Health care for incarcerated women: analysis based on the Theory of Basic Human Needs

ABSTRACT

Objective  To analyze how incarcerated women perceive their health care using Wanda de Aguiar Horta's Theory of Basic Human Needs.

Method  a descriptive and exploratory study using the qualitative method, conducted with eight women who answered a semi-structured interview. The material resulting from the interviews was interpreted according to Bardin's content analysis and based on Wanda Horta's Theory of Basic Human Needs.

Results  Two thematic categories emerged: impaired basic human needs and what do women think about health care? The non-attendance to psychobiological and psychosocial needs was observed through reports of unhealthy environment, excessive number of women in the cell, diseases presented and inefficiency regarding health care.

Conclusions and implications for practice  In addition to safety, improvements in confinement conditions and access to health care should be taken in account in order to meet basic human needs. The study contributes to the reflection on the health care of incarcerated women, giving visibility to the theme.

Keywords:  Prisons; Delivery of health care; Women's health; Nursing theory

RESUMO

Objetivo  analisar como as mulheres encarceradas percebem a sua assistência à saúde utilizando a Teoria das Necessidades Humanas Básicas de Wanda de Aguiar Horta.

Método  estudo descritivo e exploratório com utilização do método qualitativo, realizado com oito mulheres que responderam a uma entrevista semiestruturada. O material resultante das entrevistas foi interpretado de acordo com a análise de conteúdo de Bardin e fundamentado na Teoria das necessidades humanas básicas de Wanda Horta.

Resultados  emergiram duas categorias temáticas: necessidades humanas básicas prejudicadas e o que pensam as mulheres em relação a assistência à saúde? Observou-se o não atendimento às necessidades psicobiológicas e psicossociais, através dos relatos de ambiente insalubre, número excessivo de mulheres na cela, doenças apresentadas e ineficiência quanto a assistência à saúde.

Conclusões e implicações para a prática  devem ser levados em consideração, além da segurança, melhorias nas condições de confinamento e acesso à assistência em saúde, para que as necessidades humanas básicas sejam atendidas. O estudo contribui para a reflexão acerca da assistência à saúde das mulheres encarceradas, dando visibilidade à temática.

Palavras-chave:  Prisões; Assistência à saúde; Saúde da mulher; Teoria de enfermagem

RESUMEN

Objetivo  analizar cómo las mujeres encarceladas perciben su atención médica utilizando la Teoría de las Necesidades Humanas Básicas de Wanda de Aguiar Horta.

Método  estudio descriptivo y exploratorio utilizando el método cualitativo, realizado con ocho mujeres que respondieron un cuestionario semiestructurado. El material resultante de las entrevistas se interpretó de acuerdo con el análisis de contenido de Bardin y se basó en la Teoría de las Necesidades Humanas Básicas de Wanda Horta.

Resultados  surgieron dos categorías temáticas: necesidades humanas básicas deterioradas y ¿qué piensan las mujeres sobre la atención médica? La falta de atención a las necesidades psicobiológicas y psicosociales se observó a través de informes de entorno insalubre, número excesivo de mujeres en la celda, enfermedades presentadas e ineficiencia en la atención de la salud.

Conclusiones e implicaciones para la práctica  es necesario considerar cuestiones inherentes a la seguridad, mejorar las condiciones de confinamiento y garantizar el acceso a la atención médica para satisfacer las necesidades humanas básicas. El estudio contribuye a la reflexión sobre la atención médica de las mujeres encarceladas, dando visibilidad al tema.

Palabras clave:  Cárceles; Cuidado de la salud; Salud de la mujer; Teoría de enfermería

INTRODUCTION

Women in prison are more affected by health problems than the general female population.¹ Data from the National Penitentiary Department (Departamento Penitenciário Nacional, DEPEN) show that Brazil has the fourth largest female prison population in the world, behind only the United States (211,870 inmates), China (107,131), Russia (48,478). The growth rate of the female prison population has increased more than the male. In Brazil, there was an increase of 656% between 2000 and 2016, while male growth was 293% in the same period.²

The intensification of the incarceration of women in Brazil has drawn attention to several problems that are related to gender inequalities and the need to reduce the different forms of violence that multiply in prison and imply serious damage to the health of this population.³

It is known that confinement presents a hostile, unhealthy environment and that the increase in the prison population means a high risk for the onset of diseases, such as communicable diseases such as tuberculosis, leprosy, syphilis and HIV infection.⁴

Inmates' health conditions are precarious, and care is inadequately provided.¹ It is known that people who live in prison in Brazil do not have guaranteed their basic rights necessary for a dignified and healthy life. This is due, among other factors, to the lack of association between the legislative, executive and judicial powers, resulting in the absence of public policies that guarantee the fulfillment of the basic human needs of prisoners.⁵

Regarding to health policies aimed at women deprived of their liberty, they also have gaps regarding their effectiveness. In 2014, the National Policy for Attention to Women in Situation of Deprivation of Liberty and Prisoners from the Prison System was promulgated. This policy aims to adopt norms and procedures appropriate to the specificities of women regarding issues of gender, age, sexuality, education, maternity, religiousness, among other aspects relevant to women. However, this policy is vulnerable, in the intersectoral aspect, since the Ministry of Health is not mentioned in the text.⁶

Although this policy contributes to the end of a series of historically constructed paradigms, such as the neglect of the health of incarcerated women,⁷ there are still many obstacles, such as institutional barriers, prison overcrowding, discrimination against the imprisoned population, sometimes involved in technical and bureaucratic nuances, thus affecting the right to health.⁸

It should be noted that the health of women in prison is an old problem and little or almost no attention has been received from the Government. For women deprived of their liberty, care primarily presents actions related to maternity, making health care fragmented, with the primary aim of restricting the sexuality of prisoners.⁹

It is known that the National Policy of Attention to Women in Situation of Deprivation of Liberty and Prisoners from the Prison System aims to guarantee the humanization of the conditions of serving the sentence, protecting in addition to the right to health and motherhood, the right to education, food, work, legal assistance, among others. However, some studies have shown that in practice there is no effective enforcement of the policy, showing itself to be insufficient, including in guaranteeing women's reproductive and parental rights.^3-6

In this perspective, greater attention is needed to promote the health of women in prison. The questions related to this topic need to be reviewed and redirected.⁷ But, for this to happen, it is essential to understand what women in prison think about the health care they receive in order to plan actions aimed at improving health conditions in women's prisons.

In addition, studies on women prisoners have been mostly concerned with social representations of female crime, socio-demographic profile of women in prison, circumstances related to entering the prison system, maternity and religiousness in prison. When research deals with health-related issues, they refer primarily to the sexual and reproductive health of women in prison.¹⁰ Thus, from searches in scientific databases, there was a lack of studies published in the health field in Brazil on the health conditions of women living under the prison system.

In view of the above, the Theory of Basic Human Needs, by Wanda de Aguiar Horta, appears to be adequate as a theoretical contribution because it aims to meet human needs in the health-illness cycle at any stage of life. According to Horta, basic human needs, when not met, cause hemodynamic instability in the life cycle. According to the theory, human needs can be categorized into psychobiological, psychosocial and psychospiritual.¹¹

In this sense, the objective of this work was to understand the perception of incarcerated women about the health care offered in a public prison in Ceará, guided by the Theory of Basic Human Needs of Wanda de Aguiar Horta.

METHOD

Descriptive study, with a qualitative approach, carried out in the municipality of Iguatu, a city located in the south-central state of Ceará, classified as a pole municipality in the 18th health region and part of the Health Macroregional of Cariri.

Data collection took place in a public prison in Ceará, a mixed unit, composed of 13 cells, of which only one was female. The maximum capacity of each cell is five people. At the time of data collection, there were 12 women incarcerated.

Eight inmates participated in the study. Regarding the others, three refused to participate and one did not meet the inclusion criteria, namely, women in a closed regime for at least five months. Those who were in a provisional situation, that is, those who have not yet been tried for criminal execution, were excluded.

Data collection took place in August 2018. It was obtained through semi-structured interview containing guiding questions, in order to answer the disturbing questions of this study “How do you evaluate the permanence of women in the public prison?; How do you perceive the health care provided? How should health care be provided?” Preceded by a structured form for the socioeconomic characterization of the participants.

Data collection was carried out in the prisoners' cell, where they were interviewed individually. Audio recordings were prohibited inside the chain. Thus, the answers given to the questions were transcribed, with later reading for the interviewees in order to demonstrate agreement or disagreement. It is worth noting that there was a concern to ensure maximum precision in transcribing women's responses.

Research participants were protected from anonymity through the use of codes. Each interviewee was individually named M1, M2, M3 and so on.

The qualitative interpretation of the data was carried out using the content analysis technique,¹² in three stages, namely: 1) Pre-analysis – reading and rereading the descriptions obtained from the guiding questions; 2) Exploration of the material - in this phase, the material analyzed was classified according to its meaning, so that we can elaborate the thematic categories; 3) Treatment of the obtained results and interpretation - results were clipped for the identification of the units of meanings with subsequent interpretation of the obtained findings.

To support the analysis, Wanda de Aguiar Horta's Theory of Basic Human Needs was used. This theoretical framework was considered to understand that the human being has basic human needs, among them psychobiological, psychosocial and psychospiritual resulting from the interaction between the internal and external environment. These interactions can generate states of balance and imbalance with time and space.¹¹ Therefore, the selected theoretical framework allows the comprehension of the human being in an integral way, identifying different types of needs that can be changed in the health-disease-care process.

This study followed the Guidelines and Norms of the Research Involving Human Beings, regulated by Resolution 466/12 of the National Health Council^13, being approved under protocol number 2,755,595, CAAE: 87070518.7.0000.5055, on July 4th, 2018.

RESULTS

Eight women aged between 18 to 28 years (3), between 29 to 39 years (3), 40 to 50 years (1) and over 50 years (1) were interviewed. As for education, four had incomplete primary education; three, complete elementary school and only one completed high school.

Four declared to be married or in a stable relationship, three are single and one is divorced. Seven interviewees have children, one child (2), three children (1), five children (2), more than five children (2).

The interviewees were also asked about the activity performed before the arrest. One said she was a housewife, while seven women reported having paid jobs, two of whom were domestic servants, two salespeople, an elderly caregiver, a general services assistant and the other reported not doing formal work.

Women are incarcerated for drug trafficking (6), theft (1), homicide/concealment (1). As for detention time, five months (1), six to eleven months (4), one to two years (2) and more than two years (1). It is noteworthy that four women are repeat offenders, and none receive social benefits and/or perform paid activity in prison.

Two categories of analysis emerged from the interviews: a) Impaired basic human needs and b) What do women think about health care?

Impaired basic human needs

In this category, the perception of women in relation to guaranteeing basic needs in the prison system will be exposed, based on their daily living conditions.

According to the interviewees' statements and considering the theory of Basic Human Needs by Wanda Horta, it is evident that the needs at the psychobiological and psychosocial level are not being met in the public chain, as shown in Chart 1.

Chart 1
- Relationship between the Theory of Human Needs and women's statements. Iguatu, CE, Brazil, 2018.

Theory of Basic Human Needs		Women's speeches
Level	Type
Psychobiological	Nutrition	Here comes lunch, we eat, those who like it, eat it, those who don't like it, don't eat it (M1). I don't like the food here (M2). We only have the basic food, which is snack, lunch and dinner (M3).
Psychobiological	Body care	The clothes you bring from home, hygiene products are from home, the hygiene here is not good at all (M1). The hygiene materials we all bring from home, we depend on family members (M3). Hygiene things come from home, but sometimes we receive donations from the people (M4).
Psychobiological	Environment	Cleanliness is bad. The cell is dirty, hot, has cigarette smoke. There are some girls who smoke (M2). It's not clean. There's a lot of fly (M6).
Psychobiological	Painful perception	I have pain in my right arm, and it started here, after I started in the kitchen, there are over 150 lunch boxes a day, to wash (M2).
Psychosocial	Safety	You should have everything, have a gynecologist, nurses, doctor, social worker... the Government has money for that! (M1). There is no medical care. Come and see us, know if at least you're alive (M6).
Psychosocial	Environment/space	Here it is full. There are always more women than it fits (M5). Here it is full. There's a lot of women. It's uncomfortable (M6).
Psychosocial	Love/security	I only see people wanting to come and tear down the cells to get us out of here and send them somewhere else, away from our family (M1).

Regarding the need at the psycho-spiritual level, it was not mentioned in the women's reports. During the interviews, only the psychobiological and psychosocial needs were mentioned.

Another category identified through the interviews was: what do women think about health care.

What do women think about health care?

When asked about health care all the inmates said there was none, some reported that they were sporadically visited by a doctor, but that there is currently no care.

I don't see anyone here, neither a doctor nor a nurse (M1).

During that period, the doctor came here, but now, nobody come (M2).

No... I never even saw them here. Girls who have been around for a long time also only complain about this lack (M5).

They do not come here, when we feel things, call the agent, and say what we are feeling, they take us to the hospital or the UPA, but only if they are very sick (M5).

Regarding health problems, four women reported having arterial hypertension, respiratory diseases and depression, in addition to pain complaints.

I have high blood pressure [...] (M1).

Tiredness, because of a shot I took on the throat (M6).

I have sinusitis, and it gets worse here, because of cigarette smoke and the heat here (M8).

Some inmates claim to have aggravated or acquired the health problem during confinement. Interviewee M8 mentioned the worsening of sinusitis, as seen in the previous speech. As for the diseases that arose after incarceration, M3 says he developed depression.

I have a depression problem, which started after I got here (M3).

Another issue addressed was the use of medicines. Most say they use painkillers, muscle relaxants, nasal decongestants, as well as natural remedies, such as lickers. One mentioned using antihypertensive drugs and another controlled medication. Two women reported how they acquire medications.

I order to buy paracetamol and Amitril (M1).

They only give pain medication, when they give it (M4).

The performance of the gynecological exam also emerged through the reports. Seven women do not take the exam often and one never did. It was clear from the statements that there is no incentive or promotion of this practice during confinement.

I did it, I only did it when it was for me to be operated of the perine (sic), after I did it, never again and I have been here for a while (M2).

It's been a long time, but I still take care of myself, I wash myself with mastic soap, you know the mastic soap that is very good (M3).

It's been two years since I last did it and it didn't show up here either (M4).

Woman, do you believe that I never did it in my life? (M7).

Given this, the desire of the prisoners in relation to health care is highlighted. In their statements, they demonstrate the need for assistance related to basic conditions.

It should take care [...] it took one day, two, the next two more, to the doctor; it should be like that, make the record and take us (M3).

Ah, there should be a doctor... you, nurses... at least once a month [...] (M4).

The way the girls spoke. We don't have a vaccine... it came to a time when these vaccinations occurred, but then everything disappeared (M6).

DISCUSSION

Corroborating with the sociodemographic data of the current research, other studies also show young prisoners, of reproductive age, with low education, exercising low qualification activities before confinement, the majority being incarcerated for drug trafficking.^2,4,14

As causes for the involvement of women in drug trafficking, there is the socioeconomic and demographic profile, as well as affective involvement with their partner. After their partner is arrested or murdered, women begin to command criminal organizations, in continuity to the functions performed by their partners, pursuing criminal actions. Thus, they are considered “owners or managers of the drug den”.⁹

In addition, there is female single parenting. Many women, before being arrested, are responsible for the family, raising children and maintaining the home. Allied to this factor, the low socioeconomic condition, leads these women to enter the drug traffic, with money being the main influencing factor.¹⁵

With regard to basic human needs, it is known that confinement leads to the interruption of family relationships, especially with the children, which can lead to sadness and depression, in addition to concern for the care of the children. Many women are afraid of being transferred to penitentiaries with a distant location from their relatives, resulting in non-fulfillment of psychosocial needs.

Regarding basic human needs at the psychobiological level, women have difficulty with the adequacy and acceptance of the food offered in prisons, as well as the unhealthy environment, with poor cleaning, overcrowding and poor ventilation, making the place unsuitable for well-being and prisoners' health.⁴

Basic human needs are interrelated and universal, so they are common to all human beings. What varies from one individual to another is its manifestation and the way to satisfy or attend to it. Numerous factors interfere in the manifestation and attendance, among them can be mentioned: individuality, age, gender, culture, education, socioeconomic factors and the physical environment.¹¹

Regarding the environment, the structural conditions of prisons generate basic unmet human needs. For Wanda Horta, people have basic needs that must be satisfied to provide well-being. It is known that failure to meet the needs of human beings generates imbalances, which, when not corrected, directly interfere in the health-disease process.¹¹

In the current survey, respondents reported cardiocirculatory, respiratory and allergic complaints that emerged or worsened after confinement. These diseases can be considered manifestations of not meeting the needs of a psychobiological and psychosocial level.

It is known that Brazilian prisons have both structural and procedural deficits, reflecting the health of confined people. Aspects such as laziness, overcrowding, precarious architecture, unhealthy environment, in addition to the small number of professionals dedicated to health, social work and education, feed the stigma and act as potentiators of different inequities and diseases.¹⁶

Regarding the shortage of health professionals in prisons, oneissue that deserves attention and health concern is the low number of consultations in the system prison. Among the causes, the stigma related to prisoners, as well as the low wages paid to professionals and inadequate working conditions, can be cited.⁵

Among the working conditions that hinder assistance, the insufficient number of correctional officers and the dependence on carrying out the actions to accompany them, generates delay in care and risk to the professional's life. In addition, the difficulty in accessing some services and procedures that are performed outside the units, the lack of material resources and inadequate physical structure compromise health actions.¹⁷

With regard to women, the inefficiency in relation to assistance brings some peculiarities that further worsen the health condition, such as the absence of a gynecological exam, the failure to perform reproductive planning, deficient prenatal care, in addition to the absence of accompaniment of inmates who are in the climacteric. It was observed with the current study that women's access to health care was already deficient before confinement, worsening after imprisonment, which leads to reflect on the need for changes in the prison system, so that basic needs are met of the women.

Health care for the prison population is neglected. However, it should be a priority for the State. The lack of effective monitoring has an impact on health, worsening the quality of life inside the prison. Thus, while the woman is in prison, the Government must take responsibility for the implementation of actions to prevent injuries and promote the health of women deprived of their liberty.⁴

According to the National Health Plan in the Penitentiary System, in penitentiaries with more than 100 detainees, a permanent multidisciplinary team must be provided - which must be composed of a doctor, nurse, dentist, social worker, psychologist, auxiliary nursing and dental assistants - working 20 hours a week. In units with fewer than 100 detainees, professionals from the network should be appointed to provide weekly assistance.⁸

However, contrary to the recommendations of the National Health Plan, in the Penitentiary System, detainees are not assisted by a multidisciplinary team, a fact that makes it difficult to monitor pathologies prior to incarceration, early detection of health problems that arose or worsened during confinement, as well as carrying out educational activities.

Failure to provide health care for detainees can lead to states of imbalance, leading to disease. For Horta, these states can generate clinical manifestations, that is, health problems that require direct intervention, defined as nursing problems. Nursing, in turn, is a science that integrates the health team, being responsible for the reversal of imbalanced states in dynamic balance in time and space, through nursing care and meeting basic human needs.¹¹

It is observed that in many prisons access to health services is controlled by the hierarchy of prisoners and jailers, which is often unfair and granted according to non-health criteria. Prison officers make an informal assessment of the complaint and decide, based on personal criteria, whether or not to send the prisoner to the health service, resulting in a control of access to services.¹⁸

In addition to this, the supervisory role of human rights organizations and defenders, such as the Public Ministry, the public defender, non-governmental organizations and parliamentary commissions are faced with the indifference of those responsible and the inertia of the institutions.¹⁸

Regarding access to medications, a previous study carried out in Rio de Janeiro was similar, while detainees considered that access to medications is deficient. They reported that medications are not available in the prison, and the family has to pay for the treatment. There are times when family members are unable to afford medicines, including those for continuous use.¹⁹

It is known that the non-treatment of acute or chronic conditions or the delay in its onset, will cause an overload in health services, by worsening the clinical condition, causing admissions to urgent and emergency services, as well as in the entire assistance network. The vulnerability of persons deprived of their liberty, makes the Government also vulnerable. Controlling the aggravations in the prison system becomes an urgent health need.⁵

Thus, it is necessary for the prison population to be observed by the SUS, in a universal, integral, resolutive and continuous manner, through adequate financial investment, as well as improvements in the structural conditions of prisons and implantation of prison health teams, meeting the basic human and health needs of women in prison.⁵

The creation of favorable conditions will provide assistance and meet basic human needs, recovering, maintaining and promoting health, as recommended by the Wanda Horta’s Theory of Basic Human Needs.

It is noteworthy that nursing theories, among them that of Wanda Horta, should contribute to good assistance, as well as to the strengthening of nursing as a science, and should be applicable in professional practice, improving the health standards of the prison population. Thus, the use of theory made it possible to reflect on the precarious conditions in which the prisoners live, seeking an approximation between theory and practice, as well as giving scientific support to the results found in the research.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

It was found that health care in the studied public chain, in the perception of incarcerated women, is precarious. It is not only lacking assistance to the specificities necessary for the female sex, there is also a deficiency related to basic assistance, such as adequate food, clothing, hygiene products and medicines, resulting in the non-fulfillment of psychobiological needs, in addition to the psychosocial needs arising from interruption of family relationships related to incarceration. It is worth mentioning that there was no mention of the needs at the psycho-spiritual level, by the interviewees.

It is necessary to reinforce that the female prison population, which demands specific attention, taking into account their social and cultural singularities, these are determining factors in the planning of actions that must be carried out. This population must be fully assisted and be part of systemic health care actions.

Greater visibility to the problem and improvement in conditions of incarceration are necessary. In addition to safety-related requirements, improvements in confinement conditions and access to quality health care should be considered.

The study presented as a limitation the collection in only one place and the non-recording of the interviews, as required by the public chain administration.

It is believed that the results presented may contribute to the reflection on health care for incarcerated women, as well as to give visibility to the theme so that women can have their basic human needs guaranteed.

It is believed that the articulation between the Government, social movements, the population in general, the penitentiary system and health professionals can provide actions directed to this public that aim at quality health care. In addition, it is important that everyone involved is aware of the existing legal provisions for realizing the right to health and guaranteeing basic human needs.

Universities could also contribute to health promotion with regard to the prison population, through the development of academic research and extension activities, clinical health care and educational and legal support. With regard to the current study scenario, there are public and private universities allocated, which could be included in assistance to the prison population.

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Edited by

• ASSOCIATED EDITOR:
  Ana Luiza de Oliveira Carvalho

Publication Dates

• Publication in this collection
  09 Apr 2020
• Date of issue
  2020

History

• Received
  10 Nov 2019
• Accepted
  09 Feb 2020