Atenção básica à saúde de apenados no sistema penitenciário: subsídios para a atuação da enfermagem

Objetivo: Descrever aspectos estruturais e caracteristicas do trabalho na atencao basica a saude em penitenciarias masculinas do estado da Paraiba, e fornecer subsidios para a atuacao do enfermeiro nesse cenario. Metodos: Estudo descritivo e quantitativo, realizado em seis unidades de saude alocadas em penitenciarias. Os questionarios foram aplicados aos respectivos diretores das unidades prisionais. Os dados foram analisados sob a otica da estatistica descritiva. Resultados: O consultorio de enfermagem foi considerado o menos adaptado. Cinco unidades de saude nao atendem aos requisitos de acessibilidade. Verificou-se que pequenas cirurgias e planejamento familiar sao implementadas com restricoes. Com relacao a materiais e insumos basicos para desenvolver acoes de assistenciais, o estudo verificou abastecimento satisfatorio. Conclusao: A implantacao do PNSSP parece apontar o fim de uma serie de paradigmas relacionados a saude dos apenados. No entanto, e necessario maior empenho do Estado para eliminar entraves ainda presentes no âmbito da saude penitenciaria.


INTRODUCTION
Several national and international organizations have performed criticisms to the Brazilian prison system, related to overcrowding, small number of actions aimed at rehabilitation and inadequate physical infrastructure and foment the emergence of health problems 1 .Among the representatives of the State, responsible for performing actions and activities in health, there is the recognition of the gaps existing in the penitentiary system 1 .
The high prevalence of infectious diseases in the incarceration setting, important from the epidemiological point of view, such as syphilis, hepatitis B, tuberculosis and pneumonia 2 , assess to the prison system, the status of a public health problem in potential 1 .Faced with such situation, to implement health care directed at this audience, is a sine qua non condition to reverse this worrying scenario.
It is known that for the performance of health actions, especially of nursing, it is essential the existence of physical infrastructure and process appropriate to reality 3 .Nevertheless, unsanitary conditions recognized among prisons, exemplified by poor quality, inadequate physical structure and other items, generate situations of vulnerability among convicts, related to the acquisition of health problems 1 .
It is known that there is still much misunderstanding and misinformation about health in the penitentiary system.The issues related to this matter must be reviewed and redirected in an approach that will encourage a depth, critical and salutary reflection.To act in favor of the rupture of a number of social ties, that involve penitentiary populations, especially with regard to the issue of social rights, including health, has proved a challenge to the development of this study.

THEORETICAL REFERENTIAL
Much of health care in the Brazilian penitentiary system, must be directed to male population, given that there are about 500,000 prisoners in Brazil, 94% male, similar proportion occurs in the state of Paraíba 4 .This situation is related to greater vulnerability of this sex to the authorship of crimes of violence 5 .
In recognition of the gap in health care and aiming to supply such needs for this target population, two specific health policies were created.The first is the National Health Plan in Penitentiary Units (NHPPU), which aims at ensuring access to the Unified Health System (UHS), providing full and universal health care for all those who belong to the prison population in secure detention and both sexes 6 .
To implement the NHPPU, there is funding for the organization of physical structure as current health guidelines and contract of human resources, which includes besides doctor, social worker, psychologist, dentist and dental assistant, nurses and technical nursing, aimed at contributing to the control or reduction of health problems more frequent for 100% of the Brazilian penitentiary population 6 .
It constitute NHPPU targets, the control of tuberculosis, hypertension, diabetes and leprosy, to promote oral health, diagnosis, counseling and treatment for STI/HIV/AIDS and provide mental health care 6 .For the development of these actions, nurse practitioners play a fundamental role, since, as members of the primary care team, the nurse develops activities both at the individual and collective levels, aiming from health promotion and disease prevention, to care actions 7 .
The second initiative is the National Policy for Integral Attention to Men's Health, specific for the male population of the country, which is aligned to the National Primary Care Policy and aims to the integrality of care for this population 5 .
By the time that recognized the need for attention to the specific health prisons, as well as the health problems of the male population as recurrent and important problems to public health 5 , the federal government expanded discussions about monitoring and evaluation in health, culminating in the release of the National Assessment Program of Health Services (NAPHS), delimiting its importance in decisions related to public health policies 8 .Understood as a fundamental part in the planning and management of the UHS, the evaluation of health services is extensive, constituting the axes of analysis: structure, work process, results and user satisfaction 8 .
Considering that the improvement of health care occurs at the level of the work process or structure 9 the present study aimed to describe structural aspects and work characteristics in primary health care in male penitentiaries of the State of Paraíba and provide subsidies for nurse performance in this scenario.

METHOD
This is a transversal descriptive study, with a quantitative approach, conducted in six healthcare establishments, integrated to subordinate male penitentiaries to the State Department of Penitentiary Administration (SDPA) in the state of Paraíba.
For data collection, individual meetings were marked with the directors, within the prisons, where a questionnaire was applied, including questions about structural aspects and work characteristics, adapted from the questionnaire of the Monitoring Project and Evaluation of the Expansion and Consolidation Program of the Family Health Strategy (PROFHS) 10 .
The variables for the evaluation of the structure, referred to physical conditions and the availability of materials and supplies considered necessary in primary care health services.In relation to physical conditions, the main sectors of health units (medicine/psychology offices, dentistry and nursing, Primary health care of convicts in the penitentiary system Barbosa ML, Celino SDM, Oliveira LV, Pedraza DF, Costa GMC pharmacy and toilets) were assessed according to adequacy of physical area, lighting, ventilation and noise.To indicate the suitability, from the perspective of the director of the penitentiary, the attached questionnaire contained two alternatives, yes (to appropriate) and not (to inadequate).The actions performed by health professionals of the penitentiaries system and the use of care protocols were items addressed in work characteristics.Finally, the architectural barriers present in healthcare units were evaluated.
Data were organized into spreadsheets of Office Excel 2003 and the variables compose a database in SPSS 11.0 package (SPSS Inc., Chicago, USA) to allow the statistical analysis of variables.
The study was referred for evaluation and opinion of the Committee of Research Ethics of the State University of Paraíba, which was approved as Certified of Presentation for Ethical Consideration (CPEC) Nº 0400.0.133.000-09,fulfilling the ethical principles listed in Resolution 466/2012 of the National Health Council (NHC).

RESULTS
It was verified that the six health units, belonging to the Penitentiary System of the State of Paraíba, were established just over three years.The number of institutionalized inmates, at the time of this study, was 2827 prisoners and were performed approximately 345 healthcare services, weekly.Regarding to the registration process of convicts in health units, four health establishments (67%) were over 50% of the registered population, whereas the other two (33%) are still in the initial phase of registration.
As for the physical conditions of the offices at health units, those of medicine/psychology showed better adequacy, with an average of 4.0 ± 0.81 and the worst situation belonged to nursing, with inadequate evaluations for at least half of the directors, for the aspects: physical area, lighting, ventilation and noise, being the latter of the worst rating.The pharmacy and toilet obtained mean of 3.0 ± 0.81 and 3.3 ± 1.23, respectively (Table 1).
With regard to architectural barriers of health care establishments, there was inadequate in five (83%), considering the lack of structure to receive individuals with some physical disabilities, particularly wheelchair users, although individuals with these characteristics are present in four units.It was found that three establishments have stairs that hinder access and safe movement of people with reduced mobility, such as wheelchair users, visually impaired and the elderly.
Information about the availability of materials and supplies considered necessary in primary health care services, are found in Table 2.It is observed, in general, sufficiency of the analyzed items.Materials for minor surgeries and prescriptions blocks, of worst assessment, were indicated as insufficient in three units.
It was found that the attendance to spontaneous demand is performed in 100% of health units.As for the actions of primary health care developed within the Penitentiaty System in the State of Paraíba, stands out the diagnosis and treatment of diabetes, leprosy, tuberculosis and hypertension, being indicated by at least five (83%) of the six establishments, and diagnosis and treatment of STI/AIDS in four (67%).Minor surgery and family planning Protocols are performed in only two (33%) and one health unit (17%), respectively, being implemented with restrictions.It was found also, that the use of service protocols, for the development of these activities was indicated, mainly, for the diagnosis and treatment of disease (Table 3).

DISCUSSION
After a decade of existence, the NHPPU is currently present in 23 federal units, including Paraíba 11 .The recent classification of this Plan, which occurred in 2008, reflects the process of implementation at the national ambit, which clearly perceives greater adherence by the South, Southeast and Midwest regions of the country, the latter two in a pioneer way 11 .
Although the qualification of the State of Paraíba to implant NHPPU occurred in 2008, the state became fit only in 2009, corresponding to six years later than the publication of the decree that established the plan 11 .Such facts may reflect in the gaps still existing in health services, implanted in the penitentiary system.
In the State of Paraíba, this fact can be exemplified considering the registration of users, with health units that are still in the registration process of the prisoners, even in the case of a closed population.Although no deadlines for the registration of convicts have been formalized with the health units created from NHPPU, this procedure, through the Primary Care Information System (PCIS), including the use of the number of medical cards for all records, are proposed goals by the plan for the organization and operation of the health information system of the prison population 6 .
It is true that public health in the context of incarceration, collides with the safety logic, which can have a direct influence about administrative aspects, as in the process of registration of prisoners with health units.
In relation to the physical structure for carrying out health actions, it is noticed the discrepancy between what is expected in PNSSP and the reality from performed assessments.In a study conducted in prisons of Santa Catarina, with the aim of identifying the type of insertion of public health policy in the context of the prison population, showed that, only two prisons units had physical structure directed to health care among seventeen surveyed, although all promoted health actions with own or not professional team, demonstrating dissatisfaction among research subjects 2 .
Regarding to other assessed sectors, it is important that the adequacy of the environment to its function is of paramount Primary health care of convicts in the penitentiary system Barbosa ML, Celino SDM, Oliveira LV, Pedraza DF, Costa GMC importance.In this study, nurses' offices had the worst evaluations regarding the size, lighting, ventilation and noise.According to the rules of NHPPU 6 , the nursing offices must be adequate to care practices of this category, as recommended should have area of 7.5 m 2 and contain lavatory.Among the difficulties encountered in the clinical practice of nurses in primary care, are the structural and organizational issues of health units, associating to the fact that the architectural condition are, historically, oriented for centered medical attention 3 .
Limitations about physical structure provides barriers to assistance, as well as interfere negatively about bio-safety of professionals and users of the health unit 9 .Nurse professionals are responsible for consulting and monitoring of various patologies 6 .Thus, the adequacy of their office to the legislation is essential to the execution of effective actions.
In research developed with nurses from the Family Health Strategy of Porto Alegre, subjects pointed to the need for improvement of working conditions as regards the structure of environments, since this aspect greatly affects the quality of actions provided to the users 12 .
Although there is specific legislation and organized related to the provision of health services in the prison system in our country, penitentiaries have not proven adequate locations to provide such assistance 13 .Even in the face of that most Brazilian states are fitted to receive the funding provided by NHPPU 11 .
As verified, four of the six studied prison units have prisoners with some type of disability.These individuals, though incarcerated, should have secured the rights inherent to citizenship of being, such as access to health care.Moreover, as NHPPU, healthcare establishments of the penitentiary system should possess accessibility, understood as the possibility of condition Primary health care of convicts in the penitentiary system Barbosa ML, Celino SDM, Oliveira LV, Pedraza DF, Costa GMC of scope for use, with security and autonomy, of the securities spaces and equipment 6,14 .
In a study that investigated the criminal enforcement and disabled in the light of constitutional mandates, the author reflects about the retro concept mentioned in a parallel with the current context of the Brazilian penitentiary system, and ensures that it would not have dared to infer that there are no conditions even for locomotion of such people, violating a fundamental right of first dimension, to preclude the exercise of the right to come and go 14 .
With regard to the specific actions of primary care, developed by health teams, the results show satisfactory, considering the diagnosis and treatment of diseases and disorders that NHPPU recommends as having priority: diabetes, leprosy, tuberculosis, hypertension and STI/AIDS 6 .
The control of endemic diseases, such as tuberculosis and leprosy, is an important part of the activities of nurses as a member of the primary care team, attending the guidelines of the promotion and protection of health, recommended to basic care network 7 .Accordingly, for these disorders, the NHPPU recommends actions related to active surveillance for early diagnosis, mandatory reporting, supervised treatment and investigation of contacts 6 .
It is important to highlight that, diabetes and hypertension are the most prevalent diseases among prisoners, thus, it is fundamental that the penitentiary system, through the health care team, to provide suitable treatment for those individuals who are unable to look it autonomously 13 .
To the control of these diseases, the NHPPU establishes the development of promotion actions, in search of adopting healthy lifestyle habits, and health care, from clinical monitoring 6 .In this sense, the nurse plays an essential role, because their performance in controlling hypertension and diabetes involves not only by the guidelines and established conducts in nursing consultation, but also by health promotion activities aimed at preventing or delaying the onset of injuries resulting from these chronic diseases 15 .
In a research conducted by Damas 2 , the treatment of such injuries still proves a barrier to health care, in view of the lack of health professionals for dispensing and/or administration of medications.In these situations, these services are performed by prison guard or the medicine is in pose of the convict, the latter being a dangerous option, since the prisoner can make inappropriate use of the drug.
In the scenario of incarceration, the lack of family planning activities may be a problem, especially with regard to male Primary health care of convicts in the penitentiary system Barbosa ML, Celino SDM, Oliveira LV, Pedraza DF, Costa GMC imprisonment, given that men tend to maintain emotional ties with spouses when deprived of liberty.In other prison scenarios, also barriers were noted, related to the use of contraceptive methods, including condoms, leading to unwanted pregnancies and STIs 16 .
It is from these gaps that must be thought and rethought the family planning activities in the prison context.And since conjugal visit is a lived reality, to discuss issues related to responsible parenthood, contraception and STI prevention is becoming more important in the context of incarceration.
For actions in health care are in fact implemented, especially those recommended by NHPPU, is necessary that the health establishment contain an appropriate support material (equipment, tools, materials, supplies and drugs).The availability of materials and supplies for the execution of activities by the multidisciplinary team of health in prisons, contributes to the reduction of health inequities existing in that environment 17 .
About the care protocols, widely used by health staff in prisons, these were created for the purpose of extending responsibility and bond between professionals and users of the healthcare network, to enable coordination of care 18 .
However, in a study about health care in the penitentiary system in the state of Pará, it was seen that the protocols targeted for Tuberculosis and Hypertension were those less present in health units implanted in prisons, although these are the most prevalent health problems among convicts 13 .Accordingly, it is not enough just the creation of care protocols and recognition by NHPPU, is essential to make them present in the daily routine of health units, favoring integrity and consolidation of UHS, from a consideration of the importance between managers, professionals and users 18 .
In this study the material resources have satisfactory levels, according to the interviewees.However, in a survey conducted by Moreira 13 , it is perceived a strong discrepancy between the investments made to health care to prisoners to other sectors, such as the acquisition of safety equipment.

CONCLUSION
Although the publication of NHPPU already exceed ten years, and contribute to the end of a series of paradigms historically constructed in this scenario, such neglect to the health of prisoners, administrative and operational problems can be common, especially in more recently qualified federal units for receipt of funding, such as the state of Paraíba.Despite this state, it is understood to be a pressing need to discuss viable solutions to channel physical structure and organizational aspects, as seen in this study.
It is necessary to adequate the physical spaces of health units so that professionals perform their duties more adequately, with special attention to access the prison population.Organizational aspects, especially the registration of the prison population in health units, should be improved and updated so that it can efficiently achieve the knowledge, prevention, control and treatment of diseases in the context of incarceration, and develop actions of health promotion and assistance directed to the most frequent problems of the prison population.
In that sense, the work of the nursing staff should be able to achieve the goals and actions proposed by NHPPU, in order to ensure the integral care to the institutionalized individual in prisons, including effective pharmaceutical care.It is known that, although safety is the priority in prisons, and that fact may become a obstacle to health care, it is essential that nurses recognize the specificities of the labor process in prisons, maintaining ethical behavior and respecting the principles governing the profession, in order to ensure the right to health and human dignity.
It is considered that the developed research, although it presents limitation of addressing only structural and procedural aspects of health care services as evaluative component, represents an advance in knowledge production about health in the penitentiary system, especially by the lack of studies with such approach.Discussions about health in the prison system should be instigated in educational centers forming human resources for SUS, in view of the apprehension of knowledge and development of skills and competencies, in order to contribute to the proper performance of nurses and other health workers in this scenario.It is also important to foment scientific production in prisons, through initiatives such as the National Agenda of Research Priority.

Table 1 .
Adequacy of sectors of the healthcare units in the Penitentiary System of the State of Paraíba regarding size, lighting, ventilation and noise

Table 2 .
Availability of materials and supplies to perform the actions of primary health care within the Penitentiary System in the State of Paraíba * Information System for Primary Care.

Table 3 .
Primary health care actions developed by health professionals and use of care protocols within the Penitentiary System of the State of Paraíba