Incarcerated Health : Profile of the Multidisciplinary Team Provider of Health Assistance in Prisons

1 Nurse. Doctor of Sciences. Professor of Nursing Graduation (UFPB), João Pessoa (PB), Brazil. 2 Nurse. Doctor of Nursing from the University of São Paulo (USP). Postgraduate Professor of Health Models and Decisions (PPGMDS/UFPB). Professor of Nursing Graduation (UFPB). João Pessoa (PB), Brazil. 3 Nurse. Member of the Group of Studies and Research in Administration and Informatics in Health (GEPAIE/UFPB). João Pessoa (PB), Brazil. 4 Nurse. Doctor of Nursing. Professor of Nursing Graduation (UFPB). João Pessoa (PB), Brazil. 5 Nurse. Specialist in Pediatrics and Obstetrics. João Pessoa (PB), Brazil.


Introduction
Health, since it is a social right, is essentially the responsibility of the public authorities, which must develop public policies to be implemented through programs, projects and strategies, so as to guarantee citizens the provision of actions and services at different levels of attention, from the perspective of prevention, promotion, rehabilitation and recovery.
Universal and equitable health actions and services should be developed with a view to comprehensive care, in a decentralized manner at the three governmental levels, with the effective participation of the community, being supported by Law 8.080 of 1990.This Organic Law of Health has been considered an ideal model of political and organizational formulation, contributing to many changes in the context of the health/illness process of the population that uses the services.It also supports the areas of confinement of persons in prisons who require daily health care, raising the need for appropriate measures, which will result in solving the problems experienced by these vulnerable clientele [1].
In this way, the prisoners' health care becomes a decisive factor for the minimization of problems, and the health professional must be present in the prison units, in order to carry out preventive and curative actions, in order to identify the aggravations and promote decentralization, in compliance with the organizational principles of the Unified Health System (SUS), in addition to what is advocated in the National Health Plan of the Penitentiary System (PNSSP).
Health care improperly provided to inmates threatens the lives of this clientele and also facilitates the transmission of various diseases to the general population, with visitors, family members, or persons authorized to make visits and, in some cases, intimate visits.The precariousness of this assistance can also spread diseases, because inmates are not completely isolated from the outside world and uncontrolled contamination between them represents a serious threat to public health [2].
The number of prisoners in Brazil increased from 233,859 to 514,582 between 2011 and 2012, which represented a 120% increase in inmates in the national penitentiary system.In 2016 Brazil reached 600 thousand people in prison, a statistic of 581 thousand for the year 2015.In proportional data, the country registers 300 inmates for every 100 thousand inhabitants.The country exceeds its prison capacity in more than 200 thousand places.[3] In the State of Paraiba in 2011, a record of 8,210 inmates was detected, and in 2012 this number jumped to 8,576.In 2013, there was a record of 8,756 prisoners of both genders.In 2014, the number of prisoners increased to 9,200 inmates, resulting in a worrying statistic, considering that the annual growth considered by the Brazilian Institute of Geography and Statistics (IBGE) is ten times in 138 years.With this exponential growth the State of Paraíba occupies the third place of the Northeast, after Pernambuco and Ceará and the sixteenth place in relation to all the States of Brazil [4,5,6,7,8].
The State of Paraíba still presents a worrying disproportionality with 11 dentists, 3 clinicians, 8 nurses, 10 nursing assistants, 1 pharmacist, 22 psychologists and 34 social workers, when the need would be of 16 professionals for each modality [9].
According to the provisions of the PNSSP, establishments with more than five hundred prisoners, such as the Instituto Libertador Penitentiary Silvio Porto, which is the locus of this study, should have two health teams with a weekly workload of 20 hours for each team [10].In this Institute, during the visit to reconnoiter the area and planning the actions, it was verified the existence of 804 inmates and only one health team, composed of 01 nurse, 02 nursing technicians, 01 doctor, 01 psychologist, 01 social worker, 01 dentist and 01 dental assistant, working on a shift, which corresponds to twenty hours of work a week.
At the time, we defended the thesis that, with a quantitatively insufficient number of health professionals, incompatible with the needs of disease prevention, promotion, treatment and maintenance of health, in the short term, this sector of the Paraiban prison system would enter into a situation Collapse with a characteristic of irreversibility of the situation.
It is also worth noting the importance of carrying out this study, given the need to develop scientific research that can subsidize the improvement of the current health scenario observed in the daily life of the penitentiary system.In view of the above, it is questioned: the profile of the health team of a prison unit in João Pessoa/PB complies with current legislation?

Method
The research was carried out at the Criminal Institute of the Judge Sílvio Porto, located in the municipality of João Pessoa/PB.It is a medium security establishment with a capacity for 640 vacancies, intended to house convicts in a closed regime, serving a sentence of deprivation of liberty with a sentence of more than four (4) years [11,12].
The Institute was selected as a research scenario by the presence of a multidisciplinary health team, required by the State Health Plan of the Penitentiary System (POESSP), in compliance with the criteria established by the National Health Plan of the Penitentiary System (PNSSP).
The study was approved by the judge of the Court of Criminal enforcement of the city of João Pessoa, and the Director of the Criminal Institute for Judicial Detention Silvio Porto, formally communicated for the release of access to the institution's facilities to perform data collection.The Research Ethics Committee used to authorize the study was the National School of Public Health of the Oswaldo Cruz Foundation (ENSP/FIOCRUZ).The process was approved under the Protocol CEP/ENSP -nº 304/11 and Certificate of Presentation for Ethical Appreciation (CAAE): 0321.0031.000-11.
This is an exploratory and descriptive study, motivated by the desire to understand the profile of multidisciplinary health teams, health care providers in prisons.This type of research focuses on complex social phenomena, allowing researchers to retain the holistic and meaningful characteristics of real-life events such as individual life cycles, small group behavior, organizational, administrative, and individual processes, besides politicians, and related to them [13].
The existence of a health team within the prison unit that constituted the research scenario and is a reference for other penal establishments, being the pioneer in this initiative in the city of João Pessoa, based the option for the method for the construction of this academic investigation.There was no pre-determined number of subjects to be included in the sample, since in qualitative investigations, the concern should be the deepening, comprehensiveness and diversity in the comprehension process, be it a social group, an organization, a Institution, of a policy or representation [13].
For this investigation, we worked with eight professionals, who chose to respond to the interview script collectively.The medical professional did not contribute to the team, withdrawing from the health unit at the time the team met.The data collection took place in August 2012 and was preceded by the knowledge and acquiescence of the Informed Consent Form of the interviewees, which assured the healthcare professionals, explanations about the objectives of the investigation, the Importance of the reliability of the information provided, the guarantee of anonymity, the importance of their contribution and the right to freedom to withdraw from the research at any time if they so wished.
The Interview technique of the structured or standardized type was used.In the sequence, the statements were interpreted, following the technique of the Thematic Analysis in the search for the sense nuclei to construct a communication in which the presence of certain themes expressed the reference values and the behavior models present in the discourses related to the analytical object [13].
The research was developed in two parts.The first investigated the profile of the multidisciplinary team providing health care in the prison.In this stage, an interview form was applied to identify the sociodemographic profile and the following variables: postgraduate degree in the area and form of entry into the system.The second part of the research sought the testimonies of the multidisciplinary team in relation to the activities developed in the prison health service.At this stage, professionals answered the following questions: How many prisoners were affected within the pavilions?What illnesses did these prisoners suffer and whether these prison inmates were being treated?What are the activities developed by the team?What difficulties were encountered in the service that interfered with the development of the actions carried out by the health team?

Results and Discussion
The understanding of the profile of the multidisciplinary teams providing health care in prisons should be preceded by a reflection about basic health care and its intersection between the health-disease processes and the health work process.These two processes, of notable interest to the object of study of this research, refer to the pioneering work of Maria Cecília Ferro Donnangelo, on medicine as a technical and social practice, using Sociology in its theoretical references.Donnangelo's reflections allowed the construction of consistent analyzes on the relations between health and society, breaking with the vision of independence between social life and the way of execution of health practices.Donnangelo's studies revealed two major themes in the field of health: on the one hand, the structuring policies of care, which opened the perspective for studies on the Brazilian health system, to the current Unified Health System; On the other, studies on professions, market and health practices [14].
Ricardo Bruno Mendes Gonçalves in 1992 formulated the concept of Work Process in Health, from the analysis of the medical work process, in particular.For this author, the term "work" refers to the idea of "energy and transformation", processed in a single path.The work is a set of procedures by which the human beings act using energy, through means of production, on some object, to transform it and to obtain certain product with utility [15].
In particular, health work is characterized as a form of "live-in-work".In this case, the human work carried out determines the production of care and directs the decision making, through the interaction with instruments, norms, machines, besides several types of technology.These authors, previously mentioned, classify the technologies used in the production of health work as: Hard technologies, light-hard and light.Duras technologies are those that involve the use of instruments, while Light-hard technologies involve the use of technical knowledge, and light technologies emerge from the relationships between the subjects involved in the process [16].
In our research scenario, the production, composed of hard, light-hard and, above all, light technologies, is developed by a team that, in quantitative terms, only partially meets the provisions of the National Health Plan of the Penitentiary System (PNSSP), since it counts on professionals related to the Plan, but does not meet the numerical prerequisite.
At the time of data collection for this research, it was verified the existence of a health team, composed of 01 nurse, 02 nursing technicians, 01 physician, 01 psychologist, 01 social worker, 01 dentist and 01 dental assistant, working In one shift, which corresponds to twenty hours of work per week to serve 804 inmates.
The work process of the team was deficient, due to the high number of users in relation to the reduced number of professionals composing the health team, as well as in relation to the capacity of the unit.The proceeding is uninterrupted and follows the following processuality: -Start of work, at 08:00 in the morning, with the arrival of professionals from the health unit.
-Beginning of the professional activities, with the arrival of prisoners, escorted by penitentiary agents, and distributed to each professional, in a rotation system.-Rodízio of the prisoners in attendance by the professionals, by groups of four users in average of 20 to 30 minutes, being able to vary according to the procedures to be carried out.-Completion of the services, around 12h00min and closing of the day's activities.The follow-up of the work process of the health professionals working at the Criminal Justice Institute Silvio Porto evidenced the occurrence of a workload far superior to the capacity of the team, not only in numerical terms, but also, in relation to the complexity of the problems brought by users to the unit, such as: "Burning in the mouth of the stomach" -Pirose Stomacal; "Sleep without sleep" -Insomnia; "Palpitation" -Tachycardia; "Willing to weep" -Anguish; Sexually transmitted diseases, AIDS and infectious diseases, among others.It was verified that health activities, focused only on the morning shift, do not guarantee the care of the prison population and, therefore, the access of those who are in fact sick.
The PNSSP determines that establishments with less than 100 prisoners should not have exclusive health teams, and prisoners must be served in the public health system.Penal establishments with a number between one hundred and five hundred prisoners must hire a health team with a workload of twenty hours a week, and establishments with a capacity of more than five hundred prisoners, such as the Silvio Porto Judicial Detention Institute, should have two health teams [10].
Of the eight professionals that make up the current health team in the research scenario, five have a higher level, while three are of medium level.The team develops multidisciplinary and interdisciplinary actions in Primary Health Care.
The actions of a multidisciplinary nature occur when the holders of the various professions in the health area perform their specific activities without necessarily being connected with the others, while the actions of an interdisciplinary character are those in which the specific actions of each profession have a relation of Dependency on one another, or at least between two or more professions, in the context of basic care.Ordinance No. 2,488, dated October 21, 2011, of the Ministry of Health, defines Basic Health Care as:

A set of individual and collective health actions covering health promotion and protection, disease prevention, diagnosis, treatment, rehabilitation, harm reduction and health maintenance with the aim of developing comprehensive care that affects The health situation and the autonomy of the populations and determinants of health". [17]
Basic Attention is developed through the exercise of care and management practices, democratic and participative, in the form of teamwork, directed to populations of defined territories, for which it assumes the sanitary responsibility, considering the dynamism existing in the territory in which these populations live.It uses complex and varied care technologies, which should assist in handling health demands and needs of greater frequency and relevance in its territory, Observing criteria of risk, vulnerability, resilience and the ethical imperative that any demand in need of health or suffering must be accepted [17].

Age
The predominant age group among health professionals filled out at the Judicial Institute Silvio Porto was 40 to 50 years.In the age group between 60 and 70 only one professional was found, while two are in the age groups between 20 to 30 and between 50 to 60 years, respectively.

Wage Income
The monthly income of professionals of a higher level is approximately R $ 3,300.00(three thousand and three hundred reais), while the average salary range is around R $ 678.00 (six hundred and seventy-eight reais).

Training time, professional practice and areas of operation in prisons
According to the data obtained in the research, it was verified that half of the sample, four, is in the range between 28 and 33 years, for the time of training, professional practice and performance in prisons, two are in the range less than five years, and the rest, two, did not respond to this questioning.
Regarding the areas of action, two of the interviewees mentioned having acted in mental health, especially in prisons; Four worked in several areas of nursing, such as medical clinic and public health, and two did not respond to the question.

Qualification, post-graduation in the area, form of entry into the system and difficulties encountered in the service
Regarding training, the entire sample interviewed reported having attended a course related to the professional area, regarding the prisoner's health care.They ensured that this item is well attended by the Institute's management and that recently they participated in the First State Seminar on Penitentiary Management, in addition to in training on resocialization of the prisoner, humanization and reception.
In the aspects related to postgraduate courses in the health area, focusing on the work object of each professional of higher education, half said that they did not have a course in this level of training.However, one interviewee is trained in Forensic Sexuality and Family Health, while another, claimed to have a course in mental health and pedagogy.The rest, do not have a postgraduate course, but training or improvement, yes.With regard to admission to the state penitentiary health service, two responded through a selective process, and six in non-selective processes.
According to information obtained in the nursing service of the Criminal Institute of Justice Silvio Porto, the health team develops the following actions with inmates who request care: Administration of H-type Viral Protein Hemagglutinin and N-Enzyme Neuraminidase on the surface of the virus (H1N1), influenza, triple viral and pneumococcus, in addition to administration of other drugs; Rapid test for HIV identification; Control and follow -up of tuberculosis -TB; Treatment and follow-up of leprosy patients; Hyperdia and controlled medication.
Other services were identified in relation to health education; Such as distribution of educational material and condoms on the day of the intimate visit to the female partners; Assistance to the family of the inmate, seeking to resolve doubts; Promotion of emotional support for the prisoner's family; Inclusion and reception, with re-education for resocialization; Psychological evaluation; Psychotherapeutic accommodation; Conduct of medical, nursing and psychology anamnesis; Among these activities, depending on the need of the inmate user, the referral to other services of medium and high complexity was also part of the activities of the health team; Besides the active search for the most incidental diseases, such as tuberculosis, AIDS and sexually transmitted diseases, taking into account the communicators, with collection of material for examinations; Receiving, for treatment, inmates from other prisons, for knowing the existence of the program; Bureaucratic administrative procedures inherent to each profession and Dental extractions due to lack of material for restorations.
At that time, the health staff of the Silvio Porto Criminal Institute assisted thirty-two prisoners, suffering from tuberculosis, hypertension, sexually transmitted diseases, diabetes and AIDS, all of whom were treated with a drug regimen.Regarding the medicines and equipment used by the health team, in the research scenario, some were not found, contrary to what is established by the PNSSP, necessary for care in prisons in Brazil.
However, in addition to the pathologies mentioned above, others could be added to the list if a continuous flow of care was maintained in the health unit.Therefore, this flow is often interrupted due to the numeric deficiency of penitentiary agents to lead the inmate to the health service.It was also verified that besides the delay to the beginning of the expedient, as faults of the medical professional, also they hamper the attendance to the demand.It is worth emphasizing that the nonparticipation of this professional in the study led to a lack of deepening in the problems related to this area, in particular.
According to the PNSSP, in Brazil the actions developed by the health team should be linked to health care networks, in view of the fact that their fundamental attributions should be centered on the planning of health actions, promotion and vigilance, besides Maintenance of interdisciplinary teamwork [9].
Considering that interdisciplinary work is one in which the specific actions of each profession have a relationship of dependency among themselves or at least between two or more professions, in the context of basic care, this item of the National Health Plan of the Penitentiary System in the Institute Criminal Judge Silvio Porto is extremely deficient.
Health work is essential for human life and is part of the service sector, being in the sphere of nonmaterial production, which is completed in the act of its realization.It is a collective work carried out by several health professionals and other groups of workers, who carry out a series of activities necessary for the maintenance of the institutional structure [18].
The care model in force in the great majority of health services is guided by the neoliberal and specialist approach, which in practice defines the mission of services according to other powerful and legitimate interests.These interests unprotect the work and the worker, interfering in their labor processes.
The work of health professionals still suffers Taylorist influences, translated into accumulation of administrative norms and technical standards, guided by the belief in the possibility of controlling and regulating the total set of work.The Taylorist influence in health services occurs when people are administered as if they were instruments, things or resources, devoid of will or own project [19].
The notion of health work is based on the division of labor, in order to defend that health care, planned and executed in order to achieve what it proposes, comprises a diversified series of actions, for which a diverse cast is necessary of workers.Thus, it is necessary to achieve the conscious and coordinated relationship of a certain number of professionals, so that the whole of the work performed, the health care service, constitutes a single movement towards a single end, not the juxtaposition Alienated from a certain amount of disconnected jobs [20].
In prisons, vulnerable people are found, showing a very evident degree of fragility, due to the absence or precariousness of the basic conditions of survival in the prison environment, besides the overcrowding, insalubrity and violence, to which they are subjected.Brazilian prisons serve as a mechanism for officializing the exclusion that already hangs on detainees, such as a notarized attestation [7,21].

Conclusion
The results showed that prisoners' health care has not been developed in order to comply with current legislation, because the Criminal Justice Institute Silvio Porto complies only in part with the provisions of the National Health Plan of the Penitentiary Sys-tem (PNSSP), since it counts on professionals related to the Plan, but does not meet its numerical prerequisite, due to the reduced contingent of health professionals in the staff hired for this purpose, as well as the support staff (penitentiary agents) to enable this process.
The reduced number of professionals prevents the daily monitoring of inmates, which could be carried out through active search of the elective cases, but potentially complex.This reinforces the immediate need for expansion of this team, in line with the determination of the legislation in force.
With regard to the difficulties encountered in the service that interfere in the development of health actions, the staff of the team were unanimous in affirming that the problems listed are decisive in their creation and proliferation, the reduced number of prison staff being frequently mentioned to lead the inmate to the health sector, causing a low demand for the service; Administrative constraints caused by the inmates' condition of confinement; difficulties for medium complexity care, which do not depend on the team, but interfere with the improvement of the prisoner's health; Lack of transportation and escort to drive the inmate to the external service, making it difficult to schedule consultations and/or examinations, delaying care and, consequently, aggravating the prisoner's state of health; Occasional rebellions, which promote the suspension of care, with a break in the continuity of treatments; Delay of their individual liberty and, consequently, increasing their vulnerability to diseases.
Regarding these proposed dilemmas, we defend the position that it is necessary to propose forms of work organization that have an impact on the quality of care and, at the same time, consider the possibility of performing interdisciplinary, creative and integrative work.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.

archIves of MedIcIne sectIon: Global health & health PolIcy ISSN: 1755-7682
age, sex, wage income, training time, professional practice time, prison time, workload, training and/or InternatIonal