Participatory-Action Research (PAR) within prisons and secure settings to guarantee knowledge production from first-person narratives while maintaining quality evidence for decision-making (46–49). The outcomes intended to achieve with PAR are: o Strong sources of evidence from populations in prisons and secure settings for the promotion of high-quality health (and mental health) research and further policy- making. o Engagement of all relevant stakeholders in the decision- making process: identification of mental health needs, design of strategies, data collection, internal and external communication, implementation, evaluation, and re-designing relevant to the given context. This is not only important to identify Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 10 trends and risk factors for mental health illness in these environments, but also to identify mitigating factors. 2) Collaborative approach - Closer collaboration between the Polish Ministry of Justice and the Ministry of Health would allow for the adequate resource allocation towards preventative mental health services. We recommend the creation of an Interagency Collaboration Working Group – Mental Health in Polish Prisons (ICWG-MHPP). The ICWG-MHPP should be composed of all intersecting public and private entities who can provide a comprehensive and collaborative structure to shape policy actions deemed appropriate (42,50,51). Education, Health, Judiciary, Labour, Finance, Housing and Social Welfare are some of the departments suggested to be part of the ICWG- MHPP in equal representation along with inmate and family members, representatives and stakeholders relevant to the context. - Assess the opportunity to design, implement and evaluate a strategy to migrate from the current approach of the Polish prison system to a more human-centred approach. This is similar to the Norway ‘import model’ (See Box 4.) where prisoners are seen as an extension of the outside community. This ensures continuity of (mental) healthcare from the outside community to prison settings and vice versa. Applying the import model re-structures the prison system from a place of punishment towards a space for rehabilitation (29,50–52). 3) Capacity building - Promote quality of care by up-scaling prison staff, non-specialized healthcare providers, health planners, managers and policy makers to favour equal access to mental healthcare services within prison settings. Additionally, by developing the appropriate skill-mix among the prison workforce better integration can be achieved. This would promote capacity building and enable the compliance of the Helsinki Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 11 Recommendations on Ethical Practice of Care (24). - Adapting the Mental Health Gap Action Program (mhGAP) v2. in the design, assessment, implementation and evaluation of mental health services in Polish Prisons is highly recommended. The mhGAP is a model guide developed by the WHO that is adaptable to local contexts aiming to scale up prison staff, non- specialized healthcare providers, health planners, managers and policy makers with the overarching objective of developing a good skill- mix among the entire prison workforce (53). The Polish Prison Health System can adapt the mhGAP to the current needs in their facilities in terms of mental, neurological and substance use disorders. The integration of this tool in the Polish prison system can be the first step to achieve more sustainable goals in this matter and address current shortages in mental health and healthcare services. We acknowledge that its fulfilment depends on the level of commitment, social and financial barriers that Polish context allows. However, a joint effort involving all the stakeholders identified can be a pathway in the right direction. Limitations This policy brief does not intend to establish a comparison between prison systems in the EU. However, in order to identify the best practices that might be applicable to Polish prison system, it was needed to contrast with better performing countries. A limitation that needs to be taken into account is the language of official documents from Poland. Even though translations might be accurate, no official translations were found and this could play a role in the power of the evidence adjudicated to the information found. This limitation was counteracted by proofreading and review by one of the authors who is a native a Polish speaker. Another limitation found during the development of this policy brief was the lack of up-to-date official information regarding the prison systems and secondary sources were used to attain it. Conclusion Focusing our efforts on target 3.4 and addressing mental health is central to fully Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 12 attain SDG3, to promote health and well- being for all. Polish prison numbers in this matter are alarming because of limited chances to receive adequate care and therefore, action is required. An emphasis on mental health in Polish prison settings will promote reintegration policies that lower recidivism rates fostering social inclusion and solidarity-oriented community collaboration towards those who today are mostly abandoned to their fate. The recommendations provided in this document are based on best practices and can be applied contextually in different Member States within the Comprehensive Mental Health Action Plan 2013-2030 and a MHiAP approach. It takes time, resources and political will among relevant stakeholders for these recommendations to be applied and impact mental health in prisons. This is why recommendations are provided on the strengthening of existing structures and collaboration among Ministries and organisations. Implementing stronger data collection strategies is recommended to obtain a better insight into the extent of the problem, while better mental health care could be reached by up-scaling the prison workforce and policy-making structures. Actions taken on these policy options are useful for the Polish Prison System, and also for other countries where mental health in prisons is at risk. Conflicts of interest None declared. Acknowledgments We would like to extend our sincere gratitude to Katarzyna Czabanowska and the University of Maastricht for being facilitators of this opportunity. Lastly, we would like to thank our families, who helped and sustained us personally and professionally. Their efforts have led us to be the public health professionals we are today, and may this policy brief be a reason of pride for them and a call to action for decision makers References 1. Fair H, Walmsley R. World Prison Population List. 2021. 2. Eurostat. Prison statistics [Internet]. 2022 [cited 2022 Dec 3]. Available from: https://ec.europa.eu/eurostat/statistics- explained/index.php?title=Prison_stati stics 3. Aebi MF, Cocco E, Molnar L, Tiago MM. Prisons and Prisoners in Europe 2021: Key Findings of the SPACE I Mora Barrios, J; van den Broek, A; Buttarelli, R; Reuvers, H; Sobotka, W; Paric, M. Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. 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Policy recommendations to improve Mental Health in Polish Prisons. (Policy brief). SEEJPH 2023. Posted: 09 April 2023 Page 18 Appendix 2. The cycle of well-being. Source: WHO Regional Office for Europe. The European Mental Health Action Plan 2013-2020; 2015. ___________________________________________________________________________ © 2023 Mora Barrios et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.