Prison Setting Research Articles

Nutritional interventions in prison settings: a scoping review.

Mounting evidence has shown that incarceration can affect the health and well-being of individuals and increase the risk of noncommunicable diseases (NCDs). Diet quality is known to be one of the main determinants of risk of NCDs, and dietary changes are the first approach used in primary care to reduce the incidence of NCDs. This scoping review aimed to summarize the evidence for (1) the diet quality of inmates, and (2) the effect of nutritional intervention in prison systems. In addition, we aimed to describe limitations in the current literature and to suggest potential future research areas. A systematic search was performed in 2 databases (PubMed and Web of Science) using predefined search terms and covering the period May 2023 to June 2023. Additionally, reference lists from the retrieved studies were hand-searched to identify any additional relevant publications. The identified literature was screened based on defined search strategies, criteria, and research questions defined using the PICo (population or problem, interest, and context) framework. The review was conducted referring to the PRISMA-ScR and the PICo framework. A total of 19 studies out of 63 initially identified records were included in this review (11 cross-sectional evaluations and 9 intervention-based studies). In almost all studies, assessment of the diet quality of menus showed the menus to be nutritionally adequate, except for having a higher-than-recommended intake of total energy, saturated fatty acids, sodium, cholesterol, and sugar. In addition, some studies reported a lower-than-recommended intake of fiber, magnesium, potassium, vitamins D, E, and A, and omega-3 fatty acids. Nutritional interventions were mainly planned in the form of workshops, seminars, and written material to deliver information on healthy dietary choices. Although no significant changes in inmates' dietary choices were observed in any of the studies, a high participation rate was detected. Inmates might require additional prevention intervention to reduce their susceptibility to cardiometabolic diseases by virtue of their isolation from community facilities. Interventions should be tailored to the characteristics of prison settings and inmates to increase adherence to nutritional recommendations.

Variations in services and intervention pathways for traumatic stress in Welsh prisons: A national survey.

Both Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder are prevalent in prison settings. Both often go undetected and untreated, while prisoners who already suffered previous trauma may be re-traumatised upon imprisonment. The current study aimed to conduct a national survey of all Welsh prisons to gather information about existing services and treatments for traumatic stress. The survey identified variation within Welsh prisons with regard to NICE-recommended evidence-based therapies. It is therefore recommended that there needs to be development of a pathway of Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder in the prison system which should be achieved through a consensus process of both frontline staff and experts in the field.

Testing, diagnosis, and treatment following the implementation of a program to provide dried blood spot testing for HIV and hepatitis C infections: the NSW DBS Pilot

BackgroundDried blood spot (DBS) testing provides an alternative to phlebotomy and addresses barriers to accessing healthcare experienced by some key populations. Large-scale evaluations of DBS testing programs are needed to understand their feasibility. This study evaluated the implementation of a state-wide DBS HIV and hepatitis C virus (HCV) testing pilot.MethodsThe New South Wales (NSW) DBS Pilot is an interventional cohort study of people testing for HIV antibody and/or HCV RNA from DBS samples in NSW, Australia. Participants at risk of HIV/HCV participated in testing via: 1) self-registration online with a DBS collection kit delivered and returned by conventional postal service; or 2) assisted DBS sample collection at 36 community health sites (including drug treatment and harm-minimisation services) and prisons. Participants received results by text (HIV antibody/ HCV RNA not detected) or a healthcare provider (HIV antibody/ HCV RNA detected). The RE-AIM framework was used to evaluate reach, effectiveness, adoption, and implementation.ResultsReach: Between November 2016 and December 2020, 7,392 individuals were tested for HIV and/or HCV (21% self-registration, 34% assisted in community, and 45% assisted in prison). Effectiveness: Of 6,922 people tested for HIV (19% men who have sex with men, 13% living outside major cities, 21% born outside Australia), 51% (3,521/6,922) had no HIV test in the past two years, 0.1% (10/6,922) were newly diagnosed with HIV, and 80% (8/10) initiated HIV treatment within six months. Of 5,960 people tested for HCV (24% women, 35% Aboriginal and/or Torres Strait Islander, 55% recently injected drugs), 15% had detectable HCV RNA (878/5,960), and 45% (393/878) initiated treatment within six months. Adoption: By the end of 2020, DBS via assisted registration was available at 36 community sites and 21 prisons. Implementation: 90% of DBS cards arriving at the laboratory had the three full spots required for testing; the proportion was higher in assisted (94%) compared to online (76%) registration.ConclusionsThis study demonstrated the feasibility of DBS testing for HIV and HCV in key populations including Aboriginal and Torres Strait Islander peoples, men who have sex with men, people who inject drugs, and demonstrated the utility of DBS in the prison setting.

The Experience of Spanish Prison Nurses with the HIV Pandemic.

This study discusses the experiences of nurses in Spanish prisons during the HIV/AIDS pandemic, emphasizing administrative changes and adaptive measures, such as the creation of the Subdirectorate General of Penitentiary Health. We describe the experiences of nurses in Spanish penitentiary centers in the face of the HIV/AIDS. The interpretative and phenomenological approach explored experiences between 1981 and 2023 through focus groups and convenience sampling. Participants were recruited through telephone calls and telematic meetings using Microsoft Teams. Four key themes were identified: the stigmatization of inmates, changes in nursing, the importance of training and resources, and equal treatment between genders. The nursing vision focused on gathering information, providing comprehensive patient support, and sharing personal experiences. This research provides a historical perspective on the adaptation of prison nursing to the pandemic, highlighting coping processes and suggesting future lines of research on the experiences of inmates, prison guards, and surveillance officers. We highlight the low media visibility of the pandemic in prisons, underlining the importance of understanding and valuing the nursing experience in prison settings during health crises.

Art therapy in a multidisciplinary team with young men in prison

ABSTRACT Background People in prison often present with histories of trauma that can be difficult to process in the volatile prison environment. This article seeks to advance our understanding of the benefits of art therapy within a multidisciplinary team, and how it can help young men in prison who have experienced trauma. Context A review of the art therapy-informed interventions offered for trauma stabilisation in a service for young adult men in prison with complex needs is presented. Approach This article discusses a trauma-informed service in the prison and the variety of ways in which art therapy can support people in prison with histories of complex trauma. It explores: the use of art therapy in a group focusing on improving the prison environment; the role of art therapy in supporting trauma stabilisation and the development of ‘safe place’ processing; and the use of art therapy tools to explore dissociation with service users prior to engaging in trauma therapy. Conclusions The article highlights the vital role of art therapy as a non-verbal therapy to support young men to heal their past trauma. Reflections are offered on the importance of embedding art therapy within a service’s trauma therapy pathway. Implications for research It is recommended that research into the use of art therapy within prison settings is undertaken which could explore its utility in supporting people to process their trauma. This would provide further evidence for the role that non-verbal therapies may play in healing trauma.

Psychiatric and legal considerations for ketamine treatment within prison settings.

The fundamental right to equivalence of health care in prison settings encompasses the provision of medication to address mental health conditions. Considering the increased risk for self-harm among individuals dealing with depression, the limited effectiveness of conservative antidepressants is a major challenge in psychiatry. The high prevalence of suicidal tendencies within prison populations underscores the imperative for state-of-the-art pharmacological treatment to uphold adequate health care standards. Notably, the denial of access to effective medication could be deemed a violation of human rights of people living in prison according to international treaties, domestic law, and United Nations normative standards of detention. This article presents the authors' perspective on the accessibility of ketamine treatment in prison settings, discussing psychiatric and legal considerations as well as current challenges in this context. Implementing novel psychopharmacological interventions may alleviate the distress experienced by individuals struggling with depressive symptoms and suicidality. At the same time, unprecedented treatment alternatives bring along potential issues, including limited understanding of long-term effects and the risk of abuse. Given the scarce data-availability, a pressing need exists for further research on the benefits and risks of ketamine treatment within prison populations.

Transfer to community and prison mental health care from Ireland's main remand prison over three years: 2015-2017.

The post-release period is associated with an increased risk of morbidity and mortality. Previous studies have identified deficits in pre-release planning for mentally ill people in prison, particularly in remand settings. We aimed to determine the proportion of mentally ill people in Ireland's main remand prison who were referred for mental health follow up in community and prison settings, who achieved face to face contact with the receiving service. This retrospective observational cohort study was based in Ireland's main male remand prison, Cloverhill. Participants included all those individuals on the caseload of the prison inreach mental health team who were referred for mental health follow up in community and prison settings at the time of discharge, prison transfer or release from custody over a three-year period, 2015 - 2017. Successful transfer of care (TOC) was defined as face-to-face contact with the receiving service, confirmed by written correspondence or by follow up telephone call. Clinical, demographic and offence related variables were recorded for all participants. There were 911 discharges from the prison inreach mental health team within the three-year study period. Of these, 121 were admitted to hospital, 166 were transferred to other prison inreach mental health services and 237 were discharged to community based mental health follow up in psychiatric outpatient or primary care settings. One third (304/911) had an ICD-10 diagnosis of schizophreniform or bipolar disorder (F20-31) and 37.5% (161/911) were homeless. Over 90% (152/166) of those referred to mental health teams in other prisons achieved successful TOC, with a median of six days to first face-to face assessment. Overall, 59% (140/237) of those referred to community psychiatric outpatient or primary care services achieved TOC following referral on release from custody, with a median of nine days from release to assessment. Clinical and demographic variables did not differ between those achieving and not achieving successful TOC, other than having had input from the PICLS Housing Support Service. Successful transfer of care can be achieved in remand settings using a systematic approach with an emphasis on early and sustained interagency liaison and clear mapping of patient pathways. For incarcerated individuals experiencing homelessness and mental health disorders, provision of a housing support service was associated with increased likelihood of successful transfer of care to community mental health supports.

Assessment of tuberculosis transmission probability in three Thai prisons based on five dynamic models.

This study aimed to assess and compare the probability of tuberculosis (TB) transmission based on five dynamic models: the Wells-Riley equation, two Rudnick & Milton-proposed models based on air changes per hour (ACH) and liters per second per person (L/s/p), the model proposed by Issarow et al, and the Applied Susceptible-Exposed-Infected-Recovered (SEIR) TB transmission model. This study also aimed to determine the impact of model parameters on such probabilities in three Thai prisons. A cross-sectional study was conducted using data from 985 prison cells. The TB transmission probability for each cell was calculated using parameters relevant to the specific model formula, and the magnitude of the model agreement was examined by Spearman's rank correlation and Bland-Altman plot. Subsequently, a multiple linear regression analysis was conducted to investigate the influence of each model parameter on the estimated probability. Results revealed that the median (Quartiles 1 and 3) of TB transmission probability among these cells was 0.052 (0.017, 0.180). Compared with the pioneered Wells-Riley's model, the remaining models projected discrepant TB transmission probability from less to more commensurate to the degree of model modification from the pioneered model as follows: Rudnick & Milton (ACH), Issarow et al., and Rudnick & Milton (L/s/p), and the applied SEIR models. The ventilation rate and number of infectious TB patients in each cell or zone had the greatest impact on the estimated TB transmission probability in most models. Additionally, the number of inmates in each cell, the area per person in square meters, and the inmate turnover rate were identified as high-impact parameters in the applied SEIR model. All stakeholders must urgently address these influential parameters to reduce TB transmission in prisons. Moreover, further studies are required to determine their relative validity in accurately predicting TB incidence in prison settings.

Intervention Needs in Prison With Pedophile Inmates

There are specific treatment programs in prisons for those convicted of sexually assaulting minors; however, those who also have pedophilia require specific attention. The aim of this study is twofold: first, to offer a specific intervention proposal for pedophilia in the prison setting based on the available scientific evidence, and complementary to the Sexual Assault Control Program, and second, to justify this proposal through the case of an inmate with pedophilia. Specifically, we propose an individual intervention focused on people with pedophilia; working on low self-esteem, assessing suicidal ideation, and restructuring cognitive distortions with minors, facilitating the creation of functional personal relationships with adults, assessing past polyvictimization and its possible influence on subsequent sexual behavior, providing inmates with psychoeducation on pedophilia; specifically addressing sexual fantasies with minors, avoiding dissexual behavior, and eliminating the consumption of abusive material.

Effect of Yoga on Psychological and Emotion Regulation among Women Prisoners: A Pilot, Randomized Controlled Trial

ABSTRACT Background: Given the stress of imprisonment and isolation from families, the women prisoners are subjected to increased anxiety, depression, and emotional dysregulation. Due to these negative outcomes, it is imperative to find efficient nonpharmacological interventions. Yoga improves mental health in both correctional settings and the general population. Studies conducted on the mental health of female prison inmates are scarce. Materials and Methods: A randomized controlled trial was used and instigated on 76 women prisoners with moderate-to-severe stress levels, randomly allocated into Group 1 (n = 36) and Group 2 (n = 40). Group 1 was taught with 90 min of Integrated Approach of Yoga Therapy and Group 2 was taught with 90 min of free choice physical exercise for 15 days. Assessments were taken before and after the intervention. Data were analyzed using the analysis of covariance (ANCOVA) adjusting for the baseline differences. Results: Significant difference in effect was found between the groups in the State Trait Anxiety Inventory, Beck Depression Inventory (BDI), emotion regulation questionnaire, and positive and negative affect questionnaire schedule (PANAS). Within group analysis demonstrated improved scores in all psychological constructs in the yoga group. Although some constructs also shown significant changes in the control group, the effect size was less when compared to the yoga group. Conclusion: Yoga can be administered in the prison setting daily to maintain the mental health of the women prisoners.

Rehabilitation and control in prison settings

This article examines the factors which affect the relationship between prison officers and prisoners in Italy, especially the tension between treatment/rehabilitation and control. Using the mathematical concept of the quadrant, we describe how an individual prison officer can find their position in the system which they can use to understand their unconscious predispositions towards the two polarities of control or rehabilitation. The quadrant also offers predictive dimensions for prison officers in how likely they are to respond well to different prison cultures and to individual prisoners when asked to cope with the daily challenges of their jobs.

I. SALAKHOV – FATE AND LITERATURE

The article explores the novel "Tragedy of Kolyma" (Kolima kasireti), providing profound insights into the personality of Ibrahim Salakhov. It investigates the promotion of creative works by Tatar-Bashkir intellectuals such as Galymzhan Ibragimov and Majit Ghafuri among the general populace. Ibrahim Salakhov's personage is characterized by critical realism, a literary trend that is evident in the novel. The narrative delves into real events that transpired in the life of the writer, showcasing the influence of social conditions on human behavior. The article analyzes Ibrahim Salakhov's novel "Tragedy of Kolyma”. The objective is to uncover the multifaceted layers of the narrative, shedding light on the author's perspective on the prison environment. A particular emphasis is placed on portraying the distinct lexicon prevalent in the prison setting and illustrating the relentless conflicts between inmates and their custodians. The article strives to provide readers with a nuanced comprehension of the variances in prison life through authentic situations depicted in Salakhov's literary work. The narrative extends to the historical mistreatment and persecution faced by eminent Kazakh and Tatar writers, including figures such as Galymzhan Ibragimov and Kawi Najmi. The article observes the incorporation of memoiristic elements in Salakhov's work shifting focus towards the transformative and innovative personality of Galymzhan Ibragimov, a forward-thinking intellectual of his era. Noteworthy is the frequent use of artistic literary devices such as narratives, digressions, and monologues, which further enrich the narrative style of Salakhov's literary works. Key words: memoir, epistolar heritage, enemy of the people, critical realism.

How effective are digital/e-health interventions for supporting prisoners with mental ill-health? An integrative review

PurposeThere has been a move towards the implementation of digital/e-health interventions for some time. Digital/e-health interventions have demonstrable efficacy in increasing individual empowerment, providing timely access to psychological interventions for those experiencing mental ill-health and improving outcomes for those using them. This study aims to determine the efficacy of digital/e-health interventions for individuals detained in prison who experience mental ill-health.Design/methodology/approachA systematic search of five academic databases – CINAHL, ASSIA, PsycINFO, Embase and Medline – was completed in December 2020 and updated in February 2022. The review was guided by the Whittemore and Knafl (2005) framework for integrative reviews. A total of 6,255 studies were returned and screened by title and abstract. A full-text screening of nine (n = 9) studies was conducted.FindingsNo study met the inclusion criteria for the clinical efficacy of digital/e-health interventions in a prison setting. Subsequently, a review of the literature that made it to the full-text review stage was conducted, and gaps in the literature were identified to inform policy, practice and future research.Originality/valueTo the best of the authors’ knowledge, this is the first integrative review conducted on the efficacy of digital/e-health interventions for mental ill-health in prison settings.

“We don’t even know where it’s kept”: exploring perspectives on naloxone administration by provincial correctional workers in Manitoba, Canada

PurposePrisonersare at disproportionate risk of suffering substance-related harms. The administration of naloxone is essential to reversing opioid overdose and minimizing substance-related harms in prison and the community. The purpose of this study is to examine how naloxone administration is practiced and perceived in prison settings.Design/methodology/approachThe authors conducted surveys with correctional workers in Manitoba, Canada (n = 257) to examine how they understand and feel about the need for and practice of administering naloxone in their everyday work with criminalized populations.FindingsRespondents reported feeling a great need to administer naloxone, but most did not feel adequately trained to administer naloxone, creating the perception that criminalized populations remain at enhanced risk.Originality/valueFindings provide emerging evidence of the need for training and accompanying policies and procedures for correctional workers on how to access and administer naloxone.

Differences in HCV Seroprevalence, Clinical Features, and Treatment Outcomes between Female and Male Incarcerated Population: Results from a Matched Cohort Study.

Women represent less than 5% of the incarcerated population in Italy, with very limited data on HCV infection. Higher HCV seroprevalence and active infection rates have been described among incarcerated females in available studies. Our aim is to compare the prevalence and cascade of care of HCV between male and female populations in Italian penitentiaries. We conducted a multicentre, retrospective study comparing HCV seroprevalence, active infections, treatment, and SVR rates between female (Group A) and male (Group B) populations in Italian prison settings. No significant differences were found between the two groups regarding PWIDs (p = 0.16), nor in people living with HIV (p = 0.35) or HBV co-infection (p = 0.36). HCV seroprevalence was higher in Group A (p = 0.002). There was no statistically significant difference between the two groups regarding active infections (p = 0.41). Both groups showed a low level of fibrosis, and the dominant genotype was 3a. Almost all patients underwent antiviral treatment. All treated patients achieved SVR12. Our findings illuminate the importance of recognizing and addressing gender differences in HCV seroprevalence within penitentiary settings. Moving forward, addressing the unique needs of incarcerated females and optimizing HCV care for all incarcerated individuals are essential steps in the pursuit of achieving HCV micro-elimination goals.

Comparison of gene targets and sampling regimes for SARS-CoV-2 quantification for wastewater epidemiology in UK prisons.

Prisons are high-risk settings for infectious disease transmission, due to their enclosed and semi-enclosed environments. The proximity between prisoners and staff, and the diversity of prisons reduces the effectiveness of non-pharmaceutical interventions, such as social distancing. Therefore, alternative health monitoring methods, such as wastewater-based epidemiology (WBE), are needed to track pathogens, including SARS-CoV-2. This pilot study assessed WBE to quantify SARS-CoV-2 prevalence in prison wastewater to determine its utility within a health protection system for residents. The study analysed 266 samples from six prisons in England over a 12-week period for nucleoprotein 1 (N1 gene) and envelope protein (E gene) using quantitative reverse transcriptase-polymerase chain reaction. Both gene assays successfully detected SARS-CoV-2 fragments in wastewater samples, with both genes significantly correlating with COVID-19 case numbers across the prisons (p < 0.01). However, in 25% of the SARS-positive samples, only one gene target was detected, suggesting that both genes be used to reduce false-negative results. No significant differences were observed between 14- and 2-h composite samples, although 2-h samples showed greater signal variance. Population normalisation did not improve correlations between the N1 and E genes and COVID-19 case data. Overall, WBE shows considerable promise for health protection in prison settings.

SOCIAL BOND ANALYSIS OF CORRECTIONAL INMATES AT CLASS IIA CIBINONG CORRECTIONAL INSTITUTION: THE PHENOMENON OF VIOLENCE AMONG INMATES

Correctional Institution has the goal of guiding criminals to obtain a better life, be able to reintegrate and be accepted by the society. However, realizing such goal is not as easy. As a place where people from various backgrounds and different criminal records, Correctional Instituion has become an ideal area and prone to disputes. This includes violence among inmates, that is reported to be the most common type of violent in prison. Nonetheless, it is not impossible to avoid such issues in the prison setting. In order to understand this possibility, this article attempt to study the social life in prison in relation to violence among inmates. Mainly, this study aims to: 1) find out the condition of violence among inmates in Cibinong Correctional Institution; and 2) analyze social bond to understand the phenomenon of violence among inmates in Cibinong Correctional Institution. This study uses a qualitative approach to be able to understand the object of study concretely through their own thoughts and words. The findings of this study indicate that there were no cases of violence among inmates in the form of instrumental attacks, include bullying, domination of power among inmates, fights among inmates, or clashes between inmate groups. However, the expressive type of violence, triggered by emotional response of inmates, happened a few times. The results of the analysis show that inmates in Cibinong Correctional Institution have strong social bonds, which can completely prevent inmates from engaging in instrumental violence among inmates. Meanwhile, expressive attacks can be handled.

Validation and measurement invariance of the childhood trauma questionnaire short form among incarcerated men and women in Spain

BackgroundChildhood trauma is highly prevalent among incarcerated individuals and contributes to a range of negative outcomes. Assessing traumatic childhood events in prison settings requires valid, reliable, and effective instruments. Objectives and methodsThis study evaluated the performance of the Childhood Trauma Questionnaire - Short Form (CTQ-SF), originally developed and validated in English, within a sample of incarcerated men and women (n = 1118 and n = 207, respectively) in six Spanish prisons. ResultsThe results indicated that the CTQ-SF had an acceptable fit in our sample. However, the internal consistency of the Physical Neglect subscale was found to be deficient (α = 0.57), especially among women (α = 0.43). This finding aligns with previous research across different contexts, which may signal weaknesses in the original construction of this subscale. The CTQ-SF demonstrated limited invariance between men and women, with only configural invariance being achieved, constraining the comparisons that can be made across sexes. In the absence of scalar invariance, comparisons of factor means to assess severity may be misleading, and caution is recommended when comparing prevalence estimates for men and women in Spanish prisons. Nonetheless, our findings support the convergent validity of the CTQ-SF, as trauma severity showed moderate correlations with depression, anxiety, stress, and aggression. ConclusionsThese results underscore the importance of evaluating the performance of instruments across various cultural contexts and populations to ensure the validity of study conclusions.

Incidence of hepatitis C virus infection in the prison setting: The SToP-C study.

People in prison are at high risk of HCV given high injecting drug use prevalence. This study evaluated HCV incidence and associated injecting drug use characteristics in prison. The SToP-C study enrolled people incarcerated in four Australian prisons. Participants were tested for HCV at enrolment and then every 3-6 months (October-2014 to November-2019). Participants eligible for this analysis included those at-risk of HCV primary infection (anti-HCV negative) or re-infection (anti-HCV positive, HCV RNA negative) with follow-up assessment. A total of 1643 eligible participants were included in analyses (82% male; median age 33 years; 30% injected drugs in prison; 1818 person-years of follow-up). Overall HCV incidence was 6.11/100 person-years (95%CI: 5.07-7.35), with higher rate of re-infection (9.34/100 person-years; 95%CI: 7.15-12.19) than primary infection (4.60/100 person-years; 95%CI: 3.56-5.96). In total population (n = 1643), HCV risk was significantly higher among participants injecting drugs in prison [vs. no injecting; adjusted hazard ratio (aHR): 10.55, 95%CI: 5.88-18.92), and those who were released and re-incarcerated during follow-up (vs. remained incarcerated; aHR: 1.60, 95%CI: 1.03-2.49). Among participants who injected recently (during past month, n = 321), HCV risk was reduced among those receiving high-dosage opioid agonist therapy (OAT), i.e. methadone ≥60 mg/day or buprenorphine ≥16 mg/day, (vs. no OAT, aHR: 0.11, 95%CI: 0.02-0.80) and increased among those sharing needles/syringes without consistent use of disinfectant to clean injecting equipment (vs. no sharing, HR: 4.60, 95%CI: 1.35-15.66). This study demonstrated high HCV transmission risk in prison, particularly among people injecting drugs. High-dosage OAT was protective, but improved OAT coverage and needle/syringe programmes to reduce sharing injecting equipment are required.

Nudging food choice in a prison setting: an investigation using food choice data.

The prison population presents complex health needs and is disproportionately affected by poor health, compared to the general population. Diet has a clear role in prisoner health, and the prison food environment within which food choices are made is relatively under-researched. The aim of this study was to examine whether food choices in a women's prison changed after the introduction of a new menu design by the catering team. The adjusted menu design incorporated an emoticon (a smiley face) placed next to designated 'Healthy Choice' foods on the menu sheets, which were used to preselect meals. Data comprised all women's (n = 865) food choices (more than 115,000 selections) for a period of 8 weeks (with the new menu) as well as 8 weeks prior (baseline period). The study design was a pre-post intervention study, and food selection was examined using chi-square tests and binary logistic regression models. The selection of promoted foods overall significantly increased under the new menu design (with the emoticon nudge strategy) compared to baseline; the effect size, however, was small according to the usual guidelines (21.4% compared to 20% at baseline; χ2 (1) = 32.6, p < 0.001, φ = 0.02). Individuals were 11% more likely (p < 0.001) to select the promoted 'Healthy Choice' foods under the adjusted food choice architecture. A significant effect was found for lunch and evening meal - but not for desserts. A minority of individual food items that were promoted had significant positive changes in selection, and were 1.3-4 times as likely to be selected when emoticons had been introduced, compared to baseline. Further research is needed to examine the potential added benefit of multiple complementary nudge strategies, and the relevance of the preselection of foods in advance of consumption.