Abstract

Introduction:

The increase in the world's prison population is recorded in the UN Office on Drugs and Crime (UNODC) report, with a 25% increase since 2000. We live in a society with power structures, in global scenarios, that are real both inside and outside prison and that place the population in a vulnerable position.

Objective:

To reflect on social relations in the determinants of the health of the population deprived of their liberty, in the light of Betty Neuman's theory.

Methodology:

Theoretical essay, with a search carried out between January and March 2022. Results: The living conditions of this population are affected not only by illness but also by social structures that determine relationships before, during and after incarceration.

Conclusions:

Social relations in the health determinants of the incarcerated population are impaired. Studies are limited, reiterating the need for research in the area of prison healthcare so that we can act on the different facets of the prison system's structure. Understanding social relations, their determinants of health and their influence on the incarcerated population and civil society is essential to guarantee the effectiveness of human rights, health care and resocialization, with a view to social development as a whole.

Keywords:
Social relationships; People deprived of Liberty; Collective Health; Social Determinants of Health

Introduction

The increase in the incarcerated population is reported by the United Nations Office on Drugs and Crime, which estimated that 11.7 million people were imprisoned in the world in 2019, an increase of 25% since the previous data from 2000, when there were approximately 9.3 million (UNODC, 2021). We live in a capitalist, globalised society with neoliberal policies on the rise; we have credible power structures on a global scale inside and outside prison, where the power of the state is concentrated among those who have the greatest capital. This dynamic puts socially excluded populations at risk: before, during and after prison (Lafferty ., 2018LAFFERTY, L. et al. Measuring Social Capital in the Prison Setting: lessons learned from the inmate social capital questionnaire. Journal of Correctional Health Care, [S.L.], v. 24, n. 4, p. 407-417, 1 out. 2018. http://dx.doi.org/10.1177/1078345818793141.
http://dx.doi.org/10.1177/10783458187931... ; Soares Filho; Bueno, 2016).

The Constitution of the World Health Organisation (WHO) defines health as a state of physical, mental and social well-being, not just the absence of disease. Furthermore, it reaffirms health as a fundamental right, without distinction of race, religion, political ideology, social or economic condition, and recognises health as a fundamental condition for achieving peace and security (WHO, 2005). In Brazil, the right to health has been explicit in the Federal Constitution since 1988, in Article 6 as part of social rights and in Article 196, according to which “Health is a right of all and a duty of the State, guaranteed through social and economic policies aimed at reducing the risk of disease and other illnesses and universal and equal access to actions and services for its promotion, protection and recovery” (Brasil, 2014).

An understanding of the whole is necessary for the development of public health policies that can assist the prison population in its specificities. If we are aware that the prison institution is based on norms to conduct its dynamics, which are repeated in systems of relations: prisoner-prisoner; prisoner-agent; prisoner-judiciary; prisoner-police; prisoner-institution; prisoner-family; prisoner-society, we must critically analyse these social relations, established by the State, which directly interfere with this population (Figueiró; Dimenstein, 2016FIGUEIRÓ, R. de A.; DIMENSTEIN, M. Castigo, gestão do risco e da miséria: novos discursos da prisão na contemporaneidade. Estudos de Psicologia, [S.L.], v. 21, n. 2, p. 192-203, jun. 2016. http://dx.doi.org/10.5935/1678- 4669.20160019.
http://dx.doi.org/10.5935/1678- 4669.201... ; Marcis, 2016).

Reflecting on and critically analysing social relations in the health determinants of the population deprived of liberty (PLL) will allow us to better understand the social determinants of health (SDH) and, from this premise, will enable us to present an intervention that is committed to reality. Therefore, this study aims to reflect on social relations in the health determinants of the population deprived of liberty in the light of the Systems Model Theory developed by Betty Neuman.

Methods

This is a theoretical essay based on a structured literature review conducted on PubMed, Scientific Electronic Library Online (Scielo) and Virtual Health Library (BVS) databases. The search was performed from January to March 2022, and to preserve the relevance of the content for review, no time frame was used. We selected original articles that showed similarities with the topic and excluded review articles and editorials. The PICo strategy was used to develop the guiding question: P (Population) refers to the population deprived of liberty, I (Interest) refers to social relations, Co (Context) refers to health determinants (Dantas ., 2021DANTAS, H. L. L. et al. Como elaborar uma revisão integrativa: sistematização do método científico. São Paulo: Rev Recien. 2021, n. 37, p. 334-345, 2021.). This resulted in the question: How do social relations are expressed in the social determinants of health of the population deprived of liberty?

The Health Sciences Descriptors (DeCS)/MeSH used were: População Privada de Liberdade/Prisoners; Relações sociais/Social Relationships; Determinantes Sociais da Saúde/Social Determinants of Health. An advanced search using the Boolean operator “and” and “or” was used to access articles that intersected the different descriptors, with the aim of achieving the objective of this review.

The sample was organised and characterised by a code consisting of the letter “C” and a number in ascending order. Based on the concepts of Social Determinants of Health (SDH), Social Relations and Neuman’s Systems Model Theory (NSMT), the articles were analysed in an attempt to identify the variables and stressors arising from the social relations of the prison system, the population’s reactions/responses to these factors and the identification of protective variables and intervention in these responses. Enabling the construction of a critique that can establish the basis for the practice of Public Health Nursing for this population.

Results and Discussions

Five articles were characterised and summarised for descriptive analysis. The main language in which these papers were published was English. It was found that the highest number of publications occurred in 2015 (02) and that there is a concentration of publications in the North American continent (03).

National scientific production on the SDH of the prison population is almost non-existent, most of the articles about imprisonment have a jurisprudence profile. In the healthcare field, most of the results are articles on the epidemiology of infectious diseases, such as Araújo . (2017ARAÚJO, T. et al. Hepatitis C and associated risks in prisons: an integrative review Hepatite C e riscos associados em presídios: uma revisão integrativa. Revista de Pesquisa Cuidado é Fundamental, v. 9, n. 4, p. 939-945, 31 out. 2017), and chronic diseases, such as Ferreira . (2019FERREIRA, M. R. et al. Tuberculosis in prison and aspects associated with the diagnosis site. The Journal Of Infection In Developing Countries, [S.L.], v. 13, n. 11, p. 968-977, 30 nov. 2019. http://dx.doi.org/10.3855/jidc.11522.
http://dx.doi.org/10.3855/jidc.11522... ), as well as interventions to control and the effectiveness of treatments for such comorbidities in the population. A vision that is still very much affected by the biomedical model established in Brazilian healthcare (Pinheiro , 2015PINHEIRO, M. C. et al. Health profile of freedom-deprived men in the prison system. Invest Educ Enferm., v. 33, n. 2, p. 269-279, 2015. https://doi.org/10.17533/udea.iee.v33n2a09
https://doi.org/10.17533/udea.iee.v33n2a... ).

The theoretical model developed by Betty Neuman, used here and in other productions, allows more complex phenomena to be captured in various contexts - as in the case of the prison population, where health, justice and society are interrelated. In the Theory, the human being is understood as an open system, which can be a group, family, community or any type of collectivity, which is influenced by internal and external forces in its process, being represented by a dynamic organisational pattern (George , 2000GEORGE, J. B. et al. Teorias de enfermagem: os fundamentos para a prática. Porto Alegre: ArtMed, 2000.).

This system is influenced, positively or negatively, by the environment, characterised as a vital whole that can adjust to the individual, the community or itself. These environmental influences are identified as intra-, inter- and extra-personal factors. The balance between these protective and stressful factors is identified as health. This definition relates directly to the commission’s definition of social determinants of health as “social, economic, cultural, ethnic/racial, psychological and behavioural factors that influence the occurrence of health problems and their risk factors in the population” (Buss; Pellegrini Filho, 2007BUSS, P. M.; PELLEGRINI FILHO, A. A saúde e seus determinantes sociais. Physis: Revista de Saúde Coletiva, v. 17, n. 1, p. 77-93, abr. 2007.).

What acts on these factors can have a positive or negative influence on the system, and the reactions are classified as possible, not occurring or existing, with the responses or symptoms of this influence being identifiable (George ., 2000GEORGE, J. B. et al. Teorias de enfermagem: os fundamentos para a prática. Porto Alegre: ArtMed, 2000.). Further to a brief presentation of the basic concepts of TMSN, we now proceed to analyse the included papers.

Massoglia and Remester (2019MASSOGLIA, M.; REMSTER, B. Linkages Between Incarceration and Health. Public Health Reports, [S.L.], v. 134, n. 1, p. 8-14, maio 2019. http://dx.doi.org/10.1177/0033354919826563.
http://dx.doi.org/10.1177/00333549198265... ) emphasise that the information on the incidence of infections and illnesses, divergences in health policies, the legal system and social determinants obtained from research carried out in the United States in comparison to other continents cannot be generalised, nor can claims about a considerable positive effect on the prison population. As indicated by the results of Albertie at al. (2015ALBERTIE, A. et al. Connectivity, prison environment and mental health among first-time male inmates in Mexico City. Global Public Health, v. 12, n. 2, p. 170-184, 14 out. 2015.) and a study carried out on the living conditions of the male prison population in the prison system in the north-eastern region of Brazil. (Silva ., 2021SILVA, S. A. et al. Prison system and life conditions of the man in prison in a region of Brazilian northeast. Research, Society and Development, [S. l.], v. 10, n. 7, p. e55210716816, 2021. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16816. Acesso em: 13 set. 2021.
https://rsdjournal.org/index.php/rsd/art... ).

In study C1, eight categories were developed that were similar to the concepts of SDH identified by the WHO. Mental health and substance use services, education, employment, housing, material resources, “medical care”, maternal relationship and social support, as categories and each of them had their barriers and solutions listed by the participants. (Stelson , 2018STELSON, E. et al. Social Determinants of Health and What Mothers Say They Need and Want after Release from Jail. Preventing Chronic Disease, v. 15, 6 dez. 2018. DOI: https://doi.org/10.5888/pcd15.180260.
https://doi.org/10.5888/pcd15.180260... ).

The research sample was not only small (15 women, 69% of the total sample of 135), but was also biased by the programme to reintegrate women into the community. However, the interference of economic and political factors, even if not directly mentioned by the participants, linked the social determinants of health to the social relations they experienced, resulting in a low standard of living and health (Stelson , 2018STELSON, E. et al. Social Determinants of Health and What Mothers Say They Need and Want after Release from Jail. Preventing Chronic Disease, v. 15, 6 dez. 2018. DOI: https://doi.org/10.5888/pcd15.180260.
https://doi.org/10.5888/pcd15.180260... ).

Norms inside the prison system are related to external social elements, such as the political and ideological orientation of a country, the socio-economic conditions, culture and moral aspects of a certain society. In different contexts, another analysis is needed to understand that reality, avoiding the dissemination of “models of thought and theories about prison, incarceration and criminal justice” that develop and apply to a specific population. (Frois , 2019FROIS, C.; OSUNA, C.; LIMA, A. P. Etnografia em contexto carcerário: explorando potencialidades e limites. Cadernos Pagu. 2019, n. 55, e195503. Disponível em: n55a03 (scielo.br) Acesso em: 14 set. 2021.).

In this vein, the authors of the second article (C2) investigate the relationship between procedural justice and the mental illness of incarcerated men, seeking to investigate their perception beyond environmental and individual factors. They emphasise that the research differs from many other places in the world, because in the Netherlands, the prison system does not suffer from overcrowding or a lack of professionals (Beijersbergen . 2013BEIJERSBERGEN, K. A. et al. Procedural justice and prisoners’ mental health problems: A longitudinal study. Criminal Behaviour and Mental Health, v. 24, n. 2, p. 100-112, 5 set. 2013.).

The study aims to analyse the coping mechanisms developed to deal with the prison environment. A sample of over 1,000 men was invited to take part in the survey, and their responses were collected after the first 3 weeks and then after 3 months in prison. They were asked about procedural justice, mental health, coping mechanisms and individual characteristics. The way they are treated by staff, the presence or absence of certain mental health symptoms, the way they cope and personal factors were analysed - age at admission to prison, ethnicity, history of imprisonment and previous treatment for psychological problems. (Beijersbergen . 2013BEIJERSBERGEN, K. A. et al. Procedural justice and prisoners’ mental health problems: A longitudinal study. Criminal Behaviour and Mental Health, v. 24, n. 2, p. 100-112, 5 set. 2013.).

The results pointed to a causal relationship between procedural justice and the mental health of incarcerated individuals. Other research indicates that men with longer sentences and greater age at imprisonment felt or experienced emotional changes and reported that the prison environment did not meet their emotional needs (Perrett ., 2019PERRETT, S. E. et al. Exploring health and wellbeing in prison: a peer research approach. International Journal of Prisoner Health, [S.L.], v. 16, n. 1, p. 78-92, 11 set. 2019. http://dx.doi.org/10.1108/ijph-03- 2019-0019.
http://dx.doi.org/10.1108/ijph-03- 2019-... ). This corroborates the assertion that a higher quality environment in the system is one of the ways to minimise the mental suffering of these individuals (Beijersbergen . 2013BEIJERSBERGEN, K. A. et al. Procedural justice and prisoners’ mental health problems: A longitudinal study. Criminal Behaviour and Mental Health, v. 24, n. 2, p. 100-112, 5 set. 2013.).

In Brazil, the very experience of imprisonment has an influence on health, and exposure to stress is directly related to physical and psychological illness. Internal conflicts, isolation, power struggles, adapting to a new routine or long sentences, even the relationship between the prisoner and the agent and the loss of social support (Ariza; Arbodela, 2020ARIZA, L. J.; ARBOLEDA, F. L. T. El cuerpo de los condenados. Cárcel y violencia en América Latina. Revista de Estudios Sociales, n. 73, p. 83-95, jul. 2020.; Frois , 2019FROIS, C.; OSUNA, C.; LIMA, A. P. Etnografia em contexto carcerário: explorando potencialidades e limites. Cadernos Pagu. 2019, n. 55, e195503. Disponível em: n55a03 (scielo.br) Acesso em: 14 set. 2021.).

The study by Dill et al. (C3) captures the experience of incarcerated men in the process of resocialisation and fatherhood. We can observe dichotomous scenarios when we address the ‘gender issue’ in the profile of scientific publications. With research focused on motherhood, mental illness and the prevention of sexually transmitted infections (STIs) by “women”, while topics relating to violence, crime and substance use/abuse are found by “men”, as an example, we bring the article by Brinkley-Rubinstein et al. (2018). With the exception of HIV and the prevalence of STIs, which are largely addressed without gender influence (Barcinski; Cúnico, 2014). A systematic review conducted by Cúnico and Lermen (2020) concludes that “several studies only used the concept as a way of descriptively differentiating the data obtained”.

The masculinity structured by our socio-economic model imputes to men deprived of their liberty in disputes, the reproduction of risky attitudes and negligence towards their physical and mental health, and these attitudes are often reinforced by the social relationships experienced by these individuals (Santos; Nardi, 2014).

In the research (C3), the opportunity to be with their children, teach them and spend quality time with them can be seen as a protective factor from the perspective of Neuman’s theory. This process is extremely important for the parent-child relationship and motivates them to continue their process of reintegration into society in a firm way (Dill et al., 2015).

Employment becomes a critical analytical category, a cycle in which men look for work, don’t get it or aren’t paid fairly. As explained in the article, in regions of the United States, discriminatory policies towards the prison population make it difficult for these men to enter the labour market and prevent them from participating in social activities such as the right to vote (Dill et al., 2015). We can see that this line of defence - employment - is undermined, and the population is also deprived of exercising this right and social function outside of prison. Thus, unemployment, diagnosed as a stress factor, is related to the remission of these men to the prison system, as well as directly affecting family dynamics, leading to a cycle of poverty and inequality (Dill et al., 2015). Demonstrating the impact of imprisonment on social relations too, post-prisonment.

In addition to other stressors, the article concludes that seeking health services is not a priority, compared to the need to find employment and housing, to provide and feed oneself and urban mobility (Dill et al., 2015). In the context of the research (United States), the costs of private health services are high, and given the socioeconomic status of these men, many of them avoid seeking health services. This is detrimental and makes comprehensive health care impossible, making prevention and promotion actions unfeasible.

Dill et al. (2015) point out that social support was one of the categories elaborated with the greatest bias due to the sample being part of a support programme for men undergoing social reintegration. In addition, the programme is responsible for providing a support network related to other social needs such as work, education, housing and transport. Stigmatisation, stress and isolation due to the process of incarceration and re-socialisation are themes that have been addressed, and they are obvious stressors, but due to the experience of this group, this space provides a safe environment for sharing these negative situations arising from the experience of imprisonment, finding a protective factor. Communication, the ability to communicate effectively inside and outside the system, communication between the man-health service and the man-prison staff was seen as a positive factor for well-being, within the limitations of the prison system (Perrett 2019PERRETT, S. E. et al. Exploring health and wellbeing in prison: a peer research approach. International Journal of Prisoner Health, [S.L.], v. 16, n. 1, p. 78-92, 11 set. 2019. http://dx.doi.org/10.1108/ijph-03- 2019-0019.
http://dx.doi.org/10.1108/ijph-03- 2019-... ).

The article (C4) by Albertie . (2015ALBERTIE, A. et al. Connectivity, prison environment and mental health among first-time male inmates in Mexico City. Global Public Health, v. 12, n. 2, p. 170-184, 14 out. 2015.) seeks to understand the impact of incarceration and environmental factors that can compromise the mental health status of incarcerated individuals. The study was conducted in three penal institutions and had a sample of more than 500 volunteer participants, all of whom underwent a health assessment and answered a questionnaire with five categories of interest: socioeconomic and demographic status, history of violence and childhood, risk behaviours related to STIs and HIV, diet and physical activity, mental health and health risk attitudes; from these categories, the dependent and independent variables were listed, respectively depression and substance use; and “connectivity” - understood as “relationships/relationships”, prison environment and personal history.

The results showed poor mental health, with half of the sample suffering from depressive disorders and more than half from substance use/abuse, highlighting the lack of health care, especially mental health care, for these individuals. Situational factors such as violence in prison and overcrowding also have an impact on the mental health of incarcerated men, but work activities and involvement in other activities within the prison can minimise psychological suffering and exposure to violence (Albertie ., 2015ALBERTIE, A. et al. Connectivity, prison environment and mental health among first-time male inmates in Mexico City. Global Public Health, v. 12, n. 2, p. 170-184, 14 out. 2015.). As previously mentioned, the experience of imprisonment is accompanied by significant psychological changes, and these conditions vary according to the individual’s way of coping and their support network, and it was possible to observe in the research that marriage and visits, in other words, social support, is essential for the adaptation and reintegration of this individual, and is seen as a protective factor in the incarcerated population’s line of defence.

The article (C5) sets out to analyse the phenomenon from a racial perspective, and the impact of mass incarceration on the social determinants of health related to well-being. To this end, the data used comes from a study that investigated the impact of drug policy on the cycle of incarceration-resocialisation-readmission, which causes instability in the living conditions of these people. The sample consisted of more than 300 voluntary participants over the age of 18 who answered a structured questionnaire (Blankenship et al., 2019).

Socio-demographic information, socio-economic factors, schooling and employment were analysed. In addition to substance use, history related to criminal justice (beyond incarceration), aspects related to surveillance and community control (stemming from criminal justice), police power and police control (hypervigilance). Questions about the impact of the history of imprisonment on social and economic wellbeing were also included, with questions about education, employment and housing, personal relationships and the relationships of people close to them, as well as the impact on the difficulty of using health services or other services. This data was sectioned to assess the interference of the race factor in the process of mass incarceration under four subcategories: Criminal History; Community Supervision; Criminal Justice Surveillance; Exposure to police control/power. And then the relationship between incarceration and aspects related to health (Blankenship et al., 2019).

The authors conclude that there are differences based on racial prejudices in the experiences of imprisonment and resocialisation, where young black men have a younger age when sentenced, a greater number of arrests, primary drug convictions and a longer sentence (Blankenship et al., 2019). As in other research, social determinants have been identified that disadvantage incarcerated men, most of whom are black: economic marginalisation, a higher incidence of diseases (infectious, cardiovascular and psychological), social integration and reintegration related to insufficient work, impaired study and housing (Massoglia; Remster, 2019MASSOGLIA, M.; REMSTER, B. Linkages Between Incarceration and Health. Public Health Reports, [S.L.], v. 134, n. 1, p. 8-14, maio 2019. http://dx.doi.org/10.1177/0033354919826563.
http://dx.doi.org/10.1177/00333549198265... ). The prison population as a whole is directly affected by the ailments that follow the period of imprisonment, but the black population is at greater risk, highlighting the perpetuation of racial inequality in the issue of imprisonment.

The different expressions of social relations on the health determinants of the PLL during and after imprisonment are evident, and their critical analysis is important for the development of public health policies. As pointed out by Lafferty . (2018LAFFERTY, L. et al. Measuring Social Capital in the Prison Setting: lessons learned from the inmate social capital questionnaire. Journal of Correctional Health Care, [S.L.], v. 24, n. 4, p. 407-417, 1 out. 2018. http://dx.doi.org/10.1177/1078345818793141.
http://dx.doi.org/10.1177/10783458187931... ), the resources for developing public policies aimed at the demands of the prison population are different from those provided to general society.

In the Netherlands, for example, the conditions of the prison system are in contrast to many other continents, as described in the article by Beijersbergen . (2013BEIJERSBERGEN, K. A. et al. Procedural justice and prisoners’ mental health problems: A longitudinal study. Criminal Behaviour and Mental Health, v. 24, n. 2, p. 100-112, 5 set. 2013.), where each prisoner lives in individual cells and manages to have a strong bond with the institutional agents during the period of imprisonment. And although they suffer from common problems, they report less psychological distress related to the environment and the bond with prison workers.

Prison has a direct influence on health, making the prison system an important space for public health. In addition to the profile of chronic and infectious diseases, the influence of imprisonment on family ties, maintaining relationships and mobility, employment and education opportunities, access to health services, compared to people outside of prison are discrepant (Baillargeon ., 2017BAILLARGEON, J. et al. The changing epidemiology of HIV in the criminal justice system. International Journal of STD & AIDS, v. 28, n. 13, p. 1335-1340, 27 abr. 2017.; Lafferty ., 2018LAFFERTY, L. et al. Measuring Social Capital in the Prison Setting: lessons learned from the inmate social capital questionnaire. Journal of Correctional Health Care, [S.L.], v. 24, n. 4, p. 407-417, 1 out. 2018. http://dx.doi.org/10.1177/1078345818793141.
http://dx.doi.org/10.1177/10783458187931... ; Medina; Rico, 2020MEDINA, W. J. S.; RICO, R. H. M. Estándares nacionales e internacionales del tratamiento penitenciario y carcelario en Colombia. Un estudio del caso de la cárcel de Neiva (Huila). Prolegómenos, [S.L.], v. 22, n. 43, p. 79-92, 24 fev. 2020. http://dx.doi.org/10.18359/prole.3460.
http://dx.doi.org/10.18359/prole.3460... ; Silverman-Retana et al., 2018). This makes it essential to discuss and analyse social relations, an area that is little explored in scientific productions, especially in developing countries such as ours, as Buss and Pellegrini Filho (2007BUSS, P. M.; PELLEGRINI FILHO, A. A saúde e seus determinantes sociais. Physis: Revista de Saúde Coletiva, v. 17, n. 1, p. 77-93, abr. 2007.):

Scientific production on death in prison due to chronic and neglected diseases, cancer, AIDS and suicide is also consistent (Ariza; Arbodela, 2020ARIZA, L. J.; ARBOLEDA, F. L. T. El cuerpo de los condenados. Cárcel y violencia en América Latina. Revista de Estudios Sociales, n. 73, p. 83-95, jul. 2020.; Chies; Almeida, 2019CHIES, L A. B.; ALMEIDA, B. R. Muertes en prisión preventiva en Brasil. Prisiones que matan; muertes que importan poco. Revista de Ciencias Sociales, [S.L.], v. 33, n. 47, p. 67-90, 6 dez. 2019. http://dx.doi.org/10.26489/rvs.v32i45.3
http://dx.doi.org/10.26489/rvs.v32i45.3... ; Hulsman; Justino, 2021HULSMAN, J.; JUSTINO, D. They’re talking about penal abolition: the urgency of re-imagining different paths as alternatives to the criminal justice system. Revista Direito e Práxis, [S.L.], v. 12, n. 1, p. 444-471, jan. 2021. http://dx.doi.org/10.1590/2179-8966/2020/57285.
http://dx.doi.org/10.1590/2179-8966/2020... ; Zhong ., 2021ZHONG, S. et al. Risk factors for suicide in prisons: a systematic review and meta-analysis. The Lancet Public Health, [S.L.], v. 6, n. 3, p. 164-174, mar. 2021. < http://dx.doi.org/10.1016/s2468-2667(20)30233-4>.
http://dx.doi.org/10.1016/s2468-2667(20)... ). In this regard, the neglect of health promotion, surveillance and treatment of these individuals in the custody of their respective governments is evident. The structural remnants of a punitive system that served to isolate and exclude socially, under living conditions that were equally unhealthy and often death sentences, are repeated in these patterns of illness: tuberculosis, suicide, leptospirosis and scabies. Diseases historically referenced in studies of the development of what would become the prison institution.

The development of research in this context is necessary to expand knowledge about the living conditions and health of the population deprived of their liberty, both nationally and internationally. The complexity of the subject and the dynamics of the results found show that it is necessary to invest in better strategies to tackle structural conditions and the damage to relationships during and after deprivation of liberty. (Perrett , 2019PERRETT, S. E. et al. Exploring health and wellbeing in prison: a peer research approach. International Journal of Prisoner Health, [S.L.], v. 16, n. 1, p. 78-92, 11 set. 2019. http://dx.doi.org/10.1108/ijph-03- 2019-0019.
http://dx.doi.org/10.1108/ijph-03- 2019-... ).

Based on the interpretation of Neuman’s Systems Model Theory (NSMT), the above-mentioned group is negatively influenced by the environment, not only during the period of imprisonment, but also in their previous and subsequent daily lives, which are just as unfavourable for the SDH of these individuals. This population, whose freedom, health, housing, work, leisure, food and education are guaranteed by constitutional law, is already under the influence of stressful factors from a political and economic system that has been in place for a long time in our state.

In TMSN, “lines of defence” are mechanisms developed to protect against stressors. Thus, the normal line of defence is considered to be the “normal” level of well-being and the flexible line of defence, the prevention developed by the “system” against stressors beyond normal levels (George , 2000GEORGE, J. B. et al. Teorias de enfermagem: os fundamentos para a prática. Porto Alegre: ArtMed, 2000.).

Based on this, “normality” has different readings, after all, an individual who has always lived in economic or food vulnerability, for example, differs from an individual who is socioeconomically favoured. The social contradiction is evident here, as economic and food vulnerability is considered a factor in illness. By definition, would the normal level of well-being of this socially ill individual be their adaptation to social injustice?

Deepening the idea of the food situation, these individuals are given the prerogative of “at least I have something to eat” (Silva ., 2021SILVA, S. A. et al. Prison system and life conditions of the man in prison in a region of Brazilian northeast. Research, Society and Development, [S. l.], v. 10, n. 7, p. e55210716816, 2021. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16816. Acesso em: 13 set. 2021.
https://rsdjournal.org/index.php/rsd/art... ). Is this a way of ensuring that this individual has the provision of food by the state as a protective factor? This right should be guaranteed without the need for deprivation of liberty (Brazil, 1988). The National Commission on Social Determinants of Health suggests that we should be prepared to intervene at all levels of social determinants, prioritising socio-economic factors and the population’s educational and labour processes, seeking to systematically reduce inequalities (CNDSS, 2008).

Finally, the lines of resistance work together with the normal line of defence. When the stressor crosses the normal line, there is a resistance reaction that seeks to defend the basic structure of the system (George ., 2000GEORGE, J. B. et al. Teorias de enfermagem: os fundamentos para a prática. Porto Alegre: ArtMed, 2000.). In the case of the prison population, even the lines of resistance are negatively influenced. Due to the environmental situations in which prisoners live: overcrowding, lack of personal hygiene resources, power disputes and many other factors, they become stressors, making it impossible to recover from illnesses that require specific interventions and actions to promote health and prevent illnesses..

Present in the doctrine of the Unified Health System (SUS), health promotion is seen as the main strategy for maintaining social well-being (Brasil, 2010). It seeks to intervene in a targeted manner with the aim of both preventing the emergence of diseases and reducing their incidence and prevalence in the population. For Neuman, primary prevention is understood as reducing the possibility of contact with the stressor and strengthening the line of defence. Secondary prevention is the early diagnosis and treatment of symptoms. And tertiary prevention is re-adaptation, re-education and maintaining stability. (George , 2000GEORGE, J. B. et al. Teorias de enfermagem: os fundamentos para a prática. Porto Alegre: ArtMed, 2000.).

The individual’s adaptation to stress factors must not be subservient to the hegemonic models of a society in collapse, such as the current capitalist society. From the point of view of social construction, it is certainly more comfortable to characterise the illness of a group as “outside the norm”, since to understand the process of their illness is to point to a structure that overlaps with society as a whole.

The environment characterised by social isolation, structural conditions that are unable to accommodate and meet the health, educational and labour needs to achieve resocialisation are stressful factors for the health of these individuals. The failure is evidenced by their return to the prison system, the economic marginalisation of the population that has experienced imprisonment and their exclusion from the job market and even constitutional rights.

As ways of preventing such circumstances at the three levels, as established by Neuman (George ., 2000GEORGE, J. B. et al. Teorias de enfermagem: os fundamentos para a prática. Porto Alegre: ArtMed, 2000.), we would have as alternatives, in primary care, health education, mental health care, adequate food, housing, leisure and work conditions, sex education and preventive examinations as a way of reducing stress factors, as well as immunisation, personal and sanitary hygiene and harm reduction as a way of strengthening the line of defence. In secondary prevention, active search, appropriate treatment, provision of health maintenance resources, early diagnosis and treatment of symptoms. And inclusion in work and educational activities, as well as continuing education for professionals and social participation as rehabilitation in tertiary prevention. For comprehensive care of the population, these measures should be applied before, during and after the prison experience.

Final considerations

Based on Neuman’s concept of illness as “a state of insufficiency in which needs have yet to be satisfied”, we can affirm that the prison population is ill and, according to the results of various studies, continues to be ill after the experience of imprisonment. Well-being, health, development and progress are the privilege of a few, while most of the population lives on the edge. In other words, the transformation must be a social one. It is necessary not only to re-establish these conditions, but also to provide support for their development after imprisonment, while also seeking to develop social models that prevent the circumstances that lead to it. It can be concluded that social relations interfere directly in the health determinants of the prison population, in a predominantly negative way, and that the prison environment, in Brazilian institutions and in other emerging countries, also identified as late capitalist, provides degrading conditions for people.

This study makes it possible to suggest some interventions: decarceration, better financing of the prison system, improvements and standardisation of the information system on the living conditions and health of the population, greater participation by society in the process of resocialisation and the training and improvement of professionals, support for effective social reintegration. Furthermore, producing science with a revolutionary theory that aims to analyse the relations of production, social development and the determinants of the population’s health, before, during and after incarceration, can be considered a breakthrough in the way we do and understand health, aiming to change the way we deal with the problems caused by the capitalist system, acting in a praxis way, thus interfering in objective reality, as proposed by the field of Public Health Nursing.

From this analysis and reflection, it is clear that only the revolutionary practice of nursing will be a tool for the praxis of social change. The antagonism of social classes will continue to perpetuate a sick system at all levels, one of these classes will be oppressed and will suffer more from this structure, and it is up to them, as workers, to act in favour of development and in line with the scientific and philosophical advancement of our work, and as social and political beings, we will continue to seek the emancipation of the whole human being, inside and outside prison.¹

Acknowledgements

Rocha, M. V. C. would like to praise the teachers at the School of Nursing at the Federal University of Alagoas who supported her during her undergraduate studies and on her journey to becoming a researcher, especially Oliveira, K. C. P. do N. and Dantas, H. L de L. who accompanied her on this first production and encouraged her to follow the path of science. And unspeakable affection and gratitude to Pereira, M. R. today and always.

References

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