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Conteúdo (article):

Acesso e cuidado a saúde de mulheres privadas de liberdade na penitenciária cearense
Access to health care among female prisoners in a penitentiary in Ceará, Brazil
Acesso à saúde de mulheres privadas de liberdade

Resumo
Este estudo analisa o acesso ao cuidado em saúde de mulheres encarceradas no estado do Ceará, rastreando transtornos mentais comuns. Estudo analítico, transversal, de natureza quantitativa, desenvolvido na única penitenciária feminina do Ceará. Participaram 90 detentas, todas com alguma das seguintes questões de saúde: gestantes, puérperas, portadoras de hipertensão arterial sistêmica, diabetes mellitus, tuberculose, sífilis, hepatite B ou HIV/AIDS. Dados foram coletados por entrevista estruturada. Evidenciou-se acesso limitado à atenção à saúde das detentas, violando direitos básicos quando da tutela do Estado. Constatou-se limitações de exames de rastreamento de doenças nas presidiárias quando de seu acesso ao cárcere, principalmente as que não se encontravam grávidas no momento do encarceramento. Houve diferenças entre as distintas condições de saúde analisadas, com prioridade da atenção às gestantes e puérperas. 68,24% das detentas apresentavam risco de Transtornos Mentais Comuns (SRQ>7). Houve correlação positiva entre idade e saúde mental (p=0,0002). Embora exista legislação pertinente de garantia de acesso à saúde no cárcere, o sistema prisional está despreparado para atender as necessidades de portadoras de comorbidades, gestantes e puérperas, deixando-as suscetíveis ao desenvolvimento/agravamento de doenças e com dificuldades no acesso às medicações.

Abstract
This study investigated access to health care among female prisoners in the state of Ceará, Brazil, and screened for common mental disorders. We conducted an analytical cross-sectional study in the only female prison in the state. Ninety detainees participated in the study. All participants were either pregnant or postpartum women or had one or more of the following health problems: hypertension, diabetes mellitus, tuberculosis, syphilis, hepatitis B, HIV/AIDS. The data were collected using a structured questionnaire. The findings reveal that access to health care was limited, violating the fundamental rights of the prisoners. Screening for diseases on admission to prison was limited, especially among non-pregnant women. Differences in health care were found between health conditions, with priority being given to pregnant and postpartum women. Most of the inmates (68.24%) were found to be at risk for common mental disorders (SRQ score > 7). A positive correlation was found between age and mental health problems (p = 0.0002). Despite legislation guaranteeing access to health care in prisons, the prison system is unprepared to meet the health needs of female prisoners with comorbidities and pregnant and puerperal women, leaving them susceptible to the development or deterioration of diseases and with difficulties in accessing medication.


Introduction
The prison population is growing worldwide, with prisoners being exposed to precarious conditions that often preclude them from accessing comprehensive and effective health care1. The situation is no different in Brazil. According to data published by the National Penitentiary Department (DEPEN), the number of detainees in the country is on the rise. In a little under 10 years, Brazil’s prison population has increased by 50.7%, from 496,251 in 2010 to 748,009 in 2019, comprising 711,080 men (95.06%) and 36,929 women (4.94%)2.
The female prison population increased 2.9 times more than the male population (564.2% versus 196.2%)2, reflecting social changes that require ongoing research and reflection.
The incarceration of women has been marked by a history of government omissions, evidenced by the limited number of public policies that consider incarcerated women to be subjects of human and, more particularly, women\'s rights3. The rights of incarcerated women are gravely violated by the state in Brazil, adversely affecting their health, reintegration into society, education, employment, and the preservation of family bonds and relationships4.
Overcrowding of women’s prisons increases the risk of health problems, especially considering that these facilities house a proportion of the socially vulnerable population. Incarcerated women in Brazil are mainly young (aged 18-29 years), black mothers who are responsible for family finances. They generally have a low level of education and income and were self-employed and/or receiving benefits from cash transfer programs such as the Bolsa Família before incarceration2,5. In addition, women’s prisons house subgroups who are at risk for specific health problems (such as HIV/AIDS, HPV, hepatitis B, syphilis and chronic diseases like high blood pressure and diabetes mellitus) and drug users6.
In view of the above and the health needs of the prison population, the Ministry of Justice and Ministry of Health implemented the National Health Plan for the Penitentiary System (PNSSP, Inter-ministerial Order 1777, 09/09/2003). The plan incorporates the prison population into the country\'s public health system, o Sistema Único de Saúde (SUS) or Unified Health System, guaranteeing that the right to citizenship is upheld from a human rights perspective7. The main lines of action proposed by the PNSSP are the control and treatment of tuberculosis, control of hypertension and diabetes mellitus, treatment of skin diseases, especially Hansen\'s disease, oral health care, and women’s health7.
With regard to women’s health, the PNSSP includes antenatal and intrapartum care, cervical and breast cancer prevention and control, contraceptive assistance and immunization, ensuring referral where necessary8. With the aim of maintaining mother-child contact, children are allowed to stay with their mothers in prison in special units, ensuring exclusive breastfeeding up to six months7.
Prison life exposes women deprived of liberty, including pregnant and postpartum women, to vulnerabilities. The precarious social conditions of mothers who give birth in prisons, poor antenatal care, the use of handcuffs during labor, accounts of violence and low ratings for care received indicate that prison health services have acted as a barrier to guaranteeing the rights of this group9.
In addition, there is currently a major epidemic of communicable diseases in Brazil’s prisons, especially sexually transmitted infections (STIs). Data from the National Survey of Penitentiary Information-INFOPEN system for 201710 show that the most common morbidities among female prisoners were HIV/AIDS, syphilis, hepatitis and tuberculosis. These problems are aggravated by poor prison conditions (lack of health information or adherence to health guidance, refusal to use barrier methods, poor hygiene, among others) and social context11.
Other health problems, often resulting from the prison setting, are also reported among prisoners. Indicators of poor mental health, such as feelings of low self-esteem, anxiety, symptoms of depression and body image issues, contribute to negative self-assessment of health. These problems can be experienced by inmates and are included within the spectrum of common mental disorders (CMDs)12.
In view of the health problems facing women deprived of liberty, it is important to understand issues related to access to health care services provided by the penitentiary system among this group, especially in more disadvantaged states such as Ceará in the Northeast of Brazil.
Ceará has 158 prison units, only one of which is a closed women’s prison. The state has the country’s sixth largest prison population, with 21,789 detainees, behind only São Paulo, Minas Gerais, Rio de Janeiro, Pernambuco and Rio Grande do Sul. The number of female detainees in the state grew 129% between 2014 and 2019, from 1,065 to 2,440. Although the number of male prisoners is far greater than the number of female inmates, the male prison population grew at a much slower rate over the same period, from 20,583 to 31,287 (53.1%)13.
In view of the above, it is important to understand the characteristics and needs (sexual and reproductive health, chronic diseases and mental health) of the female prison population. This information is essential to determine the scale of the challenge and ensure adequate planning in order to guarantee female prisoners’ the right to health and design policies tailored to the reality of women deprived of liberty. The aim of the present study was therefore to investigate access to health care among incarcerated women in Ceará and screen for CMDs among this population.

Methods
We conducted an analytical cross-sectional study in the only female prison in Ceará. Prison health facilities include a medical consulting room, obstetrics and gynecology consulting room, dental consulting room, nursing post, ward and storeroom14, which were undergoing reorganization to meet the criteria of the PNSSP at the time of data collection.
At the time of data collection, the prison housed 998 inmates held under a closed system. Information was collected from all women whose health records stated they had been diagnosed with high blood pressure (hypertension), diabetes mellitus, tuberculosis, syphilis, hepatitis B and/or HIV/AIDS, and all pregnant and postpartum women, totaling 90 study participants.
Before data collection, we contacted the Ceará State Public Security Department (SSP), the body that runs the state’s prisons, and explained the purpose and procedures of the study and its importance. We also contacted the prison management and prison health professionals to obtain a list of the women and their health problems. Prison officers were also contacted to request that they accompanied the researchers during data collection to ensure their safety.
The data were collected between September 2019 and February 2020 using a structured questionnaire prepared by the authors based on the study ‘Nascer na Prisão’ (Born in Prison)9, the documents that make up the PNSSP7, SUS guidelines15 and tuberculosis16, diabetes and hypertension17, and STI/HIV-Aids control programs18. The respondents were invited to participate in the study and signed an informed consent form confirming they had been fully informed as to the nature of study and its objectives.
The questionnaire encompassed the following aspects related to the study topic: demographic characteristics (age, education level, place of birth, etc.); socioeconomic characteristics (marital status, religion, beneficiary of the bolsa família program before confinement, etc.); vulnerability (history of violence, health history, etc.); main potential health risks (drug user, history of infectious diseases, smoking and drinking, etc.); access to health services; non-communicable diseases (hypertension –diagnosis, risk factors, treatment, tests, prevention methods, etc. – diabetes – diagnosis, consultation, medication, follow-up, etc. – tuberculosis – diagnosis, consultation, medication, follow-up, etc.); and mental health (administration of the Self-Reporting Questionnaire, used to screen for factors related to CMDs)19.
The study data were organized and analyzed in the light of the relevant literature using Stata 14.1.
The study protocol was approved by the University of Fortaleza’s research ethics committee (code number 2.934.233).

Results
Ninety female detainees participated in the study. There were no refusals. Thirty of the respondents (34.3%) were pregnant (n = 13) or postpartum women (n = 17), 35 (38%) had been diagnosed with hypertension and/or diabetes mellitus (DM) and 25 (27.7%) had been diagnosed with infectious diseases: 15 with AIDS/HIV, two with tuberculosis (TB) and 12 with syphilis. Some women had more than one health problem and/or pregnancy-related condition (Table 1). According to the medical records, none of the detainees had been diagnosed with hepatitis B.
Most of the respondents (n = 65; 72.22%) were brown, 47 (52.22%) were protestants, 50 (50.55%) had not completed junior high school, 54 (60%) had not received support from the Bolsa Família program before confinement, 82 (91.11%) were smokers and 56 (62.22%) were drinkers. Most of the women had been involved in drug trafficking (n = 56; 62.22%) and had been detained at least twice (n = 50; 55.55%).
Concerning health care, most of the respondents received health advice from prison health professionals (n = 69; 76.66%), did not do routine gynecology check-ups (n = 54; 64.44%) and did not use contraceptive methods (n = 80; 88.8%), as shown in Table 1.
Five of the pregnant women (38.48%) had had up to three antenatal consultations. Of the women who had had antenatal consultations, 92.31% (n = 12) had an antenatal card. Four of the pregnant women (30.77%) reported having had some type of abortion. Most of the postpartum women reported that their newborn baby stayed with them in prison (n = 10; 58.82%) and nine (52.94%) had been seen by a doctor in prison (Table 2).
Data on the women with hypertension (n = 35) and DM (n = 11) are shown in Table 3. Twenty-two (57.89%) of the women with hypertension and nine (81.82%) of those with DM were diagnosed before confinement. Twenty (55.26%) of the women with hypertension and four (36.36%) of those with DM reported that they received medication; however, 12 (34.21%) and five (9.09%), respectively, mentioned that there were constant medicine shortages in the prison.
None of the respondents reported participating in health promotion activities (conversation circles, counseling, etc.). Fifteen (42.11%) of the women with hypertension and six (54.55%) of those with diabetes said that they rarely had access to medical consultations.
With regard to infectious disease screening on admission to prison, 30 (32.58%) of the non-pregnant women did not do the rapid HIV test, 60 (67.42%) did not have a hepatitis A test, 60 (67.42%) did not do a hepatitis B test, 33 (32.96%) did not have a syphilis test and 80 (88.76%) did not do a sputum test for tuberculosis (Table 4).
The proportion of respondents with a risk of common mental disorders (SRQ score > 7) due to health problems was 68.24%. This rate was 53.85% among pregnant women and 27.78% in postpartum women, which is considerably lower than in the overall study population.
The findings show a positive correlation between age and mental health problems, with SRQ scores (risk of CMD) increasing with age (p = 0.0002 and rs = 0.3925), and age and length of stay in prison (p = 0.0213 and rs = 0.2424). However, no correlation was found between SRQ score and length of stay in prison (p = 0.5005 and rs = 0.0741) or between categorical SRQ (SRQ score < 7 or >7) and legal and marital status (p > 0.05) (chi-squared test).
Discussion
The findings indicate poor access to health care among the incarcerated women, reinforcing evidence of the existence of violations of the right to health in prisons. The results also reveal limitations in infectious disease screening on entry to prison, especially among non-pregnant women. Considering that access to health care is a universal right enshrined in the Brazilian Constitution and that prisoners do not have access to private health care, the findings reveal poor access to health care among female detainees, violating their fundamental rights. In addition, differences in care were observed between conditions, with priority being given to pregnant and postpartum women, who received better, albeit limited, health care than non-pregnant women.
Health policies began to prioritize women during the first decades of the twentieth century, initially focusing on pregnancy and childbirth care21. This approach appears to have been adopted by health professionals, who tend to focus on the reproductive health of women during training22.
Although Brazil has made significant strides in improving access to pregnancy and intrapartum care, inequities persist, particularly when it comes to care quality, which is generally lower for women with low socioeconomic status20. A large part of the prison population come from socially disadvantaged groups, which is confirmed in our study by the high prevalence of women with a low level of education. In addition to this risk factor, women who go through pregnancy and childbirth in prison are even more vulnerable than other female prisoners9. This vulnerability is aggravated by specific factors linked to giving birth and motherhood in a prison setting23.
While the findings show that pregnant women appear to receive better care than non-pregnant women, other studies show a lack of public policies to guarantee access to comprehensive health care in prisons to this group. The penitentiary system is not fully prepared to receive this group of women, who have specific health needs and require specialist services24.
Our findings confirm this, revealing fragile antenatal care services, with most pregnant and postpartum women reporting a maximum of three consultations, which is well below the six appointments recommended by the Ministry of Health25. Most pregnant and postpartum women did not receive health advice, increasing susceptibility to other health problems (of both women and their babies) and raising questions as to the effectiveness of the state in guaranteeing the health rights of this group, given that incarcerated women do not have the option to use private health services.
Pregnant women in prison settings require special attention, especially when it comes to antenatal and postpartum care. However, health care in prison settings does not uphold the principles of comprehensiveness, responsiveness and humanization governing the SUS26.
Brazilian prisons pose a number of health risks for prisoners, including a range of morbidities such as hypertension and diabetes, which are variables investigated in the present study. According to the World Health Organization (WHO), non-communicable diseases are the leading cause of death worlwide. Medicines and health promotion should be provided in accordance with public health policy recommendations, which should be adopted by multiprofessional health teams27.
Disease prevention and health promotion activities guaranteed under the SUS should be a priority for the female prison population. However, our findings highlight the precariousness of these activities in the prison, including lack of testing and medicine shortages. Despite being mandatory for this population, the findings show lack of screening and poor health care, including shortages of medicines taken regularly for chronic diseases like hypertension and DM, which when not properly controlled can result in health risks and adverse health outcomes. A large proportion of the respondents were smokers, drinkers and/or drug users, increasing the risk of certain health problems. Health professionals are prisoners’ main source of information, and it is important that these professionals develop disease prevention and health promotion activities for inmates to avoid the development and deterioration of health problems. However, this was not the case in the prison analyzed by this study, with more than one-fifth of the respondents reporting that they had not been seen by a health professional in the prison.
Unhealthy conditions and overcrowding are risk factors for infectious diseases, especially for female prisoners28. Women deprived of liberty are susceptible to STIs due to lack of knowledge about sexual and reproductive health and prison conditions, increasing risky behavior among this group29. Lack of health education contributes to lack of knowledge among female detainees about hygiene and body care and facilitates the spread of misinformation and prejudice regarding sexual health and the use of contraceptives, especially when the latter are not properly distributed.
Nicolau et al.30 found that female prisoners were not offered condoms during intimate visits, indicating lack of protection against STIs among this group. The results of our study corroborate these findings, with the respondents reporting poor access to condoms.
To prevent the transmission of STIs/AIDS, public policies should focus on reducing vulnerability to these diseases by providing access to information/health education and implementing support networks to promote early detection and treatment, taking into account the specific characteristics of each population group, including female prisoners31.
Another important finding of this study is the low percentage of rapid HIV, syphilis and hepatitis B tests upon admission to prison and during prison stay, especially among women living with HIV. The Ministry of Health recommends that all inmates should undergo rapid tests for STIs. Our study reveals that most participants did not undergo rapid tests, constituting a risk factor for transmission to other female detainees. This situation in prisons is a serious problem and should be widely discussed in order to reduce its consequences.
The lack of control of women prisoners with HIV/AIDS can facilitate the spread of this disease in jail, placing not only the already infected women at risk but also those who could potentially become infected in the prison environment (through sexual relations, contact with infected blood or other bodily fluids, transmission during childbirth or breastfeeding, etc.)
It is evident therefore that the prison system is unprepared to meet the needs of female prisoners, who live in an unhealthy and overcrowded environment and are susceptible to infectious diseases due to gaps in access to adequate disease prevention and health promotion policies29.
Similar results were found by a scoping review of 49 studies in Africa, which revealed substandard health care provision and prison clinics, characterized by medicine shortages, lack of trained health personnel and routine medical check-ups, limited availability of equipment or lack of basic investigation equipment, and poor gynecological care coverage32. In addition to physical health problems, the resulting prison situation and unhealthy conditions associated with the lack of health actions and poor health services can lead to mental health disorders.
The Pan American Health Organization emphasizes that health problems resulting from confinement can be drivers of psychosocial problems, requiring closer attention from professionals to identify possible mental disorders and alcohol and/or drug use33. Audi et al.34 highlight that prisoners leave prison with prison-acquired physical and mental health illnesses or aggravated pre-existing health problems. The impact of imprisonment on women can therefore trigger mental disorders or aggravate existing problems and affect their ability to look after their children both inside and outside prison, affecting not only their own health but also that of their children.
Prisoners’ mental health is cause for concern in Brazil’s prison system, especially that of female prisoners, who are five times more likely to have mental health problems than non-imprisoned women35. This reality makes the mental health of female prisoners a topic that warrants further in-depth study.
In a study addressing mental health during confinement with 40 female prisoners in a penitentiary in Rio de Janeiro, respondents reported anxiety, stress, depression, changing sleeping patterns, misuse of psychotropic drugs and other legal and illegal drugs, sexual abstinence, precarious prison conditions and family disruption36. Our findings show that two-thirds of the incarcerated women were at risk of CMDs, which is much higher than the average rate among women. However, rates were lower among pregnant and postpartum women.
The literature on non-imprisoned women demonstrates that the rate of CMDs among pregnant and postpartum women is frequently higher than in other women37. Our findings show that this relationship was inverted in the prison, which may be explained by the care imprisoned pregnant and postpartum women receive. These women are separated from other inmates in units that are more suited to pregnancy, the post-partum period and breastfeeding. It may be assumed therefore that if prison conditions and health care were better, there would be lower risk of CMDs and perhaps a better environment for resocialization, facilitating the social reintegration of incarcerated women.
While incarceration increases the risk of CMDs, the findings of the present study did not show a significant relationship between SRQ score and length of prison stay. These findings corroborate the results of a study undertaken with 287 women in a female prison in Porto Alegre, Rio Grande do Sul, showing that symptoms of depression did not increase with increasing length of detention. On the contrary, the findings showed that symptoms were less frequent in women who had spent more than 26 months in prison38.
The situation outlined above underlines that there are still major challenges in improving access to health services and humanizing women’s health care in prisons, despite formal guidance on the provision of comprehensive care in prisons. It is important to highlight that people deprived of liberty should not be deprived of their other rights, including the right to health, enshrined in law as a universal right.
Despite its importance, this study has some limitations. These include potential bias due to the fact that we only interviewed women with the existing conditions outlined above and pregnant and postpartum women. In addition, we had originally intended to investigate a larger group; however, this was made impossible by the onset of the COVID-19 pandemic. We believe that the inclusion of female detainees without existing health problems would have revealed an even more precarious situation in relation to prison health care services.

Conclusion
The findings of this study suggest that the prison system is unprepared to meet the health needs of female detainees. Pregnant and postpartum women do not have access to ideal conditions for labor and childbirth and non-pregnant women are susceptible to the development and deterioration of infectious diseases, as they do not have adequate access to disease prevention and health promotion policies and contraceptives and most do not have routine gynecology check-ups and rapid tests for HIV, hepatitis B and syphilis. In addition, access to medicines and other tests is limited.
Our results indicate that, despite current legislation guaranteeing access to health care for the female prison population, services are limited in quantity and quality. Our findings are new for the region where this study was conducted and have the potential to guide actions to improve women\'s health care in prisons as they show gaps in care provision and the shortcomings of the state, reinforcing the need for dignified and humanized care for women deprived of liberty, as enshrined in law.


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