The physical health of women deprived of their freedom in a prison in the state of Rio de Janeiro

Objective: To identify factors that influence the physical health of women imprisoned in a prison institution in the State of Rio de Janeiro. Methods: A descriptive study with a qualitative approach, undertaken with forty incarcerated women, using semi-structured interviews, subjected to thematic analysis. Results: Factors such as difficulty related to diet, lack of physical activity, sedentary lifestyle, smoking and restriction of exposure to the sun affect the physical health of the women interviewed. Conclusion: Although these women's understanding regarding their own health is conditioned by the absence of diseases, it is fundamental to have public policies that encourage actions to prevent ill health and promote health and comprehensive health care, as, in the daily life of the institution studied, incarcerated women live with difficulties that influence health conditions. Thus, over time, expanded health concepts may emerge that will stimulate better health and living conditions for this vulnerable group of women.


INTRODUCTION
Health is a fundamental right of all human beings, without discrimination based on ethnicity, sex, age or economic, social or cultural condition.It must be understood taking into consideration the existence of factors which determine its promotion and protection.To this end, it is necessary for there to be democratic participative involvement which encourages people -individually and collectively -to seek situations which promote the achievement of good health. 1,2 population's health and living conditions undergo constant influences from factors such as diet, transport, leisure, housing and safety -among others.In considering social, environmental, political and cultural diversity, it is necessary to recognize the various processes which determine the levels of health of people and populations.][3] In prison, the conditions of confinement are determinants for the health-illness process and the relationship between the health problems and needs of the person who is deprived of liberty.5][6][7][8] As if that were not enough, violence is also part of the daily life of women deprived of liberty, almost irreversibly compromising the physical health of this specific group. 9n recent years, the female prison population has increased considerably.In 2014, 37,380 women were in prison in Brazil, representing nearly 7% of the prison population.In 2000 -2014, this population grew by 567.4%, while the male prison population grew by 220.2%. 8Thus, an increase in the female prison population has occurred in recent decades, with the proportion of women imprisoned varying between 2% and 9%. 5Due to this increase, the healthcare provided for women in prison requires strategies in order to encompass the specific characteristics of the female population. 10,11s a result, in order to understand what it is that affects the physical health of imprisoned women, it is necessary to investigate their daily habits and the conditions of the prison system which influence the routine of each one, with a view to implementing actions geared towards the prevention of illness and the promotion of health -as, upon entering the prison system, they may develop health problems or experience a worsening of situations already in place due to the poor conditions found in prisons. 11,12sed on the understanding that the female prison population is vulnerable, the Health Policy of the Brazilian Prison System for Women Deprived of Liberty was created, in accordance with Interministerial Ordinance N. 210, of 16 th January 2014, which instituted the National Policy on Care to Incarcerated Women and Women Discharged from Prison (PNAMPE). 12he objective of this policy was to ensure humanization while prisoners were serving their sentences, along with the right to health, education, food, work, safety, and protection for motherhood, leisure, sport, legal assistance and other human rights; factors which aim to improve the quality of life and of health of the female prison population, prioritizing comprehensive care based on activities of prevention of ill health and promotion of health. 13ence, the study had as its objective to identify factors which influence the physical health of women incarcerated in a prison institution.

METHODS
This is descriptive, exploratory research with a qualitative approach, undertaken in October 2014 -January 2015, with 40 women incarcerated in a women's prison located in the State of Rio de Janeiro.
Initially, from a total of 358 women incarcerated in the prison at the first point of data collection, a simple random selection was made based on the Institution's official list of names.This resulted in the possibility of the inclusion of 45 women for participating in this study.This simple selection was undertaken intentionally, considering the goal of inserting, initially, a number which was greater than 10% of the women imprisoned.The fact of arriving at 45 women and not going beyond this number is explained due to the limitation of the time made available by the Institution for data collection.
Among these 45 women, five were not included, because one was released, two were suspended for reasons of security, one declined to participate in the study and one was transferred to another prison unit.As a result, 40 women participated in the interviews, being accessed based on their respective medical records in the Health Service.
The criteria used for including the participants were: to be interested and to have the physical and psychic conditions to participate in the study, and to have authorization from the prison guards on duty at the time of the holding of the interviews.The following women were excluded: those who, during data collection, did not have medical records in the health service, those who were released or who were suspended for reasons of security, and those who were transferred to another prison unit.
It is necessary to make clear that the health service of the penitentiary system of the Institution studied was a place with various rooms, divided into the dentist's consulting room, the prenatal consulting room, the consulting room for attendance by health professionals, the store-room, a procedure room where injections were given, dressings room, archives department and kitchen area.

Physical women health deprived of freedom
Santos MV, Alves VH, Pereira AV, Rodrigues DP, Marchiori GRS, Guerra JVV In order to get to this outpatient center, it was necessary to go through an iron door which remained closed when not needed.The female prisoners had access to this service only upon written requests to the professionals; hence, it was a self-referral outpatient center.
The interviews took place in one of the rooms available in this outpatient center, a place which was considered appropriate for ensuring that the participants' accounts remained private.Nevertheless, it was possible to observe that many of the women arrived in the outpatient center appearing frightened because they had not sent any written requests for attendance -it being necessary to explain to them that they had been called there to be interviewed, and not for consultations with the Institution's health professionals.
It is important to emphasize that for the undertaking of the study in the prison system to be authorized, the State Penitentiary Administration Department of Rio de Janeiro stipulated compliance with certain conditions for data collection, such as: 1) the researcher's entrance into the prison could only take place after the roll call had taken place; 2) the researcher had to leave one hour before the evening roll call; 3) audio and film recording, photographs and the reproduction of any document whatsoever were prohibited within the prison; 4) limitation on the daily number of interviews; 5) the accompanying of the women by a prison guard upon entering and leaving the outpatient center, for addressing the women safely and undertaking the interviews; 6) the signing of the Terms of Free and Informed Consent was also not permitted, as the above-mentioned governmental body does not authorize the identification of information related to the names of people deprived of liberty.In this case, in the name of the State, the Institution is the body responsible for authorizing and taking responsibility for the incarcerated women's participation in activities involving the study.
Data collection was undertaken by the researcher, based on information found in the medical records, added to those which resulted from the semistructured interview.At the beginning, the researcher presented the research objective and guaranteed the interviewees' anonymity.All responded voluntarily to a script containing open and closed questions.
Considering that the use of an audio recorder was not permitted, the researcher needed to transcribe the answers given to the questionnaires, and to read the transcription made so that the interviewees could hear it and show their agreement or disagreement with the researcher's writing.The researcher, in her turn, sought to ensure the maximum of accuracy in the participants' responses.With the intention of ensuring confidentiality and the interviewees' anonymity, the respective accounts were identified by alphanumerical codes (I1,..., I40).
Content analysis, in the thematic mode, was used. 14Initially, the transcription and checking of the data obtained in the semistructured interviews was undertaken.The phases of analysis occurred through successive readings of the material.Initially, in order to comply with the pre-analytical phase, skim reading was undertaken, the aim being the operationalization of criteria such as exhaustiveness, homogeneity and exclusivity.
For purposes of analysis, after the organization and successive readings of material, characterizing the exploration phase, 14 it became viable to identify the interviewees' feelings regarding their health in their accounts.In the process of association and indicating of differences, it was possible to identify recurring units such as: poor food, absence of physical activity, presence of physical and mental morbidities, use of medications and the demand for the doctor and the nursing staff, as well as participation in physical activities, such as stretching exercises.
So as to promote dialogue, at the beginning of the interview, the following question was put: Are there any problems related to your health which have arisen during the period of your imprisonment?Tell me a little about these problems which affect your health.As a result, numerous issues emerged relating to health as a whole.The present article focusses on physical health, which made it viable to construct two thematic categories, namely: 1) Factors which affect the physical health of incarcerated women; and 2) Actions for preventing women deprived of their liberty from becoming ill. The

RESULTS AND DISCUSSION
Among the women interviewed, participation was mainly from those of reproductive age, totaling 31 women in the age range from 18 to 49 years old.This group characterizes an important social segment for the elaboration of health strategies and actions, as it is the young adult population which contributes to society's active economy. 4,15Regarding race/ethnicity, 23 stated that they were of mixed black/white descent, corroborating information from the National Penitentiary Department, in which there is a predominance of this selfdeclaration. 8Regarding educational level, 10 women stated that they were illiterate, and a further 10 stated that they had not completed their basic education*.Lack of education is a factor which directly influences health, as it hinders the understanding of issues related to prevention of ill health and promotion of health. 16egarding marital status, 21 women indicated that they were single prior to their imprisonment, it being the case that 24 lived with a partner while at liberty; 36 were mothers, the majority of whom had two children.A large portion of the imprisoned women had been abandoned by their family members, friends and partners; this being a factor which makes their life in prison difficult. 17egarding the women's insertion in the job market prior to their imprisonment, 34 women stated that they had worked; of these, only 6 stated that they had had some form of formal work.In relation to family income, 16 stated that they had an income Physical women health deprived of freedom Santos MV, Alves VH, Pereira AV, Rodrigues DP, Marchiori GRS, Guerra JVV of up to one minimum salary, and 13, of two minimum salaries, a minimum salary valuing R$ 724.00 at the time of the research.The lack of formal work and the low family income are factors which contribute to criminality among women. 17,18he National Penitentiary Department, in a 2014 report, stated that women remain imprisoned from five to nine years. 8In this study, it was identified that 3 female prisoners had to serve sentences from one to four years; 18 prisoners had to serve from five to nine years; and 6 women had not yet been judged.As a result, the study identifies the profile of the women interviewed and understands that all will spend a period of their lives in the prison environment.It is necessary, therefore, to create healthy habits within the female penitentiary system such that, once released, these women will not have restrictions due to problems of physical health acquired in the period of imprisonment.

Factors which affect the incarcerated women's physical health
Among the numerous factors which affect the health of women who have been deprived of liberty, the difficulty in adapting to the food offered in the penitentiary system allows one to identify accounts which indicate intolerance and resistance on the part of the interviewees:

Horrible, the food is awful. I eat almost no food, I am very fussy about food. I live on milk and cookies. My cellmate helps me to buy them. (I5)
Poor -there isn't any bread, the food is poor, I get stomach ache.It's very bad, the food offered here is poor, but I eat a lot of junk.(I34)

It is horrible, I don't eat everything, I eat junk in the canteen. (I38)
The majority of people deprived of liberty are more vulnerable and prone to becoming ill.In the case of women, one of the factors which slowly provokes physical illness is, for example, (lack of) weight control, so much so that some presented a tendency for obesity, and others, for malnutrition.The difficulties related to the quality of the food offered are directly related to the standard of consumption and, in their turn, to the appearance of comorbidities, as the fact that the possibility of rejection exists, with the need for substitution, in the majority of cases, provokes a distancing from healthy styles of eating. 19,20n relation to the difficulty related to the quality of the food, the need was reported in the interviews for a diet based on recommendations made by a physician; however, due to the lack of options, some women stated that they accept the food offered by the Institution, as may be observed in the following accounts:

I presented my prescription, I would prefer to eat food based on that diet. (I10) I eat what there is. There isn't anything else. I used to eat in the Garotinho popular restaurant** for R$1.00, so I'm accustomed to it. (I21) This is what prisoners have to eat. (I22)
One of the goals of the National Policy on Care to Incarcerated Women and Women Discharged from Prison (PNAMPE) is to provide -in women's prisons -food which complies with the basic nutritional criteria and dietary restrictions, when necessary; which does not take place, due to the fact that there is no control or nutritional monitoring by a specialized professional, resulting in an inadequate diet when the health of the prisoner presents some weakness needing to be corrected.A balanced diet recommended by a nutritionist promotes the development of healthy habits and can help the women to live with greater health, even when within the prison system, avoiding the appearance of comorbidities. 19,20s a result, the difficulty in guaranteeing specific dietary requirements, along with specified needs, ends up affecting weight control and the parameters of tests, such as, for example, glycemia and lipid panel.In relation to this issue, there are the following accounts:

I have gained 50 kg since my imprisonment. (I2) I have lost a lot of weight [...] Lack of appetite. (I15) I've gotten fat. I live on junk food. (I20)
In this way, factors such as overweight or obesity appear frequently in the interviewees' accounts.As a result, among restrictions related to the acceptance of food, to the need for specific diets which are not offered, to a lack of weight control and difficulties monitoring health and preventing illnesses, it becomes evident that the prisoners live with health problems which become chronic in the adult and older adult phases of life, such as diabetes and hypertension. 20Below, excerpts from accounts resulting from questions on the existence of problems related to physical health, which arose during the period of imprisonment.

I have had hypertension since my imprisonment, and have had my gall bladder removed. (I4) A few things have appeared here, such as hypertension, things which didn't exist before. (I19) I have nothing but problems, with diabetes, hypertension and my eyesight. (I28) I am hypertensive and have a heart problem. (I32) My health is awful, I am hypertensive. (I36)
A large proportion of the adult Brazilian prison population is exposed to various health risk factors, and comorbidities which are prevalent in this group can appear, including hypertension Physical women health deprived of freedom Santos MV, Alves VH, Pereira AV, Rodrigues DP, Marchiori GRS, Guerra JVV and diabetes mellitus.The World Health Organization, incidentally, estimates that the chronic illnesses are the main ones responsible for the high rate of deaths in the world's population.In order to control these conditions, it is necessary to develop health promotion actions, as stipulated by the Public Health Policies for the Penitentiary System, not least because the chronic noncommunicable diseases are pathologies which can be prevented through health actions undertaken by a multidisciplinary team. 13s seen, associated with these morbidities, another important factor -smoking -was present in the daily life of some interviewees.Among these, 27 confirmed that they were smokers, with four reporting that they consumed less than half a packet per day; ten, one packet per day; seven, three packets per day; and six, three packets a day and more.This habit, which is considered harmful for health, was mentioned in the women's accounts, as below:

I smoke a lot of cigarettes (...) When I don't have any, somebody gives me some (I12) I smoke one packet of cigarettes a day, cigarettes help to pass the time. (I20) I couldn't go without cigarettes, I buy cigarettes every day in the canteen. (I25) I love smoking, my family brings me cigarettes and I buy them when I run out. (I30)
The habit of smoking cigarettes is a social problem, and the greater the length of time a person has spent in education, the less they have this habit.It is important to emphasize that smoking is the second most important risk factor in deaths from Chronic Noncommunicable Diseases, being responsible for 71% of deaths from lung cancer. 21As a result, health promotion actions need to be elaborated within women's prisons so that these women may be able to identify and understand that the habit of smoking causes physical diseases, which will bring serious consequences for their quality of life both inside and outside the prison system.
In relation to the communicable diseases, records were identified based on six interviewees who mentioned having some type of Sexually Transmitted Infection (STI).Of these women, four reported having had only syphilis, and two had syphilis and HIV/ AIDS.This information corroborates the data from the report of the National Women's Penitentiary Department, that syphilis and HIV are the STIs which most affect the female population in the national prison system. 8s with the chronic diseases, a large proportion of the Brazilian prison population is exposed to STI/AIDS, as in the case of incarcerated women, who have a history of unprotected sexual behavior, making them more vulnerable to these diseases, 22 as in the example of the 24 interviewees who -when asked about condom use -stated that they had not used them when they were free.
It is possible to perceive that in the group investigated, the majority of the women showed concern with their physical health, mentioning it only as the absence of diseases.This issue can be observed when they refer to seeking the health service for pre-existing illnesses and other comorbidities.It may be noted that they feel a need to understand and resolve their health issues, the demand for medical and nursing professionals being the common focus.Thus, confirming a relationship based in the curativist perspective of health, [13][14][15][16] one can observe, based on some accounts, that there is a focus directed towards individual medical consultations and the use of medications for resolving health-related problems.

I have been to the doctor twice, I feel pain, I get medication. (I4) I have chronic pulmonary emphysema, I have been to the doctor, I get medicine from the nurse when there is any, I have never been attended by another professional. (I6) Yes, because of my blood pressure and the medicine. (I16)
From the women's accounts, it may be observed that they evaluate health as the absence of disease, and use medicalization to resolve their immediate problems.This being the case, the prison system could create health promotion strategies for changing certain habits found in the prison routine, and, through this, could improve this group's living conditions and, consequently, reduce the social inequalities.
However, to a certain point, it can be ascertained that some women show a specific concern related to the improvement of their quality of life, such as: care with food, ingestion of water, and physical exercise.These women find means of resistance and seek alternatives for facing the possibility of falling ill in prison, as can be seen in some reports:

I ask my family to bring nutrients and healthy foods, brown bread, sweetener. (I2) I avoid foods which increase my glycemia, and I am already a diabetic. (I7)
I care for myself, as much as is possible.I eat fruits, vegetables and salads.(I14) I drink a lot of water, and I eat well, I don't eat anything from the canteen, I care for myself inside so that the outside will be well, I do my stretching exercises, I dance, I don't care about the television, I dance a lot and I read.(I40) Physical women health deprived of freedom Santos MV, Alves VH, Pereira AV, Rodrigues DP, Marchiori GRS, Guerra JVV The interviewees indicated some difficulties within the penal system for relating to one's own health, in a perspective which is less curative and more preventive.None of the women mentioned having undertaken a preventive gynecological test or mammography in 2014, a fact which is concerning, because these tests are undertaken in order to diagnose cervical cancer and breast cancer, respectively, at an early stage.These are, therefore, tests which should be part of the Health Program for Women Deprived of Liberty, as the diseases which most kill women from the age of 29 years old onwards are the neoplasias, and after the age of 60 years old, diseases of the circulatory system. 15The prison system needs to understand that a prison specifically for the female population must respond to the specific health needs of women who are deprived of liberty throughout their life cycle, and must not neglect these rights, which are guaranteed by the PNAMPE 12 and by the Brazilian Constitution.
Another difficulty for caring for one's own health during imprisonment, verbalized by the women, was related to the daily period of exposure to the sun, recognized as occurring in an open environment, supervised by inspectors from the penitentiary administration.However, when this study was undertaken, the interviewees showed lack of interest in making use of this time.It may perhaps be possible to infer that the possibility of episodes of violence and, to some extent, the inexistence of the scheduling of some form of directed physical activity, may contribute to a certain resistance on the part of interviewees to leaving their cells, as may be seen in the following accounts: The reality shown through the interviewees' accounts is that this time period, on the majority of occasions, is not used for carrying out guided activities, this even being regulated by the Institution with specific days for happening, thus failing to ensure the right to leisure and sport for women who are deprived of liberty, as stipulated by the National Policy on Care to Incarcerated Women and Women Discharged from Prison (PNAMPE).
As a result, exposure to the sun is presented as a moment which does not arouse interest and does not even viabilize the undertaking of activity related to leisure.However, daily exposure to the sun, physical activities, and leisure, are actions which are encouraged little, or which are difficult to implement in the prison system.Even so, it is worth remembering that these are essential for promoting quality of life, social inclusion, citizenship and human development, and that their results bring benefits for physical and mental health. 23 a result, efficacious strategies for overcoming unfavorable health conditions must be implemented, with a view to creating healthy living habits, including: discouraging tobacco consumption, offering physical activities monitored by qualified professionals and diets produced in accordance with the guidance of nutritionists, an environment with as little institutional stress as possible, and activities which encourage self-esteem and occupying the periods of enforced idleness of the incarcerated women.
Furthermore, the absence of adequate monitoring of the prison population's health conditions allows one to indicate the fact as an important factor conditioning health which has been neglected, when it should be a priority of the State's policy.It is inferred that the absence of this specialized and appropriate monitoring ends up worsening the quality of life in the prison system.Hence, while the woman is imprisoned, her custodianship falls to the State, meaning that the prison body is responsible for determining and implementing actions which aim for quality of life and the prevention of health problems in the health of the female prison population.
This study dealt with specific issues related to the health of women within the prison system, making it viable to reflect as to at what point some contradictions have negatively affected these women's health.However, it is important to stress some limitations which make it hard to generalize, and cause there to be a need for further investigations.Besides having been a study limited to 40 interviewees in one female prison in the State of Rio de Janeiro, Brazil, there are other aspects which need to be taken into consideration: the bureaucracy, established institutionally for achieving authorization of the study; the prison system's failure to authorize the guaranteeing of the signing of the Terms of Free and Informed Consent, required for research with human beings; prohibition from making recordings; the need to make written records in the interviews, and the researcher's difficulty entering the institution, it being necessary to undergo daily inspections and searches.

CONCLUSION
Upon analyzing the health of the imprisoned women, based on records emphasized in their own accounts, it was possible to observe that there were difficulties in the routine of the present institution which negatively influence the women's physical health conditions, ranging from difficulty related to food, smoking, sedentarism, lack of weight control, forced idleness and limitations on directed physical activities, through to the daily exposure of the body to the sun.Even though it is not possible to make generalizations, the study made it possible to infer that the present institution is presented as a locale which is prone to the existence of chronic degenerative and communicable diseases such as, for example, hypertension, diabetes, syphilis and HIV/AIDS.Hence, institutional interventions related to the encouragement of self-care and to the protection of one's health need to be implemented, as avoiding the appearance of morbidities related to the period of imprisonment could be a decisive point for the woman's return to the labor market and to normal life.

Physical women health deprived of freedom
Santos MV, Alves VH, Pereira AV, Rodrigues DP, Marchiori GRS, Guerra JVV Furthermore, it is necessary to take into account that imprisoned women have the right to health, like other citizens, in accordance with the National Policy on Care to Incarcerated Women and Women Discharged from Prison.Specifically, this leads to questions which aim to achieve changes related to the health conditions of the female prison population and to the institutional structures.Thus, it is based in this process that, in the long term, expanded conceptions of health could contribute to the operationalization of actions related to the prevention of poor health and the promotion of health, in a comprehensive way, of imprisoned women.
For this to happen, however, it is necessary for the prison management to be aware of the health needs of the women who are deprived of liberty and that together they may define and organize actions which promote health within the female prison system, thus creating a new culture of health for all the participants.
Very rarely.I don't like to.I don't like the sun much.(I5) No, I don't like going to the yard.(I8) I don't get any sunlight.I don't like going down there, it causes fights.(I14) I don't like it, I go twice a week.(I22)I don't go there, there are people there who are too different from us). (I36) study was approved by the Research Ethics Committee of the Fluminense Federal University (UFF) under protocol N. 696.795/2014 and Certificate of Ethical Consideration (CAAE) N. 27061114.3.0000.5243,and was authorized by the State Penitentiary Administration Department of Rio de Janeiro in accordance with Process E-2108753/2014, complying in both cases with Resolution N. 466/2012 of the National Health Council, which regulates research involving human beings.