Aim: to identify the activities that promote mental health carried out by women deprived of their liberty, given the difficulties encountered during the period of imprisonment. Method: descriptive, exploratory, qualitative study with forty women deprived of liberty in a female prison in the state of Rio de Janeiro, who were interviewed based on a semi - structured script. The data obtained, subject to the analysis of content in the thematic modality, gave rise to the category Protection factors of the mental health of the incarcerated women. Results: women have pointed to factors that protect their mental health: studying, working, performing leisure activities (singing, talking, reading) and religious activities. Conclusion: health promotion activities with a focus on mental health should be rethought in order to ensure the mental health of women deprived of their liberty.
Descriptors: Women's Health; Prisons; Mental Health; Health Promotion.
Social differences within Brazilian society become acutely evident in the area of mental health, especially in the prison system(1). Recent studies have shown an increase in the number of women imprisoned in several countries, including Brazil(2) which has the fourth largest prison population in the world behind the United States, China and Russia. In Brazil, 41% of prisoners are still awaiting trial, 3% are in an open regime and 15% are held in a minimum-security regime. This has resulted in prison overcrowding, and exposes ever larger numbers of women to the consequences of incarceration(3).
Prison has the expressed objective of transforming the character of individuals. To achieve this objective, it adopts varied approaches such as social isolation, work (imposed in some institutions) and corrective techniques. Currently, regarding the return of prisoners to society, there is a consensus that such measures are ineffective. This can result in former prisoners relapsing into crime and, consequently, their return to prison(4). This further increases their vulnerability within a prison environment.
Considering that the prison system may lead to health problems or aggravate existing conditions(5), it is important to offer conditions of confinement that favor the physical and mental well-being of the individual deprived of liberty, guaranteeing them the right to health, as determined by the Article 196 of the Brazilian Constitution. A subject that deserves special attention for their peculiarities is the health of women deprived of liberty, because of the great vulnerability of this population facing issues related to the female gender. And, considering that most female prisons are adapted male prisons(6) and that the female prison population has been increasing rapidly, this issue has become increasingly relevant as an object of study.
According to the National Penitentiary Information System, there are 34,058 women incarcerated in Brazil, representing 7% of the total Brazilian prison population, with a deficit of 13,000 places in the Brazilian prison system for women deprived of their liberty(3).
Furthermore, when referring to health within the prison system, there is a great deal of concern about mental health as the number of mentally ill people involved in the Brazilian criminal justice system has continued to increase.(7) An American study found that 75% of women living in US prisons reported mental health problems, compared to 12% of women in the general population(8). This suggests that the mental health of incarcerated women is likely to deteriorate as a result of imprisonment, a factor exacerbated by their past and current life history(9).
Promoting health in a population involves identifying their needs and then modifying the environment to address these. This incorporates a wider recognition that health is the greatest resource for social, economic and personal development, as well as an important dimension of quality of life(10). For such promotion to be effective, a multiprofessional team is required to determine and coordinate a program of activities that constitutes an effective intervention and ensures the needs of the group in question are addressed. Additionally, knowing whom is being cared for is fundamental to the planning of strategic actions, their implementation and the evaluation of the impact professionals have as facilitators of prisoners’ health(11).
The objective of this study was to analyze the activities that promote mental health carried out by women deprived of their liberty, given the difficulties they mat experience while imprisioned.
This is a descriptive, exploratory research with qualitative approach, carried out from October 2014 to January 2015 in a female penitentiary located in the Gericinó complex, Bangu district, West Zone of the city of Rio de Janeiro, RJ, Brazil.
It is worth clarifying that in order to be authorized to carry out the research in the prison system, the Department of Penitentiary Administration of the State of Rio de Janeiro required compliance with certain requirements for data collection, namely: entry to the prison could only occur after daily conference of the prisoners; exit would have to occur one hour before the conference of the prisioners, in the nocturnal period; audio recordings, filming, photographs and reproduction of any document were prohibited inside the prison; the signature of the detainees in the Free and Informed Consent Form was also not allowed because the Penitentiary Administration Secretariat of Rio de Janeiro does not authorize the identification or nominal information of the prisioners, and it is necessary to sign the term by the prison supervisor after authorization from the participants. In this case, the requirements are justified based on that the Criminal Institution, on behalf of the State, is responsible for authorizing and taking responsibility for the participation of the incarcerated women in activities involving researchs.
The study participants were selected based on the official list of the institution to identify them in their health records. It occurred in a random and simple way, taking into account the odd end of the number on the respective chart, resulting in the selection of 40 women incarcerated.
These women were included according to the following criteria: to have medical records in the health service; Have an interest in participating in interviews for the collection of data; Being physically and mentally well to do so; And to have the authorization and presence of the penitentiary agents who were on duty at the time of the interview. Excluded were those who were released, suspended for security reasons or transferred to another prison unit.
Data collection was performed from information contained in the medical records and from the technique of semistructured interview carried out by the main investigator in the prison health clinic. Participants voluntarily answered a script containing open and closed questions. Prior to the start of the interviews, all the detainees were informed about the purpose of the research, being guaranteed the confidentiality of what was said, using an alphanumeric code (M1 ... M40) to be registered in the respective transcribed and validated interview.
In this sense, and considering the impossibility of using any electronic device at the time of the interview, for reasons already explained, the researcher had to capture and transcribe the answers to the questions, and then read the transcripts so that the interviewees could listen and demonstrate agreement or disagreement with the writing of the researcher, who sought to ensure the accuracy of the participants' speeches.
In order to perform the analysis and discussion of the results, we opted for content analysis in the thematic modality, in order to obtain information that expresses approximation with the reality given by the participants. It was identified the nucleus of meaning of the interviews that, in this study, enabled the elaboration of the construction of the following thematic category: Protection factors of mental health of icarcerated women.
The research was approved by the Ethics and Research Committee of the Federal Fluminense University (UFF), under protocol no. 696.795/2014, with CAAE no 27061114.3.0000.5243 and authorized by the Department of Penitentiary Administration of Rio de Janeiro by process E-2108753/2014, in compliance with Resolution No 466/2012 of the National Health Council, which deals with research involving human beings.
Protecting factors of mental health of incarcerated women
Women reported that psychological suffering in relation to mental health during their period of incarceration was mitigated through activities carried out in the prison environment such as education, an important social determinant of mental health. Within the interviews, they showed considerable interest in participating in educational activities within the prison. The reasons included: satisfaction in learning, facing the possibility of new dreams and keeping up to date with the "world" outside the prison, as shown in the following statements:
(...) School. I don’t miss class! They gave me a great opportunity to study. My dream was to read and write. (M3)
(...) School, a good thing, makes me feel good. Discuss daily things in class. School is a current communication way. (M12)
As for the work offered to the prisoners by the penitentiary system, it has the function of occupying the spare time and allowing the remission of the sentence. The satisfaction of the interviewees in working to "occupy" the mind was observed, as reported:
(...) My work help me a lot in here. (M5)
(...) I do laundry and cleaning, I occupy my mind. (M9)
(...) I finish cleaning, I wait nightfall and do cleaning in the cell. (M16)
Although women expressed considerable interest in both educational and work activities within the prison, work was generally dissociated from education, i.e., women either work or study, and this is demonstrated in the following statements:
(...) Who works, doesn’t study. (M2)
(...) I already studied, quit school to work. (M12)
(...) I’m working, don’t study. (M19)
Another situation found was that some women, such as pregnant women and the elderly, could not work:
(...) I asked to the Judy to work and took several courses. The elderly had no right to work. From the age of 60 we did not work. (M29)
(...) Pregnant does not take course or work. (M33)
Leisure contributes to a woman's quality of life. What the institution offers to inmates is the sunbathing, which takes place in an open environment, with predetermined hours and supervised by prison agents, when physical activities can be done in groups or individually. However, the interviewees showed no interest in sunbathing, as reported:
(...) I don’t like. I don’t like much of sun. (M5)
(...) I have not had it in a long time. When we can go, I don’t want to go. (M10)
(...) Never. If I went twice was a lot, I never liked. (M13)
In their testimonies, the interviewees described their preferred forms of leisure:
(...) I occupy my mind by reading. I love reading, music. (M2)
(...) I chat, lie down, discuss, play with my partner. She helps me spend time. (M5)
(...) I watch TV, read. I am cataloging the library books. (M32)
(...) I sit in the cafeteria, I sing and pray. (M38)
Religious activities, according to the women, were perceived as moments of well-being, beneficial for their mental health and a mechanism for survival within the prison system:
(...) I go to worship (...) whenever they have it. I’ll go whenever I can. I feel comfortable with the word of God. (M19)
(...) I go to worship, I like. I like of the Gospel. (M26)
(...) I go to worship twice a week, I feel good. (M33)
(...) God put me in here to reflect, so that I could be a new woman outside. (M36)
(...) I’ll pay what I messed up, I’ll take my jail with balance, with God. In the street I knew God as culture, but God can touch, I feel it here. (M40)
Although some of the interviewees didn’t attend any religious service, they demonstrate that they seek spiritual comfort through prayer:
(...) I do not go, there is no day or time (religious worship), I pray alone, talk with God. I really like the Gospel. (M12)
(...) I pray, read the Bible a lot. (M22)
(...) I pray a lot, I calm down. (M35)
Many interviewees are aware that they have to do something to prevent mental illness, and for this they develop some activities that make them feel good, as shown in the following statements:
(...) I prevent myself of many things, work my psychological, he commands my whole body. (M8)
(...) Writing does not make me sick, I write letters for my house, for my husband. (M17)
(...) The first time I got to prison, I looked at the food, put it in my mouth and remembered of my food. It is from this that a feed myself. I work my mind. (M29)
(...) I try to chat a lot, to forget, I avoid being alone. (M34)
Those constitute some of the activities developed by women in the prison system to promote their mental health and which function as protective factors for illness, reducing their psychological suffering.
Incarcerated women expressed the view that some of the activities they engage in bring them satisfaction and thus become protective factors for mental health, consequently they are psychologically healthier during their period of incarceration. Activities mentioned by these women include work, education, religion, reading, making friends, writing, listening to music, interacting with their partners and attending religious services seeking spiritual comfort. These may all be mechanisms that protect them from mental illness, and accords with female’s prisoners right to health as determined by the Brazilian Constitution.
Regarding the importance of the role of education and work, it is clear both activities include aspects that involve improving the image of women(12), effectively qualifying them for the labor market when they are released. However, work in the jail is an activity whose effective return to life in society is quite restricted(13).
Despite the expressed benefits of work and education for the preservation of their mental health, there are instances where prisoners are excluded from such activities, for example pregnant women, those who do not work or study, and elderly women who are unable to work. These women are left idle and often in isolation, which makes daily prison life difficult and can result in chronic suffering that leads to psychic discomfort. It is also important to remember that the preservation of prisoners’ mental health also promotes the preservation of good citizenship(14).
Another issue considered was the fact that people who worked did not study and vice versa, i.e., the two situations do not simultaneously happen as women choose to either work or study. Given that both factors may protect mental health and provide satisfaction for these women, this practice needs to be reviewed within the prison system. If it is appropriate for people in wider society to work and study, so why not offer the same conditions to incarcerated women? The clear implication is that that these activities have the objective of promoting mental health and will enable these women to enter the labor market when they are free.
Activities that promote mental and physical quality of life, social inclusion, citizenship and human development are carried out through sport and leisure(15). In Brazil, in 2003, according to Law No. 10.79214, Art. 52 § 4, "every prisoner shall be entitled to leave the cell for two hours a day for sunbathing", and in 2014, the National Policy on Attention to Women in Situation of Deprivation of Liberty and Egress from the Prison System (PNAMPE from the Portuguese - Política Nacional de Atenção às Mulheres em Situação de Privação de Liberdade e Egressas do Sistema Prisional)(16), Art. 3, guaranteed to women deprived of liberty the possibility of enjoying leisure in the prison institution. However, the interviewees showed no interest in sunbathing, an activity offered by the penitentiary system in an open place, with a day and time to happen.
According to the National Plan of Policies for Women, for women in general, leisure is seen as a family-related activity, alongside children, and almost always restricted to domestic space, little or nothing differing from routine. And for this plan, it is necessary to value and promote the initiatives and cultural production of women, their participation in the preparation and the accomplishment of sporting events, noting also that the sedentarism also contributes to the health problems(15).
Since it is necessary to encourage women to develop physical activities, the sunbathing provided by the female prison needs to be restructured and should be organized by specialized professionals who organize this leisure through healthy practices and promote change in the habits of the inmates. Incidentally, incarcerated women reported leisure when they performed other activities that provided them with more satisfaction, such as reading, talking to friends, watching television, singing, praying and working, which bring them a mental balance. It is necessary, therefore, to rethink what leisure means for the female gender within the penal system, and to pay more attention to the gender issue in the prison, paying attention even more to its peculiarities and needs(13).
Regarding religion, it was evaluated as an activity that brings satisfaction and provides emotional support to those interviewed. In this context, religious conversion to improve inmates' self-image functions as a strategy for adaptation to institutionalization(14).
It is important to emphasize that there are differences between the constructs religion, religiosity and spirituality: religion is the organized system of beliefs, rituals and symbols that facilitate access to the sacred; Religiosity refers to how much the individual believes and follows a religion; And spirituality concerns the personal search for understanding, related to existential questions and their relation to the sacred(17,18). In this way, women deprived of liberty seek, through worship, to express their spirituality in order to safeguard their own mental health, constituting a factor of personal protection against illness.
Religious care plays an important role in improving the mental health of an individual within the prison, whether male or female, because it offers emotional support in the face of specific sufferings and deprivations(19). Thus, religious assistance should be stimulated among the inmates, since it helps to alleviate the emotional situation of this population(20).
From the foregoing, it can be inferred that the interviewees themselves adopt measures that seem to them the most correct for the confrontation of psychic disorders, which must be respected by the prison authorities.
Knowing the activities developed by the interviewees with the purpose of promoting their own mental health in the period of incarceration, it is considered that it is possible to rethink the actions carried out within the female prisons, with the objective of preventing the psychological suffering of these women, understanding that the specificities of the gender should be considered as one of the determinants of health for the formulation of public policies. These should focus primarily on the promotion and prevention of mental health problems in this population that, when incarcerated, is much more vulnerable to psychic illness.
Through public policies designed specifically for the penitentiary system, the transformation of the living conditions of this population in this environment is desired. However, promoting health is not the exclusive responsibility of the health sector, but of several sectors, such as political, economic, social, cultural, environmental, behavioral and biological. Promoting health is ensuring a healthy lifestyle, a global well-being. In this sense, it is necessary for managers, health professionals, prison agents, incarcerated women and all the actors involved in this process to understand that the occupation activities in the jail should not be just another task for the incarcerated woman to occupy her spare time, but to be part of a project with specific activities aimed at this population and their real needs so that they are able to promote mental health within the female prison system.
All authors participated in the phases of this publication in one or more of the following steps, in according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the version submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf
Received: 04/05/2016 Revised: 01/31/2017 Approved: 02/02/2017