ABSTRACT

Objective:

to understand the Generalized Resistance Deficits of people deprived of liberty with hypertension in a Brazilian prison unit.

Method:

qualitative research, anchored in Salutogenesis, carried out with 38 people with hypertension from a Brazilian prison unit, from February to July 2022, with a semi-structured interview with open-ended questions, whose analysis was thematic, explaining the limitations to health in prison.

Results:

13 Generalized Resistance Deficits were reported, mostly related to the prison environment and, to a lesser extent, to the social group and the individual, respectively. Living in prison for people with hypertension implies living with a high number of Generalized Resistance Deficits, accentuating the movement towards the disease pole.

Final considerations:

knowing Generalized Resistance Deficits allows directing health promotion to support the use of available Generalized Resistance Resources and contributes to the expansion of intersectoral policies.

Descriptors:
Prisoners; Prisons; Health Promotion; Salutogenesis; Adult Health

RESUMEN

Objetivo:

comprender los Déficits de Resistencia Generalizados de personas privadas de libertad con hipertensión arterial sistémica en una unidad penitenciaria brasileña.

Método:

investigación cualitativa, anclada en la Salutogénesis, realizada con 38 personas con hipertensión arterial sistémica de una unidad penitenciaria brasileña, de febrero a julio de 2022, con entrevista semiestructurada con preguntas abiertas, cuyo análisis fue temático, explicando las limitaciones a la salud en prisión.

Resultados:

se reportaron 13 Déficits de Resistencia Generalizados, en su mayoría relacionados con el ambiente penitenciario y, en menor medida, con el grupo social y el individuo, respectivamente. Vivir en prisión para personas con hipertensión arterial sistémica implica vivir con un elevado número de Déficits de Resistencia Generalizados, acentuando el movimiento hacia el polo de la enfermedad.

Consideraciones finales:

conocer los Déficits de Resistencia Generalizada permite orientar la promoción de la salud para apoyar el uso de los Recursos de Resistencia Generalizada disponibles y contribuye a la ampliación de políticas intersectoriales.

Descriptores:
Personas Privadas de Libertad; Cárcel; Promoción de la Salud; Salutogénesis; Salud del Adulto

RESUMO

Objetivo:

apreender os Déficits Generalizados de Resistência de pessoas privadas de liberdade com hipertensão arterial sistêmica de uma unidade prisional brasileira.

Método:

pesquisa qualitativa, ancorada na Salutogênese, realizada com 38 pessoas com hipertensão arterial sistêmica de uma unidade prisional brasileira, de fevereiro a julho de 2022, com entrevista semiestruturada de questões abertas, cuja análise foi temática, explicitando os limitantes à saúde na prisão.

Resultados:

foram relatados 13 Déficits Generalizados de Resistência, relacionando-se em maioria ao ambiente prisional e, em menor proporção, ao grupo social e ao indivíduo, respectivamente. O viver na prisão para pessoas com hipertensão arterial sistêmica implica conviver com elevado número de Déficits Generalizados de Resistência, acentuando o movimento em direção ao polo doença.

Considerações finais:

conhecer os Déficits Generalizados de Resistência permite direcionar a promoção da saúde para apoiar o uso dos Recursos Generalizados de Resistência disponíveis e contribui com a ampliação de políticas intersetoriais.

Descritores:
Pessoas Privadas de Liberdade; Prisão; Promoção da Saúde; Salutogênese; Saúde do Adulto

INTRODUCTION

People deprived of liberty (PDL) have a greater burden of physical and mental illness and risk of becoming ill when compared to the community outside prison, which is related to living conditions prior to prison, such as poverty, low education, limited access health, drug and alcohol use and trauma; situations that can be perpetrated and/or intensified in the prison environment. It is noted that health in prisons is understood as a fundamental human right and an element of social justice, and health services are components of primary care and constitute points of the Health Care Network, and must act within the scope of health promotion, prevention and recovery, including acute and chronic diseases(¹1 World Health Organization (WHO). Prisons and health [Internet]. 2014[cited 2023 May 18]. Available from: https://apps.who.int/iris/bitstream/handle/10665/128603/Prisons%20and%20Health.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand...

2 Silva PN, Kendall C, Silva AZ, Mota RMS, Araújo LF, Pires Neto RJ, et al. Hipertensão em mulheres presas no Brasil: muito além do biológico. Ciênc Saúde Coletiva. 2023;28(1):37-48. https://doi.org/10.1590/1413-81232023281.10672022
https://doi.org/10.1590/1413-81232023281... -³3 Woodall J, Viggiani N, South J. Salutogenesis in Prison. In: Mittelmark MB, Bauer GF, Vaandrager L, et al, organizers. The Handbook of Salutogenesis. 2. ed. Springer Cham: Suiça; 2022. p. 553-61. https://doi.org/10.1007/978-3-030-79515-3
https://doi.org/10.1007/978-3-030-79515-... ).

It is considered that the approach that guides this study is the Salutogenic Theory, whose focus is on what generates health, i.e., it focuses on understanding how people remain healthy despite stressors, as they are located at the healthy pole of the health-disease continuum. Thus, health or illness conditions depend on the adequate management of subjects’ tensions(⁴4 Antonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass Publishers; 1979.).

From this perspective, the salutogenic approach to health in prisons emerges when prison health begins to be understood as a component of primary care in general, whose care must be equivalent to that outside the walls. Thus, the salutogenic model in prisons aims to implement public health strategies that allow creating health in such a context, with health promotion being the target, since the aim is to develop healthy correctional policies that provide opportunities for PDL and employees to access resources to improve the health of these inmates. It is worth highlighting that, to build healthier spaces, listening to PDL’s and employees’ opinions is essential so that strategies meet their needs(³3 Woodall J, Viggiani N, South J. Salutogenesis in Prison. In: Mittelmark MB, Bauer GF, Vaandrager L, et al, organizers. The Handbook of Salutogenesis. 2. ed. Springer Cham: Suiça; 2022. p. 553-61. https://doi.org/10.1007/978-3-030-79515-3
https://doi.org/10.1007/978-3-030-79515-... ).

Furthermore, the approach to chronic non-communicable diseases (NCDs) is also fundamental in this context, considering that they account for 54.7% of total deaths in Brazil(⁵5 Ministério da Saúde (BR). Vigitel Brasil 2021. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico [Internet]. 2022[cited 2023 Sep 23]. Available from: https://www.gov.br/saude/pt-br/centrais-deconteudo/publicacoes/svsa/vigitel/vigitel-brasil-2021-estimativas-sobre-frequencia-edistribuicao-sociodemografica-de-fatores-de-risco-e-protecao-para-doencascronicas
https://www.gov.br/saude/pt-br/centrais-... ). Cardiovascular diseases (CVD) were the main causes of death also among incarcerated and recently released people in the United States of America, with 89% of deaths related to NCDs(⁶6 Wang EA, Redmond N, Himmelfarb CRD, Pettit B, Stern M, Chen J, et al. Cardiovascular disease in incarcerated populations. J Am Coll Cardiol. 2017;69(24):2967-76. https://doi.org/10.1016/j.jacc.2017.04.040
https://doi.org/10.1016/j.jacc.2017.04.0... -⁷7 Loeb SJ, Penrod J, McGhan G, Kitt-Lewis E, Hollenbeak CS. Who wants to die in here? perspectives of prisoners with chronic conditions. J Hosp Palliat Nurs. 2014;16(3):173-81. https://doi.org/10.1097/NJH.0000000000000044
https://doi.org/10.1097/NJH.000000000000... ). Among CVDs, hypertension affects the general population with a percentage of 26.3%(⁴4 Antonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass Publishers; 1979.) and, in a survey of 1,327 female PDL, found rates of 24.4%(²2 Silva PN, Kendall C, Silva AZ, Mota RMS, Araújo LF, Pires Neto RJ, et al. Hipertensão em mulheres presas no Brasil: muito além do biológico. Ciênc Saúde Coletiva. 2023;28(1):37-48. https://doi.org/10.1590/1413-81232023281.10672022
https://doi.org/10.1590/1413-81232023281... ). Therefore, controlling blood pressure in prisons is essential to avoid complications arising from it.

Furthermore, the prison context is also a setting for health promotion, and to this end, the salutogenic approach allows a focus on people’s health and lives instead of disease. The model’s central concepts are sense of coherence (SOC) and Generalized Resources of Resistance (GRRs). SOC consists of a global orientation to observe the world, in the sense of demonstrating belief in the possibility of overcoming the challenge so that the person believes in their ability to overcome them, such as understanding that they have the resources to meet the challenges stimuli and is motivated to deal with the situation. GRRs are any phenomena that are effective in combating stressors. Both elements, SOC and GRRs, have a reciprocal relationship, i.e., GRRs promote strong SOC and, in turn, this helps in mobilizing resources to manage tensions. Therefore, strong SOC facilitates the person’s movement towards health, considered a predictor of health(⁸8 Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass Publishers; 1987.-⁹9 Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int. 1996;11(1):11-18. https://doi.org/10.1093/heapro/11.1.11
https://doi.org/10.1093/heapro/11.1.11... ).

Generalized Resistance Deficits (GRDs) are also components of the Salutogenic Model, and are described as stressors or as the absence of resources, contributing to increasing chaos and disorder in people’s lives. In this regard, it is the negative experiences that favor the person to migrate to the disease pole on the health-disease continuum, which weakens SOC(⁸8 Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass Publishers; 1987.,¹⁰10 Saboga-Nunes L, Bittlingmayer UH, Okan O. Salutogenesis and health literacy: the health promotion simplex! In: Okan O, Bauer U, Levin-Zamir D, Pinheiro P, Sorensen K, organizers. International handbook of health literacy: research, practice and policy acrossthe lifespan. Policy Press: Chicago, 2019. p. 649-664. https://doi.org/10.51952/9781447344520.ch042
https://doi.org/10.51952/9781447344520.c... -¹¹11 Idan O, Eriksson M, Al-Yagon M. Generalized Resistance Resources in the Salutogenic Model of Health. In: Mittelmark MB, Bauer GF, Vaandrager L, et al, organizers. The Handbook of Salutogenesis. 2. ed. Springer Cham: Suiça, 2022. p. 93-106. https://doi.org/10.1007/978-3-030-79515-3
https://doi.org/10.1007/978-3-030-79515-... ).

The reciprocity between SOC and GRDs is asserted when they become chronic in a person’s life, which can contribute to failure to manage tensions effectively, leading subjects to the disease pole, with the potential to provide experiences that addict people’s low SOC(¹⁰10 Saboga-Nunes L, Bittlingmayer UH, Okan O. Salutogenesis and health literacy: the health promotion simplex! In: Okan O, Bauer U, Levin-Zamir D, Pinheiro P, Sorensen K, organizers. International handbook of health literacy: research, practice and policy acrossthe lifespan. Policy Press: Chicago, 2019. p. 649-664. https://doi.org/10.51952/9781447344520.ch042
https://doi.org/10.51952/9781447344520.c... -¹¹11 Idan O, Eriksson M, Al-Yagon M. Generalized Resistance Resources in the Salutogenic Model of Health. In: Mittelmark MB, Bauer GF, Vaandrager L, et al, organizers. The Handbook of Salutogenesis. 2. ed. Springer Cham: Suiça, 2022. p. 93-106. https://doi.org/10.1007/978-3-030-79515-3
https://doi.org/10.1007/978-3-030-79515-... ). GRDs, therefore, play a relevant role in people’s health. To the extent that they have the potential to weaken SOC, especially in those with weak SOC in early adulthood, they lead subjects into a vicious circle that weakens SOC, making life chaotic, uncontrollable and meaningless(⁸8 Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass Publishers; 1987.). Therefore, when there is a lack of knowledge about GRDs and GRRs of a group of people, it is unlikely that it will be possible for health professionals to provide suggestions so that such subjects can strengthen their SOC. Thus, qualitative research can obtain knowledge about these people’s individualities, directing health promotion actions focused on their needs and also providing opportunities for them to manage stressors and create different life and health experiences(¹²12 Wennerberg MMT, Eriksson M, Lundgren SM, Danielson E. Unravelling Swedish informal caregivers’ Generalised Resistance Deficits. Nordic Coll Caring Sci. 2017;32(1):186-96. https://doi.org/10.1111/scs.12446
https://doi.org/10.1111/scs.12446... ).

It is worth noting that, in the context of chronic diseases, a Brazilian integrative review on the use of SOC, the Salutogenic Theory’s key construct, concluded that nursing professionals use it in different groups of pathologies, in order to observe its relationship with objective and subjective health measures, with the Antonovsky Questionnaire correlating variables and scales. However, the predominant approach is quantitative instead of qualitative, which appears to be an open field for research(¹³13 Costa MC, Mantovani MF, Miranda FMD, Paes RG, Paz VP, Souza TN. Sentido de coherencia en las enfermedades crónicas: una revisión integradora. Enferm Univ. 2021;18(4):1-31. https://doi.org/10.22201/eneo.23958421e.2021.4
https://doi.org/10.22201/eneo.23958421e.... ). Furthermore, a study carried out in Sweden, with elderly caregivers, found a greater number of GRDs in relation to GRRs, concluding that both can be drivers of health promotion actions at the individual and collective level as well as being able to direct health policies(¹²12 Wennerberg MMT, Eriksson M, Lundgren SM, Danielson E. Unravelling Swedish informal caregivers’ Generalised Resistance Deficits. Nordic Coll Caring Sci. 2017;32(1):186-96. https://doi.org/10.1111/scs.12446
https://doi.org/10.1111/scs.12446... ).

Gap in knowledge on GRDs in the context of health in prisons is considered, since no studies were found that discussed GRDs in such a scenario in searches carried out in databases such as Virtual Health Library, PubMed and Scopus, which justifies the need to expand research on the topic and, in particular, based on the Salutogenesis framework. Thus, the relevance of this study is based on the understanding of Woodall et al.(³3 Woodall J, Viggiani N, South J. Salutogenesis in Prison. In: Mittelmark MB, Bauer GF, Vaandrager L, et al, organizers. The Handbook of Salutogenesis. 2. ed. Springer Cham: Suiça; 2022. p. 553-61. https://doi.org/10.1007/978-3-030-79515-3
https://doi.org/10.1007/978-3-030-79515-... ) about the importance of PDL being able to express their experiences, opinions and needs and the absences with which they live in prison, which can direct future actions by prison health professionals and managers - a focus that is intended to be highlighted with this study, as PDL statements are made visible regarding the factors that make it difficult to maintain their health in prison.

OBJECTIVE

To seize the GRDs of PDL with hypertension from a Brazilian prison unit.

METHOD

Ethical aspects

The study was conducted in accordance with national and international ethical guidelines, and approved by the Research Ethics Committee of the Health Sciences Sector of the Universidade Federal do Paraná (UFPR), following the recommendations of Resolution 466/2012, whose opinion is attached to this work. To guarantee participant anonymity, identifying codes were used to replace their names, such as P (participant), M (male) and X (Arabic number in ascending order of the participants interviewed) (e.g., MP_1). Furthermore, for employees of the penal system who were mentioned in the interviews, Arabic numbers were used in sequence, and all participants signed the Informed Consent Form (ICF).

Study design

This is a descriptive and exploratory study, with a qualitative approach, based on the Salutogenic Model. This is part of a doctoral thesis project whose title is “Doença crônica e saúde das Pessoas Privadas de Liberdade à luz da Teoria Salutogênica: estudo de métodos mistos”. In this approach, it is possible, through its subjective nature, to dialogue, create meanings and meanings, capturing the phenomenon through the perceptions of the people who participate in the research(¹⁴14 Silva LS, Oliveira GS, Salge EHCN. Entrevista na pesquisa em educação de abordagem qualitativa: algumas considerações teóricas e práticas. Prisma [Internet]. 2021;2(1):110-22[cited 2023 Jul 7]. Available from: https://revistaprisma.emnuvens.com.br/prisma/article/download/46/38
https://revistaprisma.emnuvens.com.br/pr... ). To guide the research report, the COnsolidated criteria for REporting Qualitative research (COREQ) was used.

Theoretical framework: Salutogenesis

The Salutogenic Model was developed by Aaron Antonovsky (1923-1994) in the 1970s and focuses on the origin of health: the central question is to understand how and why certain people remain well even after experiencing situations of intense stress and, even so, are located at the health-disease continuum healthy pole, despite stressors, and others are not. Thus, health or illness depend on the adequate management of tensions and the way in which people understand their lives(⁴4 Antonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass Publishers; 1979.,⁸8 Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass Publishers; 1987.). Salutogenesis rejects the dichotomous health-disease classification, understanding it as a continuous process in which people are faced with the two poles throughout their lives - health and disease -, which are integrated into a multidimensional continuum. Therefore, people find themselves in progression or regression in relation to the health-disease poles(¹⁵15 Eriksson M, Lindstrom B. Validity of Antonovsky’s sense of coherence scale: a systematic review. J Epidemiol Commun Health. 2005;59(6):460-6. https://doi.org/10.1136/jech.2003.018085
https://doi.org/10.1136/jech.2003.018085... ).

Therefore, human nature is understood as heterostatic, meaning that the human organism is in a dynamic state of imbalance; illness and internal and external stressors are the norm, inevitable; and non-homeostatic, with the organism regulated, balanced and occasionally disturbed by the disease, which seeks to control stressors, risk factors. Thus, chaos and stress are seen as part of life and the natural conditions of human living(⁸8 Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass Publishers; 1987.,¹⁵15 Eriksson M, Lindstrom B. Validity of Antonovsky’s sense of coherence scale: a systematic review. J Epidemiol Commun Health. 2005;59(6):460-6. https://doi.org/10.1136/jech.2003.018085
https://doi.org/10.1136/jech.2003.018085... ). The search, from the salutogenic perspective, is not to determine whether an individual is healthy or sick, but to understand how close they are to the health-disease continuum poles and what are the factors that promote movement towards the healthy pole(⁸8 Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass Publishers; 1987.).

Study setting

The present study was carried out in a Brazilian prison unit, in a large city in the South region, which housed 614 male people over 18 years of age on the initial date of collection, from February to July 2022. The aforementioned penal unit had a small outpatient clinic for PDL health care, with the work of a multidisciplinary team (doctor, nurse, nursing technician and dentist) who monitored PDL’s health demands. During the research period, the team maintained all the penal unit’s usual precautions.

Data source

The sampling used was for convenience, and used all PDL from the unit with a diagnosis of hypertension and who accepted participation (n= 38 or 6.2%). It was decided not to use saturation for sample delimitation, understanding that an ideal qualitative sample is one that reflects quantity, intensity and the phenomenon multiple dimensions, actions and interactions throughout the process(¹⁶16 Minayo MCS. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Rev Pesqui Qual [Internet]. 2017[cited 2023 Sep 21];5(7):1-12. Available from: https://editora.sepq.org.br/rpq/article/view/82
https://editora.sepq.org.br/rpq/article/... ) that, for this study, was the delimitation of GRDs of PDL with hypertension. The inclusion criteria were being a PDL in the unit and having a diagnosis of hypertension.

Participant recruitment began in 2021 with the dissemination of research verbally and through folders in the penal unit. Subsequently, participants who met the inclusion criteria were invited to participate individually, at which time the research, objectives, usefulness and procedure were presented. The PDL who agreed to participate in the research signed the ICF and were instructed that non-participation would not cause them any disadvantage, and that they would maintain their standard treatments in the penal unit. One participant who met the inclusion criteria declined to participate.

Data collection and organization

A semi-structured interview was used to collect data, as it is more flexible in nature and gives participants the opportunity to construct versions and meanings for the world in which they live, in addition to being possible for exchanges to take place between researcher and participant(⁹9 Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int. 1996;11(1):11-18. https://doi.org/10.1093/heapro/11.1.11
https://doi.org/10.1093/heapro/11.1.11... ). In this way, PDL were invited to speak freely about the topic, which was guided by the question: what are the factors that you consider make it difficult to maintain your health in the prison context? Thus, an instrument created by the researchers was used with 7 open-ended questions, using as frameworks the salutogenic model key concepts, such as SOC, GRRs and GRDs. It is evident that, for this study, we worked with excerpts that include the GRDs corresponding to the aforementioned question.

Interviews were carried out in an office in the prison health unit’s outpatient clinic by the first author, who is a nurse in a prison health unit. Therefore, they were audio recorded and transcribed, a priori, with Transkriptor^® and, afterwards, checked and organized by the researchers. Subsequently, data were arranged in a Microsoft Excel^® spreadsheet, with rows corresponding to participants and columns corresponding to the answers obtained in open-ended questions. The aforementioned spreadsheet was then imported into NVivo^® (version 12 - release 1.7 for Windows), which was used to store and organize the data. It should be noted that the software was used as an auxiliary resource to facilitate and organize the data analysis process, since it allows generating graphs, word clouds and word counts, automated coding, matrices, among others, but it does not replace the researcher and, therefore, it is not a data analysis modality.

In NVivo^®, the main researcher read the material, automated analyzes provided by the program to direct coding (the software provides possible coding), and codes constitute the research analysis categories. Subsequently, exhaustive readings of reports were carried out, refinement and reorganization of codes or categories through thematic analysis. This study worked with codes/categories and subcodes/subcategories.

Data analysis

Data were subjected to content analysis in thematic modality, following the steps relating to comprehensive and exhaustive reading, material exploration, and data treatment and interpretation(¹⁷17 Bardin L. Análise de conteúdo. São Paulo: Edições 70 Brasil, 2016.-¹⁸18 Sousa JR, Santos SCM. Análise de conteúdo em pesquisa qualitativa: modo de pensar e de fazer. Pesq Debate Educ. 2020; 10(2):1396-416. https://doi.org/10.34019/2237-9444.2020.v10.31559
https://doi.org/10.34019/2237-9444.2020.... ), initially being coded by the first author, with review and discussion by the research team. They then resulted in four categories: 1) Generalized Resistance Resources and Generalized Resistance Deficits; 2) Health, well-being and quality of life in prison; 3) (Lack of)Hope with life and the future; and 4) (Lack of) Health care. Furthermore, they generated ten subcategories: i) Factors that help maintain health in prison; ii) Factors that make it difficult to maintain health in prison; iii) Concept of health in prison; iv) Concept of quality of life in prison; v) Hopes for the future and life; vi) Hopelessness about the future and perception of life; vii) The search for maintaining health before prison; viii) The search for maintaining health in prison; ix) Sources of health information; x) (Lack of)Information. However, for this study, the “Generalized Resistance Resources and Generalized Resistance Deficits” category is highlighted only in relation to GRDs, included in the “Factors that make it difficult to maintain health in prison” subcategory.

RESULTS

A total of 38 male PDL participated in the study, 68.4% aged between 30 and 44 years, 50% married, 36.8% with between 9 and 12 years of education and 32.6% with less than 9 years of education. The total categorization of the corpus resulted in four categories and ten subcategories. For the present study, we worked with a subcategory included in the analysis of the “Generalized Resources of Resistance and Generalized Deficits of Resistance” category, with emphasis on the GRD “Factors that make it difficult to maintain health in prison”, nomenclature used in the guiding question for adequate and understandable language to participants at the time of the interviews. In the process of exhaustive reading of the material, speeches that dealt with limitations/absences for maintaining life and health in prison - GRDs were coded, resulting in 111 coded references (16.1%), listed by PDL in the total corpus. Figure 1 presents the GRDs found.

Below are the excerpts referred to and their respective descriptions.

a) Excesses and restrictions in food

Food is described by PDL as a factor that makes it difficult to maintain health in prison due to: abundance and PDL’s impasse in maintaining a healthy diet, linked to the anxiety generated by the prison context; restriction on the quantity of food supply such as fruits and vegetables; and frequent supply of processed foods, such as breaded and sausages and restriction of food entering the unit.

b) Inactivity, time and space limitations for physical activity

According to PDL, the absence of activities is an element that makes it difficult to maintain their health, since they remain idle for a long time and restricted to the environment of cubicles (cells, which are very small compartments similar to a room where PDL), situation that they themselves present as generating physical and psychological illness. The routine of deprivation of liberty, for some PDL, is characterized by the lack of occupations and/or objectives and, therefore, they use a large part of the time to sleep and/or reflect on life; reports the difficulty in carrying out activities in a small place, a cubicle, which is shared with 5-8 people as well as highlighting the difficulty in being directed to study and/or work activities; some PDL already carry out such activities and indicate a minimum amount of time reserved for them.

PDL pointed out limitations to physical activities related to time available to them on the sun patio, which varies between reports of 40 minutes to 5 hours a week, being canceled on rainy days and/or when there are other activities in the penal unit. They also point to the limited space of the place, which limits the possibilities of different types of physical exercise as well as the high number of people in the small space.

The situation of imprisonment, idleness and the treatment reserved for PDL generate, at times, the “desire to be worse”, and the support to face such a situation is related to “thinking about life” and their families. They feel, at certain times, in the same and/or worse conditions than those reserved for animals.

c) The cubicle: structural, ventilation and climatic conditions

The cubicle’s structural conditions were highlighted by PDL as elements that make it difficult to maintain health related to: insufficient space for all people to coexist (some pointing out five and others eight people in the same cubicle, related to differences in the number of people between the unit galleries, which is made up of the main building and the annex), in particular making it difficult to practice physical exercises in this location; insufficient ventilation, with extreme heat during summer and cold in winter - which is related to the lack of blankets and clothing for heating and fans that cannot be turned off in the cell; sharing bedroom/bathroom space; fully closed door that makes it impossible to see outside; and place ventilation.

d) Living in a cubicle

Living with cubicle mates was also presented by some PDL as an element that makes it difficult to stay healthy, related to the stress that living with so many people in a small, closed place can generate and/or with the possibility of resulting in physical attacks and illnesses.

e) Delays, lack of health care and lack of autonomy to seek the service

The delay in accessing health care was another element that makes it difficult to maintain health, with health teams in insufficient numbers; high number of PDL attached to the team; lack of autonomy to access the health service, since, to travel to the unit’s outpatient clinic, PDL need help from the “gallery cleaner” (nomenclature directed to another PDL that works in galleries and provides information about inmates’ needs) and, in particular, from security team employees, who need to comply with all safety procedures and routines for subsequent transfer of PDL to health care: activation of internal control employee (who opens doors); opening the cubicle door; opening the gallery door; user magazine; and displacement to the health sector. This difficulty is accentuated on days and times when the health team, which works on a daytime outpatient basis, is not at the unit, requiring, in addition to the procedures mentioned above, the request for escort and activation of the municipal network’s Mobile Emergency Care Service as well as services that require referrals to the municipal health network due to the need to activate the escort.

f) The family: concerns, distance, lack of news

Concerns about the family, especially wives and children, mainly related to lack of news from family members, were presented as elements that generate stress, depression and repercussions on physical health by PDL, as they worry about their health, financial conditions, food, bonding with family, among others. They point out the distance from their family members as one of the elements that make it difficult for family members to visit them, a fact that can be understood, since the unit studied brings together inmates from a certain criminal faction from all over the state.

g) Unit rules

The unit rules, routines and safety procedures, according to PDL reports, constitute limitations for maintaining health, as they cannot use weights in the cubicle to carry out physical activities, such as restricting the entry of certain foods and medications, in addition to bathing only once a day and the oppression.

h) The prison itself

The condition of imprisonment and absence of freedom make health impossible, as they generate stress, anxiety and suffering, described as a bad feeling.

i) Employees

A participant reported that, at times, they are disrespected verbally with humiliation and insults and, physically, with pepper spray and rubber bullets.

j) Temporal disorientation

MP_35 also pointed out temporal disorientation as an element that makes it difficult for him to stay healthy.

k) The person deprived of liberty

MP_15, MP_19 and MP_38 attributed the difficulty in maintaining their health to themselves as they did not adhere to drug and non-drug treatment.

l) Everything makes it difficult

For MP_16 and MP_24, everything in the prison environment harms the maintenance of their health, since nothing helps them.

m) Pandemic

The context of the coronavirus pandemic was presented by MP_33 as aggravating health maintenance as it made contact with family members difficult.

DISCUSSION

This study was designed to present GRDs among PDL with hypertension, an essential concept for the health and life management process, since GRDs can weaken SOC, determining the person’s movement in the health-disease continuum. It should be noted that Salutogenic Theory has been identified as an adequate theoretical framework for health promotion, and can be used in planning health actions and policies also for PDL. However, it is worth highlighting that knowledge about GRDs is still scarce(¹²12 Wennerberg MMT, Eriksson M, Lundgren SM, Danielson E. Unravelling Swedish informal caregivers’ Generalised Resistance Deficits. Nordic Coll Caring Sci. 2017;32(1):186-96. https://doi.org/10.1111/scs.12446
https://doi.org/10.1111/scs.12446... ), especially in imprisoned populations.

It is considered that, from the reports, 13 GRDs emerged, lack of resources or factors that make it difficult to maintain health in prison, which were related to individuals (self-care), social group (other inmates, penal and health system employees) and environment (structures, services and routines in prison). Therefore, the high number of GRDs seized is highlighted, which highlights the difficulty of maintaining health in prison, since when GRDs are insufficient, combating stressors becomes more difficult(¹⁹19 Vinje HF, Langeland E, Bull T. Aaron Antonovsky’s Development of Salutogenesis, 1979-1994. In: Mittelmark MB, Bauer GF, Vaandrager L, et al, organizers. The Handbook of Salutogenesis. 2. ed. Springer Cham: Suiça, 2022. p. 29-45. https://doi.org/10.1007/978-3-030-79515-3
https://doi.org/10.1007/978-3-030-79515-... ).

It is worth noting that GRDs, or the absence of GRRs, interfere with the person’s movement along the health-illness continuum, with the possibility and ability to manage the tensions inherent to life and migrate to the health pole(²2 Silva PN, Kendall C, Silva AZ, Mota RMS, Araújo LF, Pires Neto RJ, et al. Hipertensão em mulheres presas no Brasil: muito além do biológico. Ciênc Saúde Coletiva. 2023;28(1):37-48. https://doi.org/10.1590/1413-81232023281.10672022
https://doi.org/10.1590/1413-81232023281... ). Therefore, for PDL, movement in the continuum presents a high number of stressors, therefore, reflecting Antonovsky’s River of Life metaphor. These people are at the forks of the river that lead them to the rapids (which represent danger). For those close to the waterfall, the fight for survival is more difficult(⁷7 Loeb SJ, Penrod J, McGhan G, Kitt-Lewis E, Hollenbeak CS. Who wants to die in here? perspectives of prisoners with chronic conditions. J Hosp Palliat Nurs. 2014;16(3):173-81. https://doi.org/10.1097/NJH.0000000000000044
https://doi.org/10.1097/NJH.000000000000... ). However, knowing such GRDs can lead to health-promoting actions in order to minimize them and/or support GRDs.

In this sense, given the GRDs seized and because they are mostly related to the environment, it is reiterated that, despite the legal delimitation, health care in prison needs to be equivalent to that provided in the community(¹1 World Health Organization (WHO). Prisons and health [Internet]. 2014[cited 2023 May 18]. Available from: https://apps.who.int/iris/bitstream/handle/10665/128603/Prisons%20and%20Health.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... ). This study establishes relationships of conclusions with other Brazilian studies, such as the research carried out in Minas Gerais, which pointed out the right to health is still perceived as a norm that does not materialize in PDL’s daily lives(²⁰20 Martins ELC, Martins LG, Silveira AM, Melo EM. O contraditório direito à saúde de pessoas em privação de liberdade: o caso de uma unidade prisional de Minas Gerais. Saúde Soc. 2014;23(4):1222-34. https//doi.org/10.1590/S0104-12902014000400009
https//doi.org/10.1590/S0104-12902014000... ), as well as being aligned with the study with women inmates, which highlights the principle of equality as historically subjugated in prisons(²2 Silva PN, Kendall C, Silva AZ, Mota RMS, Araújo LF, Pires Neto RJ, et al. Hipertensão em mulheres presas no Brasil: muito além do biológico. Ciênc Saúde Coletiva. 2023;28(1):37-48. https://doi.org/10.1590/1413-81232023281.10672022
https://doi.org/10.1590/1413-81232023281... ).

Furthermore, the reports of participants in the present study point to delay, absence of health care and lack of autonomy in seeking health services, corroborating the Italian qualitative study with 10 PDL, which showed that the health system in those prisons did not meet the needs of the people imprisoned there(²¹21 Testoni I, Marrella F, Biancalani G, Cottone P, Alemanno F, Mamo D, et al. The value of dignity in prison: a qualitative study with life convicts. Behav Sci. 2020;10(6):1-11. https://doi.org/10.3390/bs10060095
https://doi.org/10.3390/bs10060095... ). Furthermore, the present data are also included in another study with Brazilian PDL, which found barriers to the inclusion of such subjects in the Health Care Network(²²22 Schultz ALV, Dotta RM, Stock BS, Dias MTG. Limites e desafios para o acesso das mulheres privadas de liberdade e egressas do sistema prisional nas Redes de Atenção à Saúde. Physis. 2020;30(3):1-19. https://doi.org/10.1590/S0103-73312020300325
https://doi.org/10.1590/S0103-7331202030... ).

It is also in line with the Swiss qualitative study, which interviewed 35 PDL over 60 years old, which highlighted situations that were harmful to PDL’s health: limitations in infrastructure; cell structures that did not adapt to the specific health needs and the health unit itself; schedules; security measures; shortages of certain medical equipment and treatments; and limitation of autonomy for access to services(²³23 Heidari R, Wangmo T, Galli S, Shaw DM, Elger BS. Accessibility of prison healthcare for elderly inmates, a qualitative assessment. J Forensic Leg Med. 2017;52:223-8. https://doi.org/10.1016/j.jflm.2017.10.001
https://doi.org/10.1016/j.jflm.2017.10.0... ). Thus, PDL find themselves constrained in positions of submission to a hierarchical disciplinary order, since they depend on the security team for their referral to the health sector(²⁰20 Martins ELC, Martins LG, Silveira AM, Melo EM. O contraditório direito à saúde de pessoas em privação de liberdade: o caso de uma unidade prisional de Minas Gerais. Saúde Soc. 2014;23(4):1222-34. https//doi.org/10.1590/S0104-12902014000400009
https//doi.org/10.1590/S0104-12902014000... ).

As in the aforementioned study(²³23 Heidari R, Wangmo T, Galli S, Shaw DM, Elger BS. Accessibility of prison healthcare for elderly inmates, a qualitative assessment. J Forensic Leg Med. 2017;52:223-8. https://doi.org/10.1016/j.jflm.2017.10.001
https://doi.org/10.1016/j.jflm.2017.10.0... ), this research demonstrated that prison can limit access to health care related to the prison health service opening hours, which may not be available full-time. As in the unit of this investigation, the Swiss prison analyzed by the authors also had daytime health services only, which implied demonstration by PDL of the need to activate the emergency service at night, submission to bureaucracy, the possibility of non-attendance and the need for logistics from the security team to transport PDL to health care. Swiss PDL also expressed that consultations outside the prison caused them discomfort related to transportation in prison clothing and/or handcuffs(²³23 Heidari R, Wangmo T, Galli S, Shaw DM, Elger BS. Accessibility of prison healthcare for elderly inmates, a qualitative assessment. J Forensic Leg Med. 2017;52:223-8. https://doi.org/10.1016/j.jflm.2017.10.001
https://doi.org/10.1016/j.jflm.2017.10.0... ).

With regard to social ties, the conflicting relationship with security team employees in relation to verbal and physical disrespect. PDL’s statements in this research corroborate a study with 35 PDL in the United Kingdom, which obtained reports that prison officers were not concerned with inmates’ health and well-being, lived with low interaction, and had their requests ignored and devalued(²⁴24 Viggiani N. Unhealthy prisons: exploring structural determinants of prison health. Sociol Health Ill. 2007;29:115-135. https://doi.org/10.1111/j.1467-9566.2007.00474.x
https://doi.org/10.1111/j.1467-9566.2007... ). It is emphasized that severe conditions of imprisonment do not reduce the likelihood of recidivism, but may result in an increase in post-release criminal activities(²¹21 Testoni I, Marrella F, Biancalani G, Cottone P, Alemanno F, Mamo D, et al. The value of dignity in prison: a qualitative study with life convicts. Behav Sci. 2020;10(6):1-11. https://doi.org/10.3390/bs10060095
https://doi.org/10.3390/bs10060095... ): situation explained in the testimony of a participant in this research, who pointed out the desire to “be worse” due to the situations he is subjected to.

In relation to the difficulties of coexistence with other PDL in cubicles, reported by the participants of this research, which generate physical and verbal insults, they are in line with reports of aggressions from other inmates that were also narrated by PDL from the United Kingdom(²⁴24 Viggiani N. Unhealthy prisons: exploring structural determinants of prison health. Sociol Health Ill. 2007;29:115-135. https://doi.org/10.1111/j.1467-9566.2007.00474.x
https://doi.org/10.1111/j.1467-9566.2007... ).

Regarding relationships with family members, reports indicated that the absence of news from family members and/or visitors negatively affected their health. Therefore, social relationships, especially with the family, are closely related to the concept of being healthy for PDL. Contact with the family is central to their values, as it restores personal dignity, positively impacting their rehabilitation and reintegration into society, including the potential to prevent criminal recidivism(²¹21 Testoni I, Marrella F, Biancalani G, Cottone P, Alemanno F, Mamo D, et al. The value of dignity in prison: a qualitative study with life convicts. Behav Sci. 2020;10(6):1-11. https://doi.org/10.3390/bs10060095
https://doi.org/10.3390/bs10060095... ,²⁵25 Woodall J. Exploring concepts of health with male prisoners in three category-C English prisons. Int J Health Promot Educ. 2010;48:115-22. https://doi.org/10.1080/14635240.2010.10708194
https://doi.org/10.1080/14635240.2010.10... -²⁶26 Crewe B, Liebling A, Hulley S. Staff-prisoner relationships, staff professionalism, and the use of authority in public-and private-sector prisons. Law Soc Inq. 2015;40:309-44. https://doi.org/10.1111/lsi.12093
https://doi.org/10.1111/lsi.12093... ).

Living in prison, for PDL not included in work and/or study activities, is routine with long periods of idleness in cubicles and, thus, they live without occupations and/or goals, using much of their time to sleep and/or or reflect on their lives, as they only have activities outside the cell for about 40-60 minutes a day. Then, in their speeches, they highlighted the need for more time outside the cell, access to open air and natural light to feel well as well as highlighting the difficulty they encounter in engaging in study and/or work activities. Those who have already been deployed in such occupations explained a minimum amount of time reserved for these activities. In contrast to the reports is the legal provision, explained in the Criminal Execution Law (CEL)(²⁷27 Presidência da República (BR). Lei nº 7.210, de 11 de Julho de 1984. Institui a Lei de Execução Penal [Internet]. 1984[cited 2023 Sep 21]. Available from: https://www.planalto.gov.br/ccivil_03/leis/l7210.htm
https://www.planalto.gov.br/ccivil_03/le... ), which is insufficient to guarantee PDL access to rights such as education, health and work.

This research is corroborated by an ethnographic study carried out with 500 male PDL in the United Kingdom, which concluded that they were forced into long periods of idleness and/or underemployment in prison. PDL complained of idleness, apathy, boredom, lack of motivation, lack of limited and rationed education and training opportunities(²⁴24 Viggiani N. Unhealthy prisons: exploring structural determinants of prison health. Sociol Health Ill. 2007;29:115-135. https://doi.org/10.1111/j.1467-9566.2007.00474.x
https://doi.org/10.1111/j.1467-9566.2007... ). Furthermore, the study with Italian PDL found reports that education and knowledge in the perceptions of PDL could even increase the confidence of inmates in institutions and in society as a whole, since occupations provide them with existential motivation to become better people(²¹21 Testoni I, Marrella F, Biancalani G, Cottone P, Alemanno F, Mamo D, et al. The value of dignity in prison: a qualitative study with life convicts. Behav Sci. 2020;10(6):1-11. https://doi.org/10.3390/bs10060095
https://doi.org/10.3390/bs10060095... ). A study carried out in South Korea stands out, which showed that horticulture resulted in a reduction in depression, increased self-esteem and satisfaction with life(²⁸28 Lee AY, Kim SY, Kwon HJ, Park SA. Horticultural therapy program for mental health of prisoners: case report. Integr Med Res. 2021;10(2):100495. https://doi.org/10.1016/j.imr.2020.100495
https://doi.org/10.1016/j.imr.2020.10049... ).

Another GRD reported by PDL in the research presented here was the limitation of time and space for physical activity, which makes it difficult to maintain their health in prison. In a Swiss study with 152 PDL, it was concluded that physical activities reduce psychological and psychiatric suffering, anxiety and depression in PDL(²⁹29 Sfendla A, Malmström P, Torstensson S, Kerekes N. Yoga practice reduces the psychological distress levels of prison inmates. Front Psychiatr. 2018;9:1-7. https://doi.org/10.3389/fpsyt.2018.00407
https://doi.org/10.3389/fpsyt.2018.00407... ).

Furthermore, another element presented as GRD was food in the penal unit. Although planned by a nutritionist, its abundance was aligned with PDL’s difficulty in maintaining a healthy diet, along with the anxiety generated by the prison context; restriction on the quantity of food supply such as fruits and vegetables; frequent supply of processed foods, such as breading and sausages; and restriction of external food entering the unit. All these situations corroborate the studies with 25 PDL from the state of Rio de Janeiro, in Brazil, in the sense of low nutritional quality, diverging with reports of tasteless, spoiled food, with impurities, insects and periods of hunger(³⁰30 Minayo MCS, Ribeiro AP. Health conditions of prisoners in the state of Rio de Janeiro, Brazil. Ciên Saúde Colet. 2016;21(7):2031-40. https://doi.org/10.1590/1413-81232015217.08552016
https://doi.org/10.1590/1413-81232015217... ). Thus, the situation concerns a Mexican study that concluded that prison exposed PDLs to low-quality diets(³¹31 Silverman-Retana O, Servan-Mori E, Bertozzi SM, Orozco-Nuñez E, Bautista-Arredondo S, Lopez-Ridaura R. Prison environment and non-communicable chronic disease modifiable risk factors: length of incarceration trend analysis in Mexico City. J Epidemiol Community Health. 2018;72(4):342-8. https://doi.org/10.1136/jech-2017-209843
https://doi.org/10.1136/jech-2017-209843... ). Thus, even though legislation guarantees them food with sufficient nutritional value for health and physical vigor, the right does not seem to be covered in prisons.

Considering the GRDs discussed, it is considered that incarceration in itself is harmful to health, even if the statistics do not capture the experiences lived in prison and even if they demonstrate lower mortality among PDL than in the community. Living in prison implies health problems related to confinement that can be maximized by poor housing conditions, inadequate food, poverty, discrimination, loss/lack of support networks and control over their lives(³²32 Vanjani R. On incarceration and health: reframing the discussion. N Engl J Med. 2017. https://doi.org/10.1056/NEJMp1704120
https://doi.org/10.1056/NEJMp1704120... ), as the present study shows by the high number of GRDs, directing PDL to the disease pole. Thus, health inequities in this population arise from marginalization of PDL in access to health before deprivation of liberty related to social vulnerability, high rates of physical and mental illness, abuse of illicit substances and alcohol. These situations continue and worsen with restricted access to prison health services and unsanitary conditions in prisons(³³33 Trotter RT, Lininger MR, Camplain R, Fofanov VY, Camplain C, Baldwin JA. A Survey of health disparities, social determinants of health, and converging morbidities in a county jail: a cultural-ecological assessment of health conditions in jail populations. Int J Environ Res Public Health. 2018;15(11):2500. https://doi.org/10.3390/ijerph15112500
https://doi.org/10.3390/ijerph15112500... -³⁴34 Aquino LCD, Souza BG, Laurindo CR, Leite ICG, Cruz DT. Poor self-rated health: prevalence and associated factors on women deprived of liberty. Esc Anna Nery. 2022;26:e20210275. https://doi.org/10.1590/2177-9465-EAN-2021-0275
https://doi.org/10.1590/2177-9465-EAN-20... ).

Therefore, prison health needs to reflect on PDL’s health, their experiences, in addition to understanding the prison context, its physical (environment) and organizational structures, relating such factors to the social determinants of health that permeate the prison setting, in constant dialogue with society in general, in order to create better living and health conditions for this population group(²2 Silva PN, Kendall C, Silva AZ, Mota RMS, Araújo LF, Pires Neto RJ, et al. Hipertensão em mulheres presas no Brasil: muito além do biológico. Ciênc Saúde Coletiva. 2023;28(1):37-48. https://doi.org/10.1590/1413-81232023281.10672022
https://doi.org/10.1590/1413-81232023281... ,²⁴24 Viggiani N. Unhealthy prisons: exploring structural determinants of prison health. Sociol Health Ill. 2007;29:115-135. https://doi.org/10.1111/j.1467-9566.2007.00474.x
https://doi.org/10.1111/j.1467-9566.2007... ). Knowing the GRDs of such a population group makes it possible to direct actions to these people’s demands. It is highlighted that better prison structures, recreation, productive occupation, reduction of abuse and extinction of violence are indirect mechanisms that can promote health and result in fewer needs to activate the health service(³⁵35 Sanhueza GE, Candia J. Acceso a la atención sanitaria en cárceles chilenas: una mirada desde los internos. Rev Esp Sanid Penit [Internet]. 2019[cited 2023 May 12];21:5-11. Available from: https://scielo.isciii.es/pdf/sanipe/v21n1/es_1575-0620-sanipe-21-01-5.pdf
https://scielo.isciii.es/pdf/sanipe/v21n... ).

Knowing the GRDs, then, allows health professionals to direct health care planning to the PDL group’s needs, filling the gaps and absences that are explained by the PDL themselves. Thus, it provides opportunities for the health team to manage the health-disease continuum with a view to strengthening GRRs and minimizing GRDs in a continuous process of advocating for better living and health conditions for PDLs. Furthermore, it provides support to prison health managers and the prison itself in the search for improvements in structures, routines and work processes, aiming to minimize GRDs.

Study limitations

The limitations of this study are related to lack of research on the topic, making it difficult to discuss the results. However, it is asserted that this fact highlights the originality of the theme.

Contributions to nursing, health and public policies

The findings of this research expand the scope of knowledge about health in prisons from a salutogenic perspective, providing support for the development of prison health policies based on absences perceived by PDL. In care practice, they can direct health professionals to actions that promote GRRs, with a view to strengthening SOC for better life and health management conditions for PDL.

FINAL CONSIDERATIONS

A high number of GRDs were detected in the reports of PDL with hypertension, with a predominance of those related to the prison environment and, to a lesser extent, to the social group and the individual, respectively. Therefore, possibilities for effective management of their lives and health are limited, with greater chances of migrating towards the disease pole. The need for health-promoting actions with PDL is evident, in individual and collective approaches, through intersectoral policies to support the use/availability of GRRs, especially related to the prison environment, which is shown to increase illness.

This study reveals the relevance of understanding the GRDs present in a group of people, and asserts that such knowledge allows the planning of health-promoting actions centered on the population group’s needs. The salutogenic approach and GRDs are emphasized, among other concepts, as fundamental to direct policies for Primary Health Care.

AVAILABILITY OF DATA AND MATERIAL

https://doi.org/10.48331/scielodata.SCQYEN

REFERENCES

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