Abstract

Introduction

Based on the experience of six years (2012-2018) developing a course of health promoters in the Penal Institution No. 4 of the city of Bahía Blanca, we generated a space for reflection at the Department of Health Sciences of the Universidad Nacional del Sur¹1. Grunfeld Baeza MV , Palomo DM , Arnaudo MC , Arena MC , D’Annuncio V , Troccoli M . Formar promotores de salud en contextos penitenciarios: una experiencia de la labor extensionista universitaria . Edumecentro . 2017 ; 10 ( 1 ): 1 - 17 .in order to question and objectify a part of what happens during the training of health sciences students and its relation with health in contexts of confinement.

Training of health sciences students

The institutions that educate health sciences students have to face the challenge of triggering debate processes about what kind of worker they want their students to be, based on the needs of the populations. It is important that populational and individual diversity be acknowledged during the training process and the design of the curricula. In this sense, including contexts of confinement as a training setting means to make visible the specific characteristics of this population’s health-disease-care process and the special approach that it requires.

In 1910, the Flexner Report -as a part of a process of questioning regarding medical education in the United States²2. Martínez Martínez A , Miranda Martinez D , Crespo Toledo Y . Abraham Flexner, Benjamín Bloom y Fidel Ilizástigui Dupuy: paradigmas de la educación médica americana . Rev Cienc Med . 2013 ; 17 ( 6 ): 202 - 16 .- made some proposals that affected the training of health field workers in most of the world, defining the biological dimension of the disease as fundamental, basing healthcare of individuals on the departmentalization of knowledge and on the specialization of medical practice, and giving a higher status to hospitals and laboratories as teaching settings³3. Borrell R . La educación médica en América Latina: debates centrales sobre los paradigmas científicos y epistemológicos . In: Madis Chiara R . Proceso de transformación Curricular: otro paradigma es posible . Rosario : Editorial Universidad Nacional de Rosario ; 2005 ..

The transformations that started after this report were strengthened by the technological expansion that took place after the Second World War, which fostered the extreme specialization of the medical education profile without any comprehensive approach to people, families and communities²2. Martínez Martínez A , Miranda Martinez D , Crespo Toledo Y . Abraham Flexner, Benjamín Bloom y Fidel Ilizástigui Dupuy: paradigmas de la educación médica americana . Rev Cienc Med . 2013 ; 17 ( 6 ): 202 - 16 .. This profile is still in force at training institutions, despite being questioned for its limitations in the approach to current health problems and in the answers to social demands³3. Borrell R . La educación médica en América Latina: debates centrales sobre los paradigmas científicos y epistemológicos . In: Madis Chiara R . Proceso de transformación Curricular: otro paradigma es posible . Rosario : Editorial Universidad Nacional de Rosario ; 2005 ..

Even today, graduates’ admission to specialized medical residencies is considered a positive result by part of the training institutions, and only a few of them take into account that the quality of training is related to the answer that the graduates can give to public health needs and demands, which are dynamic, historical and sociocultural⁴4. Organización Panamericana de la Salud . Federación Panamericana de Asociaciones de Facultades de Medicina . Los cambios de la profesión médica y su influencia sobre la educación médica . Educ Med Salud . 1994 ; 28 ( 1 ): 125 - 38 .. Despite defining their “object” of study as people living in a social, comprehensive and complex context, most formal curricula of health sciences careers do not manage, in practice, to widen their conception of health, which is focused on diseases and their natural history. This problem has already been taken into consideration at the Pan American Sanitary Conference in 2007^dd27 Pan American Sanitary Conference, Washington, D.C., October 1 to 5, 2007. Available in: https://www.paho.org/hq/index.php?option=com_content&view=article&id=1280:2009-pan-american-sanitary-conference&Itemid=1158&lang=es , during which concern was raised about the lack of social commitment in medical careers and the absence of an approach based on health promotion and disease prevention at an individual, familiar and community level since the beginning of training⁵5. Organización Panamericana de la Salud . La formación en medicina orientada hacia la atención primaria de la salud . Washington, DC : OPAS ; 2008 . ( Serie La renovación de la APS en las Américas, No. 2 )..

At present, we can find training institutions that question this model by taking into account the complexity of the health-disease-care process (HDCP) due to factors such as diversity among people and populations, and special features inherent to work, organization, management and government within the health field⁶6. Spinelli H . Las dimensiones del campo de la salud en Argentina . Salud Colect . 2010 ; 6 ( 3 ): 275 - 93 ..

We consider that students have to develop, since the first years of their careers, skills that foster a HDCP approach in which historical, social and cultural dimensions are valued. We have to go through settings in which the specific characteristics of every population and their contexts regarding different spheres of life are valued, giving emphasis to people, families and communities, their problems and needs, the ways in which they take care of their health, and their desires and aspirations.

There’s a persisting generalized idea according to which problems faced at the first level of healthcare and in the communities are “of low complexity, trivial and simple”⁷7. Campos GWS , Gutiérrez AC , Guerrero A , Cunha GT . Reflexões sobre a atenção básica e a estratégia de saúde da família . In: Campos GWS , Guerrero AVP , organizadores . Manual de práticas em atenção básica: saúde ampliada e compartilhada . São Paulo : Hucitec ; 2008 . p. 132 - 53 .. If the competences developed in those settings are assumed to have “less scientific rigorousness”, it is expected that university decision-makers privilege hospital training based on hard technologies⁷7. Campos GWS , Gutiérrez AC , Guerrero A , Cunha GT . Reflexões sobre a atenção básica e a estratégia de saúde da família . In: Campos GWS , Guerrero AVP , organizadores . Manual de práticas em atenção básica: saúde ampliada e compartilhada . São Paulo : Hucitec ; 2008 . p. 132 - 53 ..

Recognizing the complexity of the HDCP and centering it in life rather than in an institution, discipline or disease, will enable training proposals and strategies that prioritize other learning settings such as communities, homes, clubs, geriatrics or prisons. It is necessary to include different learning settings in the curricula in order to incorporate populations’ cultural, historical and social features, and the distinct ways in which they live their HDCP. This is the reason why training in contexts of confinement is necessary: it gives an idea of the needs and special features of a population that has been excluded from the academic discourse.

Training in contexts of confinement

In Argentina, education in contexts of confinement started to develop in the year 2002, when it went from being under the responsibility of prison services to depending on the National Ministry of Education⁸8. Herrera P , Frejtman V . Pensar la educación en contextos de encierro: primeras aproximaciones a un campo en tensión . Buenos Aires : Ministerio de Educación de la Nación ; 2010 .. In 2006, it became regulated by the sanction of the Law of National Education^eeLaw N. 26,206 of National Education, sanctioned on December 27th, 2006. General Provisions .

Developing learning settings in contexts of confinement is complex due to the characteristics of the whole educational process and of the place where the work is carried out. Training health promoters inside a prison means a double challenge. On the one hand, activities have to be appropriate to the setting and the population, and they should be performed trying to question the course contents and to incorporate inmates’ previous knowledge. And, on the other, the process is carried out in a place determined by disciplining and a correctional and normative attitude. We are constantly put into tension by these two situations, as it is very easy to end up performing school-like practices, similar to prison’s discipline and normalization. We must bear in mind that education in these kinds of contexts, where security-oriented systems take precedence and every external action is difficult to implement, is complex but not impossible⁸8. Herrera P , Frejtman V . Pensar la educación en contextos de encierro: primeras aproximaciones a un campo en tensión . Buenos Aires : Ministerio de Educación de la Nación ; 2010 .. Some aspects have to be recognized in order to deal with this complexity, like the ones described by Ervin Goffman⁹9. Goffman E . Internados: ensayos sobre la situación social de los enfermos mentales . 2a ed. Buenos Aires : Amorrortu ; 2012 ., who characterizes total institutions as an obstacle to social interaction. The key fact consists in dealing with many human needs using the bureaucratic organization of human conglomerates, which are indivisible⁹9. Goffman E . Internados: ensayos sobre la situación social de los enfermos mentales . 2a ed. Buenos Aires : Amorrortu ; 2012 .. Both professors and students should incorporate this basic knowledge in order to carry out this learning journey.

Health promotion in contexts of confinement

This section’s subtitle seems to be a contradiction or a paradox. Considering the Ottawa Charter^ffFirst International Conference on Health Promotion. Ottawa, Canada, 1986. , and specially many other health promotion conferences that took place after it, we could state -in a provocative way- that health promotion in contexts of confinement is impossible. The subtitle should be written the following way: “Health promotion in an impossible setting”. Is this setting impossible for health promotion? We believe that the answer is no, as long as we avoid the reductionist conception of health fostered by international declarations, which think, increasingly, in terms of a universal citizen, with no cultural or historical background, and therefore nonexistent. The Ottawa Charter states that health promotion consists in providing people with the necessary means to increase control over, and to improve, their health, and that, in order to reach their full potential health, people need to take control of everything that determines it. The prerequisites to achieve this are: peace, education, shelter, food, income, a stable ecosystem, social justice, and equity¹⁰10. Organización Mundial de la Salud . Carta de Ottawa para la promoción de la salud . Ottawa : Canadian Public Health Association ; 1986 .. If we think about health promotion in contexts of confinement, these prerequisites are impossible conditions, or at least to a great extent. The clearest example of contradiction in this case is peace, due to the fact that inmates are confined against their personal will and controlled by force by an armed group. Good housing and food conditions, economic recognition of work and a stable ecosystem would not be included, in principle, in any description of penal institutions. This way of conceiving health promotion can look like a decontextualized theoretical outburst or an instrumentalized reason that is dissociated from prison reality. However, if we understand that reality is not something given by itself and that it can be modified and constructed, then we can think of prisons as settings with fissures where possibility emerges from apparent impossibility, and health promotion actions become practicable. Therefore, in relation to this section’s title and the initial question, we can say that no setting is impossible in itself regarding health promotion, because health is determined or conditioned by situational contexts and actors in play. That is the reason why many spaces, moments and instances of health promotion appeared during the experience to which we are referring. We can identify that the different places where this course was carried out became health settings, with aesthetics, discourses, technologies -such as reading material and dynamics, active listening, CPR dummies and sphygmomanometers-, and ways of occupying space that are associated with care and the right to health. Health promotion was present not only in moments when an agenda centered in care and the inmates’ prominence was discussed and debated, but also in the place that each attendee took in the course and in the dialogue between them and the professors -with a logic that was different from the penal dynamic-, all of which constituted in itself health promotion. Apart from that, other health promotion instances were generated outside of the course, such as dialogues between fellows and reading of material, during which the center of the agenda and the discussion was put in the value of people and their care, generating many other promotion instances that are important, despite not being that foreseeable or measurable. Thus, the proposal of a health promotion course and its actions go through fissures that produce and foster care practices and the actual possibility of health promotion, in places where it seemed to be impossible.

We understand that new contents have to be potentially meaningful and subjects need willingness to associate new and previous concepts -that is to say, they have to want to learn- in order to generate a proposal of health promotion and to produce significant learning¹¹11. Buelvas Anderson R , Patiño AA , Narvaéz MS . Promoción de la salud bucal de las personas privadas de la libertad: una observación académica . Biosalud . 2010 ; 9 ( 2 ): 46 - 55 .. The potential dimension of the empowerment in people deprived of their liberty can be understood as a process of personal and collective transformation, in which a rights-based approach to health tries to motivate, among other aspects, the development of self-care practices¹¹11. Buelvas Anderson R , Patiño AA , Narvaéz MS . Promoción de la salud bucal de las personas privadas de la libertad: una observación académica . Biosalud . 2010 ; 9 ( 2 ): 46 - 55 .. That is the reason why it is so important that inmates themselves identify their health problems and necessary resources, learning, in that way, to design strategies and to use the appropriate materials to satisfy their needs¹⁰10. Organización Mundial de la Salud . Carta de Ottawa para la promoción de la salud . Ottawa : Canadian Public Health Association ; 1986 .. The mere invitation to think about which needs they have, what they want to learn and in what way, generates a moment of participation and relative freedom within the “university classroom” inside prison. In this setting, the generated moments of subjectivation enable thinking about care of oneself and the others, which makes this a transgressive proposal in this institution.

Our experience report

The idea of carrying out a university extension project to train health promoters in prison population originated at the Department of Health Sciences^ggsite: http://www.cienciasdelasalud.uns.edu.ar/ as an opportunity to include in the curricula a population group that has been excluded from the sanitary discourse. Both professors and students of the careers in medicine and nursing of the Department of Health Sciences participate in the course voluntarily, as an extracurricular activity of university extension. An open call was made using the institutional means of communication of the Department of Health Sciences. The requirements for being admitted in the project were: being a regular student and having at least four available hours per week to dedicate to the project.

Professors of different areas of the Department of Health Sciences -medical doctors, psychologists and nurses- formed an interdisciplinary team with the purpose of conducting the activities. Students participated actively during the whole process, including the design of in-person learning activities, the preparation of reading material, and the organization of practical tasks requested to inmates. During this process, medical and nursing students apply and reinforce contents that are included in their training programmes, learn to work in a setting with its own features, develop communication skills and empathy, and assimilate contents of their own curricula at the same time.

Objectives and course development

Our objectives are: to train the inmates to become health promoters, to educate university students and professors about health in contexts of confinement, and to learn skills of pedagogy and university extension in such contexts.

The course consists of twenty-five in-person classes (two hours per week) and the assignment of practical tasks to apply the theoretical concepts seen in class (another two hours per week). The addressed contents include: health promotion and disease prevention, first aid, cardiopulmonary resuscitation, diabetes, hypertension, sexual health and responsible procreation, sexually transmitted infections, mental health, addictions, smoking, tuberculosis, adult health and food handling.

Analysis of experience of the students and professors of the Department of Health Sciences

An opinion poll was carried out¹²12. Minayo MC . Investigación social: teoría, método y creatividad . 2a ed. Buenos Aires : Lugar Editorial ; 2012 .employing a written questionnaire in a direct way consisting of four open questions as a means to analyse the experiences of the former and current participants of the course, both university students and professors¹³13. Quispe Pari DJ , Sanchez Mamani G . Encuestas y entrevistas en investigación científica . Rev Act Clin Med . 2011 ; 10 : 490 - 4 ., in order to explore the project’s contribution to their lives, training and careers, personal sensations related to the experience, and the aspects of the course that they considered to be beneficial to the inmates. The questionnaire was answered by eight of the eleven professors and nine of the twenty university students. Although all former and current participants were asked to reply, no answers were received from three professors who do not work in the department any more, and from students who did not maintain any relation with this institution after graduation. A 62.5% of the people who answered the survey belonged to the career in medicine, and 37.5% to the career in nursing. The mean age was 34.7 years, with a range that varied from 20 to 57 years.

The answers were studied using content analysis as a method, and three empirical categories were established: subjectivity and institutional logics, academic training, and impact on the inmates’ life.

“Subjectivity and institutional logics” is a category that refers to the dialectic relation between subject and social structure, in which the former produces social and institutional logics and, at the same time, is produced by them. Different authors that work on this dialectic relation agree in the existence of some kind of tension or discontent generated from the narcissistic renunciation carried out by the subject in order to live in society¹⁴14. Freud S . El malestar en la cultura . In: Freud S . Obras completas . Etcheverry JL , traductor . Madrid : Amorrortu Editores ; 1992 .^,1616. Kaës R . La institución y las instituciones . Vassallo M , Alcalde R , traductores . Buenos Aires : Editorial Paidós ; 1989 ..

According to René Kaës, Sigmund Freud, Castoriadis and Aulagnier, social groups, family and school, instill in subjects, since childhood, a way of being, which is mediated, in turn, by the relations these groups maintain with reality and their exterior. The subject then commits to reproduce those discourse fragments in exchange for the support provided by the fact of being part of a social network. All these processes are unconscious and collective¹⁴14. Freud S . El malestar en la cultura . In: Freud S . Obras completas . Etcheverry JL , traductor . Madrid : Amorrortu Editores ; 1992 .^,1616. Kaës R . La institución y las instituciones . Vassallo M , Alcalde R , traductores . Buenos Aires : Editorial Paidós ; 1989 ..

The subject that enters prison has to go through a great psychological effort in order to adapt to the rules imposed by this institution for survival. This process, denominated “process of prisonization”, implies an impact on the way in which the person has to connect with their exterior, many times affecting their ability to create and maintain networks beyond the limits of the institution, as prison life logic ends up prevailing over the subject’s way of conducting themselves and building bonds¹⁷17. Wittner V . Salud mental entre rejas: una perspectiva psicosocial y de género . Buenos Aires : JVE ediciones ; 2016 ..

Participants acknowledge that health promotion, as a part of the health-disease-care process, has to be contextualized based on the health situation of people and groups. They consider that health promotion and disease prevention actions tend to follow general guidelines and do not work on situational specificity. Regarding populations in contexts of confinement, preventive actions could be designed in order to address the negative impact that some aspects of the institutional logics have upon mental health, by fostering recreation and dialogue settings to promote relations of solidarity within the penal institution.

It could be observed that certain institutional logics of prison appeared to be very evident before the eyes of the professors and university students the first time they entered this place, after which they expressed discomfort for being in a setting that is so unusual in relation to their everyday life. It may be the rigid structuring of prison life what makes more evident for professors and university students, during this first contact, that health policies need to be adapted to the special features of every community:

When relating to the institution and its members, we noted an abyss between our work, social and family environments, and the logics of communication and the continuous tension exerted by hierarchy relations in the penal institution. This distance, which generated rejection and anguish in both professors and university students, enabled us to relate this kind of bonds with health determination. It is impossible to think about the HDCP in contexts of confinement without interpreting and introducing in the analysis these logics that we objectified when we entered the institution.

Concurrently, reflections, conclusions and ideas about the social role fulfilled by this institution are imposed by the contact with a reality that is difficult to naturalize. Professors and university students refer that it is difficult to consider these institutions as settings that promote people’s social reintegration, fundamentally because of the living conditions and the intimidating environment. By observing the way in which institutions adopt logics that are, many times, different from formal rules and explicit goals and objectives, it becomes evident that specific dynamics -beyond official frameworks- are held and reproduced by us, people, and our way of relating to one another. In this sense, preventing violence and conflict situations should be one of the main objectives included in policies regarding health in contexts of confinement, a necessarily intersectoral work that would concretely affect the institutional dynamics repeated over the years.

Consequently, the question arises of prisons’ role in the reproduction of criminal behaviour, of consolidation of an identity in marginalization and the break of social bonds that worsen inequalities and discrimination instead of fostering social reintegration, all of which is included, many times, in the inmates’ life stories.

Finally, professors and university students value the course as a place of dialogue with people that live in a context that is completely different from everyday life, which has enabled them to dismantle prejudices regarding inmates and life in prison. Prison regime certainly tends to homogenize people in some way, causing their singularity to be devastated, in a sense, by their social position as prisoners/inmates and its symbolic value. Following the Department of Health Sciences’ general guidelines, there was space, during the course, for the inmates to discuss and to put ideas and experiences in common, accommodating singularity and promoting stronger bonds between fellows.

Inmates found a place where they could relate in other ways and have talks based on care and solidarity. They remembered their experiences and their families’ regarding the health issues which were addressed during the course. This fostered moments of well-being and health promotion.

The possibility of bringing into discussion examples of health situations lived by them, both inside and outside the penal institution, and analyzing potential causes or variables that affect those situations, along with the feeling that they were allowed to talk and share their experiences, which served as the main inputs to think about health in these contexts, initially was not an objective of this course. This space’s openness, and the dynamic that the classes adopted over time, resulted in the need to include it as a relational dimension of the activity.

We define the category “academic training” as the aspects related to knowledge, skills, attitudes, abilities and values considered to contribute to the future professional performance and to the professionalization of professors.

Taking into account the graduate profile aspired by the Department of Health Sciences, we consider that extension projects are a fundamental opportunity to include new learning settings that enable us to work on socially important issues in depth, something that would not be possible otherwise due to their specificity.

As far as inmates are concern, the course provides them with the experience and the look of people from the exterior, and their relation with professors favours an exchange between prison life and university life. The responsibility bonds that are promoted work as vocational stimuli for those who have the opportunity to leave prison and to think of studying a career.

Both professors and students highlight the development of learning objectives and the acquisition of new abilities and competences during the course. Each module’s design implies having to adapt contents, working methodology and activities to the target population. This exercise invites professors and university students to reconsider their practice based on the context, focusing on the students of the course instead of on the teaching team. It was noted that there was a need to adapt contents in order to make them more understandable and more useful inside of the penal institution, and it was acknowledged a need to acquire communication skills appropriate to the context.

The importance of soft technologies⁷7. Campos GWS , Gutiérrez AC , Guerrero A , Cunha GT . Reflexões sobre a atenção básica e a estratégia de saúde da família . In: Campos GWS , Guerrero AVP , organizadores . Manual de práticas em atenção básica: saúde ampliada e compartilhada . São Paulo : Hucitec ; 2008 . p. 132 - 53 ., which have proven to be the problematic core of teaching practices, arises from this analysis. In general, during their training, students of the department come across settings of material, subjective and symbolic vulnerability, but in this case they are also challenged to work on their own prejudices to design a high-quality course, in which the inmates’ singularity and the guarantee of their rights are taken into account as the main framework.

We defined the category “impact on the inmates’ life” as experience-based aspects of knowledge regarding community, family and self-care, relations, and their future liberty.

An essential question for us -professors and university students that carried out this course- would be: what concrete contribution are we making to the inmates’ life? We have the feeling that it consists of something more than technical tools and structured knowledge about health issues, as we believe that this space promotes, in itself, healthy behaviours, as well as participation and solidarity between fellows. Another essential point to highlight is that this kind of courses can be computed to reduce the penalty and to favour liberty conditions.

According to the professors and the university students, the course contributes with an educational experience in which they are invited to express themselves freely based on care and solidarity, accepting the responsibility, at the same time, of carrying out educational objectives and tasks, in favor of the experience within the penal institution and of life possibilities outside of it. In this sense, the creation of social networks between inmates that took place during the course generates healthy spaces and supports a better feeling of well-being, while they go through the vital crisis of being deprived of their liberty¹⁷17. Wittner V . Salud mental entre rejas: una perspectiva psicosocial y de género . Buenos Aires : JVE ediciones ; 2016 ..

Talking about health, their health, understanding how this process is determined, and sharing strategies to work, to the extent possible, on difficulties that may present, is also a way of favoring empowerment and control over some aspects of their lives that are being devastated by institutionalization.

Conclusions

Despite controversies and difficulties that may arise when working in contexts of confinement, we have been able to carry out and maintain health promoter’ training in prison. During these six years, every activity has generated a new learning point in professors and university students, both at a personal and at an academic level.

It was an enriching experience, in which many aspects that determine people could be identified from different points of view: law, health, context, education, policies and their exclusions, and society and its blind spots.

This kind of work makes you rethink about the training of health sciences students and its modalities. It also helps you to think that the HDCP should be seen based on the diversity of individuals and populations, and of the contexts where they live. Recovering the concept of health promotion from a wider and more diverse view, and in relation to the situational context where it takes place, we are enabled to ask ourselves: what spaces, moments and instances of health promotion could be carried out in this context? The ones that include self-care as a way of being aware of one’s own needs and those of the group, and that allow to manage, as well as possible, the appropriate measures to address health problems. The ones that stimulate listening skills and empathy, leaving time to answer together questions related to the health problems detected by each person and the measures that could be implemented beyond the formal system. Health cannot be promoted in contexts of confinement without giving prominence to the inmates’ stories. We are convinced that in this way we will encourage graduates with an orientation based on the right to health and at the service of the community, and professors that work and learn focusing on the different realities of diverse populations, something that was, after all, our starting point, our motivation.

Acknowledgements

We thank the Penal Institution No. 4 of Bahía Blanca, the Department of Health Sciences, the General Secretariat of Extension and Culture of the Universidad Nacional del Sur, and the university students and professors that are part of the Research and Extension Group in Health in Contexts of Confinement (GIESCE).

References

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