Self-reports of health before and during imprisonment in female inmates

Resea ch A icle Po J Public Heal h 2017;35:132–140 Sel -Repo s o Heal h be o e and du ing Imp isonmen in Female Inma es Joana Al es Ângela Cos a Maia School o Psychology, Uni e si y o Minho, B aga, Po ugal Recei ed: Decembe 7, 2016 Accep ed: May 22, 2017 Published online: Decembe 1, 2017 Joana Al es School o Psychology, Uni e si y o Minho Campus de Gual a PT–4710-057 B aga (Po ugal) E-Mail joana0812 @ gmail.com © 2017 The Au ho (s). Published by S. Ka ge AG, Basel on behal o Escola Nacional de Saúde Pública E-Mail ka ge @ka ge .com www.ka ge .com/pjp DOI: 10.1159/000481967 Keywo ds Female inma es · Risk beha io s · Heal h su eillance · Heal h complain s · Heal h s a us Abs ac The heal h o emale inma es has been desc ibed as mo e ulne able han ha o de ained male and he o e all emale popula ion. The pu pose o his s udy is o desc ibe heal h beha io s, his o y o diseases, heal h complain s, and heal h s a us o 232 inca ce a ed women. The women epo ed isk beha io s and unexpec ed heal h su eillance be o e hei imp isonmen . In p ison, hei obacco use inc eased, d ug consump ion dec eased and high a es o diseases, use o medicines, heal h complain s, and poo heal h s a us we e ound. The women’s pe cep ions o hei cu en heal h, compa ed wi h he ime pe iod be o e p ison, e ealed di - e en ypes o impac , wi h one- hi d epo ing heal h im- p o emen s. These da a sugges ha women p isone s’ heal h and he p ison’s impac on hei heal h mus be be e s udied in o de o enhance he heal h in e en ion p o- g ams du ing imp isonmen . © 2017 The Au ho (s). Published by S. Ka ge AG, Basel on behal o Escola Nacional de Saúde Pública Au o- ela os sob e a sua saúde de eclusas an es e du an e a p isão Pala as Cha e Reclusas · Compo amen os de isco · Vigilância de saúde · Queixas de saúde · Es ado de saúde Resumen A saúde das eclusas em indo a se desc i a como mais ulne á el do que a dos homens eclusos e do que a da população eminina em ge al. O obje i o des e es udo é desc e e compo amen os elacionados com a saúde, his ó ia de doenças, queixas de saúde e es ado ge al de saúde de 232 mulhe es de idas. As pa icipan es ela a- am compo amen os de isco e uma inespe ada igilân- cia de saúde p é ios à eclusão. Na p isão, o uso de abaco aumen ou e o consumo de d ogas diminuiu; e elou-se ambém a ele ada p e alência de doenças, de consumo de medicamen os e de queixas de saúde, assim como o es ado ge al de saúde debili ado. A pe cepção das eclu- sas sob e a sua saúde a ual, em compa ação com o pe ío- do de empo an e io à eclusão, e elou di e en es ipos This a icle is licensed unde he C ea i e Commons A ibu ion- NonComme cial-NoDe i a i es 4.0 In e na ional License (CC BY- NC-ND) (h p://www.ka ge .com/Se ices/OpenAccessLicense). Usage and dis ibu ion o comme cial pu poses as well as any dis- ibu ion o modi ied ma e ial equi es w i en pe mission. Sel -Repo s o Heal h be o e and du ing Imp isonmen in Female Inma es 133 Po J Public Heal h 2017;35:132–140 DOI: 10.1159/000481967 de impac o, com um e ço das mulhe es a ela a melho ia do es ado de saúde. Es es dados suge em a impo ância de ap o unda o es udo da saúde das mulhe es eclusas e o impac o da p isão no es ado de saúde, a im de ap i- mo a os p og amas de in e enção em saúde du an e a eclusão. © 2017 The Au ho (s). Published by S. Ka ge AG, Basel on behal o Escola Nacional de Saúde Pública In oduc ion The inma e popula ion has been he subjec o a num- be o s udies ha demons a e speci ic cha ac e is ics, ega ding hei amilial, social, demog aphic, economic, educa ional and beha io al backg ounds, which make hem highly ulne able [1]. This ulne abili y is e lec ed on se e al domains, bu i has a special impac on heal h. G owing up in ad e se en i onmen s, wi h less access o educa ion, heal h se ices, and job oppo uni ies, acili- a es he adop ion o isk beha io s and he de elopmen o ad e se expe iences ha could esul in poo physical and men al condi ions [2]. As a consequence, inma es usually a i e in p ison p esen ing a debili a ed heal h condi ion, including a highe p e alence o subs ance abuse, men al diso de s, and in ec ious and ch onic dis- eases [3, 4]. I heal h s a us in an imp isonmen en i onmen is wo h highligh ing, he heal h o he emale p ison popu- la ion equi es e en mo e dedica ion om bo h he sci- en i ic communi y and cu en heal h policies. Al hough gende is one o he mos signi ican demog aphic p edic- o s o heal h s a us [3], i has been g ea ly neglec ed in s udies on inma e popula ions. Because o his gap, many au ho s ha e ocused on heal h condi ions in p ison en- i onmen s and concluded ha emale inma es, when compa ed wi h de ained men o wi h he o e all emale popula ion, expe ience highe le els o ulne abili y and ha e highe a es o heal h isk beha io s and heal h p oblems, be o e and du ing imp isonmen [4–8]. Al hough in es iga ion o de ained women has been inc easing in ecen yea s, a numbe o gaps emain in he cha ac e iza ion o he gene al heal h s a us [9], sexual beha io s, women’s speci ic heal h needs [6], and p e a- lence o ch onic diseases [10]. As s a ed ecen ly by Mos- che i e al. [11], desc ip i e s udies a e needed o aise awa eness o he speci ic heal h issues o de ained women and o suppo he decision-making abou he mos ap- p op ia ed heal h se ices in emale p isons. The e o e, his a icle in ends o cha ac e ize he heal h o a sample o emale inma es in 4 ca ego ies: heal h beha io s, his o y o heal h and disease ea men , heal h complain s, and gene al heal h s a us. The s udy o hese ca ego ies pa es he way o add essing he ollow- ing objec i es: (a) iden i ying heal h isk beha io s: o- bacco, alcohol, d ug consump ion, and sexual beha io be o e and du ing imp isonmen ; (b) moni o ing sel -de- s uc i e beha io s: numbe o suicide a emp s du ing li e ime and sel -ha m beha io s du ing imp isonmen ; (c) e alua ing heal h su eillance, ha is, he use o heal h se ices be o e imp isonmen ; (d) accessing li e ime his- o ies o sexual and ep oduc i e heal h; (e) accessing li e- ime his o ies o in ec ious, con agious and ch onic dis- eases; ( ) moni o ing he consump ion o medicines du ing imp isonmen ; (g) accessing physical and psycho- logical heal h complain s du ing imp isonmen ; (h) cha - ac e izing gene al heal h s a uses and indi idual sel -pe - cep ions o heal h du ing imp isonmen , and compa ing hese wi h he indi idual sel -pe cep ions o heal h be o e imp isonmen . Once he s udy has been ca ied ou in wo Po uguese emale p ison es ablishmen s, i is ele an o cla i y ha , in Po ugal, he access o heal h ca e by he p isone s should ollow he Eu opean ecommenda ions, conside - ing he p isone as a ci izen, wi h ull igh o access o heal h ca e. The Po uguese law s a es ha a p isone has he igh o access he Na ional Heal h Se ices unde iden ical condi ions o hose gua an eed o all ci izens; e en mo e, p ison es ablishmen s mus be p epa ed wi h adequa e acili ies and equipmen o he needs o daily li e o p isone s, namely he heal h needs. The e o e, each e- male p ison has i s own heal h se ices including nu ses, a gene al p ac i ione (GP), a psychia is , a gynecologis , an in ec ologis , a psychologis , and a den is . This heal h ca e acili y ope a es 24 h/day wi h a nu se p esen a all imes. Immedia ely a e admission, all new de ainees a e submi ed o a iage p ocess by a p ima y heal h ca e nu se (wi hin he i s 24 h) and by a GP (wi hin he i s 72 h) in o de o iden i y any possible heal h p oblem. Me hod Pa icipan s Two hund ed and hi y- wo inma es in Po uguese women’s p isons pa icipa ed in his s udy. O he 596 women who we e de ained in he only wo special eminine p isons du ing he e- c ui men pe iod, 4 we e eleased be o e esea ch s a could ap- p oach hem. O he women who we e sc eened, 71 did no mee he ollowing inclusion c i e ia: abili y o communica e in Po u- guese and no being in an inpa ien clinic condi ion due o uns able physical o men al heal h. O he emaining 521, 250 (48%) wom- en we e andomly selec ed. Two hund ed and hi y- wo women Al es/Cos aMaia Po J Public Heal h 2017;35:132–140 134 DOI: 10.1159/000481967 ag eed o pa icipa e in he s udy. The emaining 18 (7.2%) de- clined o decided o in e up hei pa icipa ion du ing da a col- lec ion. The esponse a e was 92.8%. The mos common eason o de en ion (n = 131; 56.5%) was subs ance- ela ed c imes. Jus o e hal (n = 122; 53.3%) o he women had been de ained o 12 mon hs o mo e, and mos o hem (n = 150; 65.2%) had al eady been sen enced. The mean sen- ence leng h was 79.06 mon hs (wi h a minimum o 6 mon hs and a maximum o 324 mon hs). A la ge majo i y (n = 179; 77.8%) had been de ained o he i s ime and, among he ecidi is s, he highes numbe o e-o enses was 4. Ma e ials Demog aphic and Ju idical Ques ionnai e. The demog aphic measu es comp ised age, na ionali y, e hnici y, educa ion, em- ploymen , mo he hood, and ma i al s a us. The ju idical measu es we e p ison, he ype o c ime, he du a ion o imp isonmen , whe he hey had been sen enced o we e on emand, he leng h o he sen ence, and he numbe o imes he women had been a - es ed. Risk Beha io and Heal h His o y Assessmen Su ey. A isk be- ha io and heal h his o y assessmen su ey was c ea ed o his s udy. I con ained ques ions on heal h isk beha io s ( obacco, alcohol and subs ance consump ion along wi h sexual beha io be o e and du ing imp isonmen ); sel -des uc i e beha io s (numbe o suicide a emp s du ing li e ime and sel -ha m beha - io s du ing imp isonmen ); heal h su eillance (p e ious con ac wi h heal h ca e se ices); sexual and ep oduc i e li e his o y; and li e his o y o in ec ious, con agious and ch onic diseases. Pa ici- pan s we e also asked whe he hey had aken any ype o medica- ion du ing hei imp isonmen . Ro e dam Symp om Checklis [12]. This ques ionnai e e alu- a ed ecen heal h complain s and ea u ed a lis o 29 symp oms di ided in o 2 ca ego ies: physical and psychological symp oms. The i em esponses we e gi en on 4-poin Like - ype scales: “no a all,” “a ew imes,” “some imes,” and “ e y o en.” Howe e , o da a analysis pu poses, we dicho omized hese a iables and com- bined “no a all” and “a ew imes” as 0 and “some imes” and “ e y o en” as 1. The in e nal consis ency eliabili y coe icien o he scale sco ed on he Po uguese sample was e y good (C onbach’s alpha o 0.91) [13]. Sho -Fo m Heal h Su ey (SF-12) [14]. SF-12 measu es subjec- i e heal h s a us in 8 heal h aspec s and esul s in a physical com- ponen summa y (PCS – subscales o physical unc ion, physical pe o mance, pain, and gene al heal h) and a men al componen summa y (MCS – subscales o i ali y, social unc ion, emo ional pe o mance, and men al heal h). Th ough a speci ic algo i hm, we ob ained sco es anging om 0 o 100, whe e 100 co espond- ed o he bes pe cep ion o heal h. The SF-12 sco e was p oduced using he Heal h Ou comes Sco ing So wa e 4.0 (Quali yMe ic Inco po a ed, New Yo k, NY, USA). Rega ding he in e nal con- sis ency o he Po uguese e sion, he C onbach alphas we e 0.79 o he PCS and 0.81 o he MCS. Sensibili y es s ha e shown ha he SF-12 appea s o be a alid measu emen o heal h s a us [15]. O e all Heal h and Heal h p io o Imp isonmen . Two i ems we e c ea ed o measu e o e all heal h and heal h p io o imp is- onmen . On he i s i em, inma es we e asked abou hei cu en heal h: “O e all, how would you desc ibe you heal h?” This ques- ion had 5 possible answe s: “excellen ,” “ e y good,” “good,” “ ai ,” o “poo .” The second i em asked inma es o compa e hei cu en heal h wi h hei heal h p io o being inca ce a ed (“Com- pa ed wi h he ime be o e you we e a es ed, how would you de- sc ibe you cu en heal h?”). The ques ion had he ollowing 5 possibili ies o answe s: “much be e ,” “be e ,” “app oxima ely he same,” “wo se,” o “much wo se.” P ocedu e A e app o al om he E hics Commi ee o he Gene al Di- ec o a e o P ison Se ices, he da a collec ion was scheduled wi h he di ec ing boa ds o each p ison in ol ed in his s udy. Da a we e collec ed indi idually by ained esea che s who we e no pa o he p ison pe sonnel, allowing inma es o sha e in o ma- ion in an en i onmen o con iden iali y. A he beginning o each in e iew, he aims o he s udy we e explained, and da a we e col- lec ed a e ob aining he in o med consen . Analysis/S a is ical Me hods Da a analysis was conduc ed using he s a is ics so wa e IBM SPSS e sion 20. The means and s anda d de ia ions o he in e al a iables and he equencies and pe cen ages o he nominal a i- ables we e calcula ed in o de o pe o m he desc ip i e analysis necessa y o accomplish he aims o his s udy. Fo he epo o pe cen ages, we conside ed he alue o alid pe cen age o be e exp ess he di e ences amoun o missing alues o each a iable. The medians o he wo main componen s o he SF-12 we e also calcula ed in o de o compa e hese esul s wi h he no ma i e alues o he Po uguese popula ion [13]. Fo his compa ison, he one-sample Wilcoxon signed- ank es was used. Resul s A summa y o he pa icipan s’ sociodemog aphic cha ac e is ics is p esen ed in Table 1. Heal h Risk Beha io s Rega ding obacco consump ion, 56.9% (n = 132) o he pa icipan s we e smoke s, and he mean age o ini- ia ing smoking was 16.73 yea s (SD = 6.50), anging om 9 o 43 yea s. Among hese inma es who smoke, 62.9% (n = 83) epo ed smoking mo e since being de ained, wi h a mean o 15 ciga e es a day (SD = 9.89). Mos pa icipan s (n = 188; 81%) decla ed hey had consumed alcohol a leas once. Among hese, 14% (n = 26) a i med ha hei consump ion was p oblema ic, and 6.5% (n = 12) said hey had a some poin been de- penden on his subs ance. Du ing he 6 mon hs p io o imp isonmen , alcohol consump ion was conside ed p e- dominan ly occasional (n = 134; 71.3%). Since hei im- p isonmen , only 17.2% (n = 39) o inma es men ioned alcohol consump ion; among hese, 86.8% (n = 33) had consumed small po ions wi h he consen o p ison s a , and 13.2% (n = 5) epo ed hey had consumed alcohol du ing empo a y lea es. Sel -Repo s o Heal h be o e and du ing Imp isonmen in Female Inma es 135 Po J Public Heal h 2017;35:132–140 DOI: 10.1159/000481967 Thi y- i e pe cen (n = 80) o he pa icipan s epo - ed ha ing consumed illegal subs ances, and among hose, 58.8% (n = 47) conside ed hei illegal subs ance use p oblema ic. Fu he mo e, 57.5% (n = 46) epo ed being addic ed. The mean age o ini ial consump ion was 19.86 yea s (SD = 7.90), wi h cannabis (n = 48; 60%), cocaine (n = 50; 62.5%), he oin (n = 30; 37.5%), and me hadone (n = 21; 26.3%) being he mos used subs ances p io o imp isonmen . Among all inma es who epo ed ha - ing consumed hese subs ances, 27.5% (n = 22) ha e done i in a enously (6 on hei las day be o e being a es ed, 1 du ing he week be o e, ano he du ing he mon h be- o e, and 14 mo e han 2 mon hs be o e). The a e age ini ial age o in a enous consump ion was 24.86 yea s (SD = 9.02). Six een inma es (6.9%) said hey had con- sumed d ugs du ing imp isonmen , wi h cannabis being he mos used subs ance. None o he inma es answe ed posi i ely o in a enous d ug consump ion. The majo i y o pa icipan s (n = 195; 84.1%) epo ed ac i e he e osexual beha io du ing he yea p io o he imp isonmen . Among hese, only 22.7% (n = 44) epo - ed always using a condom. Du ing he de en ion pe iod, only 13.8% (n = 32) e ealed ac i e he e osexual beha io , wi hin which 23.3% (n = 7) had always used a condom. Ac i e homosexual beha io in he yea p io o he im- p isonmen was epo ed by 4.4% (n = 10) o he women, om which only 3 (30%) had always used a condom. In- side he p ison es ablishmen , 9.9% (n = 23) o he pa - icipan s epo ed ac i e homosexual beha io , wi hin which 17.4% (n = 4) had always used a condom. Table 2 shows de ailed da a on he inma es’ sexual beha io s be- o e and du ing imp isonmen . Only 1 o he pa icipan s epo ed ha ing been paid wi h money, goods o d ugs o sex du ing imp ison- men , al hough 23 (10%) said hey had been paid wi h money, goods o d ugs o he same pu pose a some poin in hei li es. Sel -Des uc i e Beha io Rega ding suicide, 31% (n = 72) epo ed a leas 1 a - emp ; he mean numbe o suicide a emp s was 2.3 (SD = 1.46), and he mean age o occu ence was 29 yea s (SD = 9.97). Wi hin his g oup, 43.1% (n = 31) said hey had a emp ed suicide a leas once while hey we e al- eady in p ison. Sel -ha ming beha io s du ing he mon h ha p eced- ed he in e iew, i.e., when inma es we e al eady in p is- on, we e epo ed by 10 (4.3%) pa icipan s, and in each case, he de ainees epo ed ha ing inju ed hemsel es o add ess eelings o age, ension, anxie y, o dep ession. Six o hese had ecei ed medical a en ion and/o psy- chological suppo in he p ison’s medical acili ies im- media ely a e he sel -ha m episode. Heal h Su eillance be o e Imp isonmen Among he pa icipan s in his s udy, 90.9% (n = 211) we e egis e ed a a p ima y heal h ca e cen e wi h a GP, and among hose, 73.9% (n = 156) had isi ed hei GPs n% Mean SD Age, yea s 36.86 10.72 Po uguese na ionali y 177 76.3 E hnici y Whi e Black Gipsy 159 37 30 68.8 16.0 13.0 Educa ion Ne e a ended school Fewe han 4 yea s Comple ed p ima y school Comple ed he six h g ade Comple ed he nin h g ade Comple ed seconda y educa ion Uni e si y deg ee 10 21 46 53 51 30 20 4.3 9.1 19.9 22.9 22.1 13.0 8.7 Had been employed be o e de en ion 138 59.5 Housekeepe 31 22.6 Had a leas 1 child 191 82.3 Numbe o child en 2.86 1.81 Had been ma ied o li ed in a ci il pa ne ship 160 69 Table 1. Pa icipan s’ sociodemog aphic cha ac e is ics (n = 232) Al es/Cos aMaia Po J Public Heal h 2017;35:132–140 136 DOI: 10.1159/000481967 a leas once in he las 6 mon hs be o e imp isonmen , 41.7% (n = 108) had had an eme gency hospi aliza ion, and 19.6% (n = 44) we e being ollowed by a psychia is . Sexual and Rep oduc i e Heal h His o y Mos inma es (n = 205; 88.4%) had been p egnan a leas once. Rega ding mens ua ion, 82.8% (n = 192) we e s ill mens ua ing a he ime o he s udy and 45.8% (n = 88) epo ed hey had mens ua ion- ela ed p oblems. The mos e e enced p oblems we e i egula mens ual cycles (n = 58, 65.9%) and e y hea y bleeding (n = 29, 33%). Be- o e imp isonmen , 51.3% (n = 119) o inma es had been using some o m o bi h con ol me hods, wi h o al con- acep i e pills being he mos common me hod (n = 72; 50.7%), ollowed by condoms (n = 35, 18.3%). Twen y- wo pe cen (n = 51) o inma es s a ed hey we e s ill using a con acep i e me hod du ing imp isonmen , wi h o al bi h con ol pills being again he mos common me hod (n = 22; 38.6%). Six een (6.9%) pa icipan s said hey had been ea ed a leas once o a sexually ansmissible disease. P e alence o Diseases The numbe o pa icipan s ecei ing, a leas once in hei li e, diagnos ic es s o in ec ious diseases and he p e alence o hese diseases a e shown in Table 3. Table 4 shows he da a on epo ed ch onic diseases p esen a he momen o he su ey, om he mos o he leas equen . Medica ion Rega ding pha maceu ical d ugs consumed du ing imp isonmen , 71.6% (n = 166) o inma es epo ed hey we e aking a p esc ibed d ug. Heal h Complain s Table 5 lis s he heal h complain s, including he e- sul s om he Ro e dam Symp om Checklis , ha in- ma es had expe ienced du ing he week be o e he su ey, by o de and equency. The mos epo ed heal h com- plain s we e essen ially psychological, wi h wo ying, anxie y, ne ousness, di icul y sleeping, despai abou he u u e, ension, i edness, and i i abili y epo ed by mo e han hal o pa icipan s. Gene al Heal h S a us The global esul s om he SF-12 showed ha he PCS sco es a ied be ween 15.15 and 71.82, wi h a mean o 49.93 (SD = 10.40) and a median o 52.37 (IQR = 14.46), and he MCS sco es a ied be ween 8.89 and 64.38, wi h a mean o 39.84 (SD = 12.84) and a median o 40.26 (IQR = 20.66). The compa ison be ween his s udy’s me- dian PCS and MCS alues and hose o he e e ence pop- ula ion, using he one-sample Wilcoxon signed ank es , showed a signi ican di e ence (z = –13.202, p = 0.05; z = –13.205, p = 0.05). Female p isone s had lowe sco es on Table 2. Sexual beha io s be o e and du ing imp isonmen Yea be o e imp isonmen Du ing imp isonmen n%n% Ac i e he e osexual beha io 195 84.1 32 13.8 Numbe o pa ne s One Two Th ee o mo e 164 21 10 70.7 9.1 4.4 31 1 0 13.5 60.4 – Condom usagea Always Some imes Ne e 44 28 122 22.7 14.4 62.9 7 3 20 23.3 10 66.7 Ac i e homosexual beha io 10 4.4 23 9.9 Numbe o pa ne s One Two Th ee o mo e 8 1 1 3.4 0.4 0.4 17 3 3 7.6 1.3 1.3 Condom usagea Always Some imes Ne e 3 – 7 30 – 70 4 1 18 17.4 4.3 78.3 aOnly conside ing sexually ac i e inma es. Table 3. Repo ed con agious and in ec ious diseases du ing li e- ime n% HIV Took he es Tes ed posi i ea178 14 76.7 7.9 Hepa i is B Took he es Tes ed posi i ea169 4 72.8 2.4 Hepa i is C Took he es Tes ed posi i ea121 18 52.2 15.0 Tube culosis Took he es Tes ed posi i ea137 6 59.1 4.4 aOnly conside ing inma es who ook he es s. Sel -Repo s o Heal h be o e and du ing Imp isonmen in Female Inma es 137 Po J Public Heal h 2017;35:132–140 DOI: 10.1159/000481967 bo h summa ies, indica ing poo e physical and men al heal h. Table 6 shows how inma es e alua ed hei heal h a he ime o he su ey. In ega d o hei global assess- men o heal h, in compa ison wi h heal h be o e im- p isonmen , 33.2% (n = 138) o pa icipan s said hey had el a posi i e shi , desc ibing hei heal h a he ime o he su ey as much be e (16.8%; n = 39) o be - e (16.4% n = 38) han he pe iod be o e p ison; ano h- e 26.3% (n = 61) epo ed no change, conside ing ha hei heal h had emained oughly he same, and 40.5% (n = 94) epo ed a nega i e change, assessing hei heal h s a uses as wo se (22.8%, n = 53) o much wo se (17.7%, n = 41). Discussion This s udy co e ed a comp ehensi e ange o heal h and heal h beha io s in emale inma es, be o e and du - ing imp isonmen . The e is a consensus in he li e a u e ha hese inma es b ing ou a en ion because o hei ulne able heal h condi ions and hei high p e alence o heal h- ela ed isk beha io s. In ac , pa icipan s epo - ed some heal h isk beha io s p io o imp isonmen , such as obacco consump ion, d ug use, and sexual isk beha io s, bu con a y o wha o he s udies [6] ha e e- ealed, alcohol abuse be o e p ison was e y low, and a - e imp isonmen , i was nea ly nonexis en . Tobacco consump ion inc eased du ing he women’s imp isonmen . Condon e al. [2] s a ed ha he ac o s b ough on by imp isonmen condi ions, such as inc eased Table 4. Repo ed ch onic diseases p esen a he momen o he su ey n% Mig aine 109 47.0 Sleep p oblems 106 45.7 Anxie y 101 43.5 Low back pain 85 36.6 Dep ession Hype ension 74 48 31.9 20.7 Diges i e p oblems 41 17.7 Acciden s 33 14.2 Skin p oblems 32 13.8 Vascula diseases 31 13.4 Ca dio ascula diseases 29 12.5 In es inal p oblems 20 8.6 Diabe es 18 7.8 Epilepsy 11 4.7 Oncological diseases 9 3.9 O he 75 32.3 Table 5. Ro e dam Symp om Checklis ’s heal h complain e- quenciesa Symp oms in he week be o e su ey n% Wo ying 207 89.2 Anxie y 171 73.7 Ne ousness 163 70.3 Di icul y sleeping 152 65.5 Despai ing abou he u u e 135 58.2 Tension 133 57.3 Ti edness 127 54.7 I i abili y 126 54.3 Tingling hands o ee 120 51.7 Low back pain 114 49.1 Dep essed mood 111 47.8 So e muscles 110 47.4 Lack o appe i e 109 47.0 Headaches 109 47.0 D y mou h 105 45.3 Di icul y concen a ing 100 43.1 Lack o ene gy 97 41.8 Dec eased sexual in e es 85 36.6 Bu ning/so e eyes 78 33.6 Cons ipa ion 75 32.3 Shi e ing 73 31.5 Dizziness 71 30.6 Abdominal aches 64 27.6 Loss o ai 63 27.2 Hea bu n/belching 61 26.3 Nausea 48 20.7 Vomi ing 35 15.1 So e mou h/pain when swallowing 24 10.3 Dia hea 17 7.3 aIn he week be o e su ey. Table 6. Global assessmen s o cu en heal h n% Excellen 22 9.5 Ve y good 22 9.5 Good 69 29.7 Fai 75 32.3 Poo 44 19.0 Al es/Cos aMaia Po J Public Heal h 2017;35:132–140 138 DOI: 10.1159/000481967 s ess and spa e ime, along wi h he a ailabili y o he sub- s ance i sel con ibu e o his endency. The consump ion o illegal subs ances, which was signi ican ly high be o e de en ion − in acco dance wi h he indings o S a on e al. [16] − was educed o spo adic occu ences du ing imp is- onmen , wi h no e iden signs o addic ion. This seems o be ela ed o p isons’ ac i e oles in de oxi ica ion om subs ances. Condon e al. [2] highligh ed he ac ha mos subs ance use s hal hei consump ion du ing imp ison- men and, al hough Plugge e al. [17] co obo a ed his idea, hey no ed ha he e is a high pe cen age o eplace- men o illegal subs ances by p esc ibed medicines such as benzodiazepines and opia es. Rega ding sexual beha io be o e imp isonmen , mos o he sexually ac i e pa icipan s in his s udy had had in e cou se wi h only one pa ne . Howe e , he incon- sis en use o condoms combined wi h he consump ion o in a enous subs ances and p os i u ion beha io s (e en bo h occu in a lowe equency) inc eased he pos- sibili y o being in ec ed wi h sexually ansmi ed dis- eases. As expec ed, du ing imp isonmen , he e osexual ac- i i y was signi ican ly educed, and mos inma es had had sexual in e cou se wi h a single pa ne . Howe e , sexual isk beha io s a e s ill p esen since condom usage was low. On he o he hand, i is wo h highligh ing ha unp o ec ed homosexual in e cou se du ing imp ison- men had inc eased. One possible explana ion o he in- c ease in he unp o ec ed homosexual ela ionships is he una ailabili y o emale condoms in he p ison and he low in es men in his domain by he heal h p omo ion policies. Al hough s udies on sexual isk beha io among emale inma es a e sca ce [6], he e ealed beha io al pa - e n is consis en wi h wha has been obse ed in he e- male inma e popula ion, ha is, inconsis en condom use, high- isk sexual pa ne s, and p os i u ion [18–20]. Conce ning sel -ha ming beha io s, while sel -ha m du ing imp isonmen was epo ed by a small numbe o pa icipan s, he p e alence o suicide a emp s be o e and du ing imp isonmen was no able. The pe cen age o inma es who epo ed a leas one suicide a emp h oughou hei li e ime was high, emphasizing he e- male inma e popula ion’s ulne abili y o his ype o be- ha io , which has been ound in p e ious s udies [6, 21, 22]. This inc eased ulne abili y o he isk o suicide is la gely ela ed o he high p e alence o men al illness among he imp isonmen popula ion [23], as well as o he high p e alence o ad e se expe iences. As an exam- ple, he esul s om women inma es’ esea ch indica e ha hose who ha e a emp ed suicide we e exposed o mo e ad e si y [24, 25]. Conside ing hese da a, suicide is a opic ha dese es special a en ion om p ison policies in he ea ly iden i ica ion o emale p isone s a isk and he c ea ion o p e en ion s a egies. Rega ding heal h su eillance be o e imp isonmen , mos inma es epo ed hey had seen hei GP and/o a heal h p o essional in eme gency se ices a leas once du - ing he 6 mon hs p io o imp isonmen , sugges ing ha access o communi y heal h se ices is equen , con a y o wha o he s udies ha e documen ed [16, 21, 26, 27]. How- e e , he eason o his beha io is no included in his s udy. Fu u e s udies should explo e he easons o his ac- i e con ac wi h heal h se ices p io o imp isonmen . Conce ning sexual and ep oduc i e heal h, mens ual p oblems we e he mos ele an issue, which is in line wi h he indings o a ep oduc i e heal h s udy ha indica ed a highe p e alence o his ype o dys unc ion among he in- ma e popula ion in compa ison wi h women in he la ge communi y [28]. In con as , he low pe cen age o pa ici- pan s who epo ed ha ing been ea ed o sexually ans- mi ed diseases seems o indica e, gi en he endency o- wa d sexual isk beha io s ha was p e iously no ed, a lack o medical ca e and/o in o ma ion on his subjec [19]. The e o e, conside ing he isk beha io s o bo h sexually ansmi ed and ch onic diseases (such as u e ine cance ) and he lack o medical ollow-up and heal h in o ma ion, sexual and ep oduc i e heal h should be an a ea o a en- ion wi hin p ison ins i u ions [29, 30] h ough he p omo- ion o sc eening measu es and sex educa ion p og ams. Mo eo e , in addi ion o p isons’ ac i e oles in heal h educa ion, hese ins i u ions a e also conside ed unda- men al in he sc eening and ea men o in ec ious dis- eases [31]. Following he indings by Ba os e al. [31], he p e alence o epo ed hepa i is C and HIV is p ominen . Fu he mo e, hough hese diseases ha e inc easingly be- come he subjec o a en ion o bo h p ison heal h poli- cies and esea che s [21], he high numbe o inma es wi h hepa i is C and HIV emains a ma e o conce n o public heal h [21, 32, 33], being he emale p ison popula- ion he mos a ec ed [34, 35]. The mos equen ly epo ed ch onic diseases we e mig aines, sleeping p oblems, anxie y, low back pain, and dep ession, wi h a no able p ominence o men al heal h complain s and men al diso de s, ein o cing, hus, he high p e alence o psychopa hology among inca ce a ed women ha has al eady been epo ed in nume ous s ud- ies [7, 9, 26, 36, 37]. S ill bea ing in mind he high numbe o epo ed heal h complain s and illnesses, i is no su p ising ha he e we e also a e y high pe cen age o pa icipan s in Sel -Repo s o Heal h be o e and du ing Imp isonmen in Female Inma es 139 Po J Public Heal h 2017;35:132–140 DOI: 10.1159/000481967 pha macological he apy. Howe e , i is impo an o highligh ha du ing he da a collec ion, mos pa ici- pan s we e unable o speci y he subs ances hey we e ak- ing, which demons a es he low inma e knowledge abou he medical ea men s hey we e being subjec ed o. Langne e al. [38] also concluded ha he e is a highe p e alence o medicine consump ion in he emale in- ma e popula ion when compa ed wi h he communi y; in he same way, Bu le e al. [5] showed ha inca ce a ed women ha e a highe pe cen age o consump ion o hese subs ances han hei male coun e pa s. This migh hap- pen due o he ac ha emale de ainees ha e a highe endency o pu sue medical se ices [27, 39], which is e- la ed o he p e iously men ioned high a es o diseases and heal h complain s, as well as he eplacemen o ille- gal d ugs by psycho opic medica ion. The epo ed heal h complain s we e equen , which co obo a es he indings o Bu le e al. [5] and Robe e al. [27], indica ing ha heal h complain s among emale inma es a e equen du ing imp isonmen . This migh be a esul no only o hei ulne abili y in e ms o men- al and physical heal h, bu also o he inc ease in sel - awa eness due o hei imp isonmen [27]. The high p e alence o anxie y- ela ed complain s is a sign o psy- chological s ess among emale inma es. Finally, conside ing he pa icipan s’ gene al heal h, i is possible o conclude ha hey ha e lowe le els o physical and men al heal h compa ed wi h he communi y emale popula ion, which is simila o he indings o Plugge and Fi zpa ick [9] in he Uni ed Kingdom and o Bu le e al. [5] in Aus alia. In addi ion, i is no su p ising ha mo e han hal o he pa icipan s in his s udy epo ed nega i e pe cep ions o hei heal h no only because o he pa e n o heal h isk beha io s, bu also due o he p e alence o in ec ious and men al diseases, he high consump ion o p esc ibed d ugs, and he ple ho a o heal h complain s. Howe e , we need o no e some indings ha could be ela ed o a posi i e impac o p ison on pa icipan heal h, such as he abo e-men ioned dec ease in he consump ion o illegal subs ances and alcohol. These ac s could con ib- u e o he high pe cen age o women who epo ed heal h s a us imp o emen du ing imp isonmen . In con as , some indings could be ela ed o he nega i e impac o p ison on pa icipan s’ heal h, such as he al eady men- ioned inc ease in smoking and he psychological s ess e- la ed o imp isonmen , which can explain he pe cen age o women who e alua e hei heal h as wo se o much wo se. These esul s e eal how p ison impac can be a iable [2]. This s udy had some limi a ions, o which he mos im- po an was he numbe o pa icipan s, which ep esen ed only 31.1% o he imp isoned emales in Po ugal in he i s qua e o 2012. Ne e heless, he sociodemog aphic and ju- idical cha ac e is ics o he s udied sample a e simila o he mos common among he o e all Po uguese emale inma e popula ion a he ime o he da a collec ion. Ano he limi a- ion conce ns he ques ionnai e on isk beha io and heal h eco ds ha had no consis en imeline ha de e mines when he issues add essed had occu ed, making i mo e di - icul o ho oughly analyze hese pa icipan s’ isk beha - io s and heal h his o ies be o e and du ing imp isonmen . The ac ha his s udy is based on sel - epo ing is mos likely i s g ea es limi a ion, due o he implied bias associ- a ed wi h his ype o measu e. E en so, he e a e no signs ha inma es a e less us wo hy han he o e all popula- ion, and sel - epo ing ins umen s such as he SF-12 a e alid when applied o he inca ce a ed popula ion [9, 17]. Gi ing he ele ance o ob aining heal h ou comes h ough o he sou ces o in o ma ion a he han sel - epo , an a pos e io i s udy was ca ied ou on he emale p isone s’ heal h in Po ugal on he basis o in o ma ion con ained in he clinical ials [Al es and Cos a Maia, in p ess]. Ou esul s emphasized he ulne able heal h s a us o de ained women and he a iable impac o imp isonmen on heal h. These seemingly agile heal h condi ions o he women con inue o d aw a en ion o he need o poli i- cians, p ison managemen , heal h ad oca es, and p ison s a o in es in p og ams and measu es ocused on im- p o emen s in emale inma es’ heal h. Be gh e al. [40] men ioned he need o change c iminal jus ice sys ems, conside ing he ailu es in gende sensi i i y. They high- ligh 4 c ucial s eps o ac ion ha we would also like o un- de line since hey syn hesize some o he mos impo an changes, conside ed in he li e a u e, o heal h imp o e- men s o women p isone s: imp isonmen o women should be conside ed only when all o he al e na i es a e una ailable o unsui able; all s a wo king wi h women p isone s should ha e ollowed gende sensi i i y aining o aise awa eness o and imp o e esponse o hese gende - ela ed issues; he Eu opean P ison Rules a e o i al impo - ance, bu hey need a e ision o gua an ee he p o ision o se ices o mee women p isone s’ speci ic needs; heal h se ices o women in p ison should be indi idualized as a as possible o mee hei speci ic exp essed needs. These e - o s will p omo e imp o emen no only in hese women’s li es bu also hose o hei communi ies because hei e- en ies will po en ially be mo e success ul. Finally, ou ind- ings should encou age u u e esea ch using quali a i e me hods in o de o be e unde s and how hey pe cei e hei heal h and which ac o s a e in ol ed in he emo ion- al and physical changes ha a ec hese pe cep ions. Al es/Cos aMaia Po J Public Heal h 2017;35:132–140 140 DOI: 10.1159/000481967 Re e ences 1 Wol H, Sebo P, Halle DM, Ey an A, Ni eau G, Be and D, e al: Heal h p oblems among de ainees in Swi ze land: a s udy using he ICPC-2 classi ica ion. BMC Public Heal h 2011; 11: 245. 2 Condon L, Hek G, Ha is F: A e iew o p is- on heal h and i s implica ions o p ima y ca e nu sing in England and Wales: he e- sea ch e idence. J Clin Nu s 2007; 16: 1201– 1210. 3 Lindquis CH, Lindquis CA: Heal h behind ba s: u iliza ion and e alua ion o medical ca e among jail inma es. J Communi y Heal h 1999; 24: 285–303. 4 F eudenbe g N, Moseley J, Lab iola M, Dan- iels J, Mu ill C: Compa ison o heal h and social cha ac e is ics o people lea ing New Yo k Ci y jails by age, gende , and ace/e h- nici y: implica ions o public heal h in e - en ions. Public Heal h Rep 2007; 122: 733– 743. 5 Bu le T, Ka iminia A, Le y M, Mu phy M: The sel - epo ed heal h s a us o p isone s in New Sou h Wales. Aus NZ J Public Heal h 2004; 28: 344–350. 6 Ha is F, Hek G, Condon L: Heal h needs o p isone s in England and Wales: he implica- ions o p ison heal hca e o gende , age and e hnici y. Heal h Soc Ca e Communi y 2007; 15: 56–66. 7 Plugge E, Douglas N, Fi zpa ick R: Pa ien s, p isone s, o people? Women p isone s’ ex- pe iences o p ima y ca e in p ison: a quali a- i e s udy. B J Gen P ac 2008; 58: 630–636. 8 Ha ne HM, Riley S: Fac o s con ibu ing o poo physical heal h in inca ce a ed women. J Heal h Ca e Poo Unde se ed 2013; 24: 788–801. 9 Plugge E, Fi zpa ick R: Assessing he heal h o women in p ison: a s udy om he Uni ed Kingdom. Heal h Ca e Women In 2005; 26: 62–68. 10 Binswange I, K uege PM, S eine JF: P e a- lence o ch onic medical condi ions among jail and p ison inma es in he USA compa ed wi h he gene al popula ion. J Epidemiol Communi y Heal h 2009; 63: 912–919. 11 Mosche i K, S adelmann P, Wangmo T, Hol- ly A, Bodenmann P, Wasse allen JB, e al: Disease p o iles o de ainees in he Can on o Vaud in Swi ze land: gende and age di e - ences in subs ance abuse, men al heal h and ch onic heal h condi ions. BMC Public Heal h 2015; 15: 872. 12 Haes J, Van Knippenbe g F, Neij J: Measu - ing psychological and physical dis ess in can- ce pa ien s: s uc u e and applica ion o Ro - e dam Symp om Checklis . B J Cance 1990; 62: 1034–1038. 13 Maia A, McIn y e T, Pe ei a MG, Ribei o E: Wa exposu e and pos - auma ic s ess as p edic o s o Po uguese colonial wa e e - ans’ physical heal h. Anxie y S ess Coping 2011; 24: 309–325. 14 Wa e JE, Kosinski M, Kelle SD: A 12-i em sho - o m heal h su ey: cons uc ion o scales and p elimina y es s o eliabili y and alidi y. Med Ca e 1996; 34: 220–233. 15 Pais-Ribei o J: O impo an e é a saúde: es udo de adap ação de uma écnica de a aliação do es ado de saúde-SF-36. Lisboa, Fundação Me ck Sha p & Dohme, 2005. 16 S a on M, Leuke eld C, Webs e JM: Sub- s ance use, heal h, and men al heal h: p ob- lems and se ice u iliza ion among inca ce - a ed women. In J O ende The Comp C iminol 2003; 47: 224–239. 17 Plugge E, Yudkin P, Douglas N: Changes in women’s use o illici d ugs ollowing imp is- onmen . Addic ion 2009; 104: 215–222. 18 Cla ke JG, Hebe MR, Rosenga d C, Rose JS, Sil a KM, S ein MD: Rep oduc i e heal h ca e and amily planning needs among inca ce - a ed women. Am J Public Heal h 2006; 96: 834–839. 19 Mi anda A, Me çon-de-Va gas P, Viana M: Saúde sexual e ep odu i a em peni enciá ia eminina, Espí i o San o, B asil. Re Saúde Pública 2004; 38: 255–260. 20 Su in CB, Tulsky JP, Goldenson J, Win e KS, Cohan DL: Eme gency con acep ion o newly a es ed women: e idence o an un ec- ognized public heal h oppo uni y. J U ban Heal h 2010; 87: 244–253. 21 Fazel, S, Bailla geon J: The heal h o p isone s. Lance 2011; 377: 956–965. 22 Ginn S, Robinson R: Women p isone s. BMJ 2013; 8318: 1–4. 23 Bailla geon J, Penn JV, Thomas CR, Temple JR, Bailla geon G, Mu ay OJ: Psychia ic dis- o de s and suicide in he na ion’s la ges s a e p ison sys em. J Am Acad Psychia y Law 2009; 37: 188–193. 24 Al es J, Maia A: Expe iências ad e sas du an- e a in ância e compo amen os de isco pa a a saúde em mulhe es eclusas. Psic Saúde Doenças 2010; 11: 151–171. 25 Ma zano L, Haw on K, Ri lin A, Fazel S: Psy- chosocial in luences on p isone suicide: a case-con ol s udy o nea -le hal sel -ha m in women p isone s. Soc Sci Med 2011; 72: 874– 883. 26 Bailla geon J, Black SA, Pul ino J, Dunn K: The disease p o ile o Texas p ison inma es. Ann Epidemiol 2000; 10: 74–80. 27 Robe D, F igon S, Belzile R: Women, he embodimen o heal h and ca ce al space. In J P isone Heal h 2007; 3: 176–188. 28 Allswo h JE, Cla ke J, Peipe JF, Hebe MR, Coope A, Boa dman L: The in luence o s ess on he mens ual cycle among newly in- ca ce a ed women. Women Heal h Issues 2007; 17: 202–209. 29 Binswange I, Whi e MC, Pé ez-S able EJ, Goldenson J, Tulsky JP: Cance sc eening among jail inma es: equency, knowledge, and willingness. Am J Public Heal h 2005; 95: 1781–1787. 30 Su in CB, C einin MD, Chang JC: Con a- cep ion se ices o inca ce a ed women: a na ional su ey o co ec ional heal h p o id- e s. Con acep ion 2009; 80: 561–565. 31 Ba os H, Ramos E, Lucas R: A su ey o HIV and HCV among emale p ison inma es in Po ugal. Cen Eu J Public Heal h 2008; 16: 116–120. 32 Thein H, Bu le T, K ahn M, Rawlinson W, Le y MH, Kaldo JM, e al: The e ec o hep- a i is C i us in ec ion on heal h- ela ed qual- i y o li e in p isone s. J U ban Heal h 2006; 83: 275–288. 33 To es A, Gomes M: D ogas e p isões: ela- ções p óximas. Toxicodependências 2005; 11: 23–40. 34 Al ice FL, Ma ino ich A, Khoshnood K, Blan- kenship KM, Sp inge S, Selwyn P: Co ela es o HIV in ec ion among inca ce a ed women: implica ions o imp o ing de ec ion o HIV in ec ion. J U ban Heal h 2005; 82: 312–326. 35 Nijhawan AE, Salloway R, Nunn AS, Poshkus M, Cla ke JG: P e en i e heal hca e o un- de se ed women: esul s o a p ison su ey. J Women Heal h 2010; 19: 17–22. 36 Al es J, Du a A, Maia Â: His ó ia de ad e si- dade, saúde e psicopa ologia em eclusos: compa ação en e homens e mulhe es. Cienc Saúde Cole i a 2013; 18: 701–710. 37 Moloney KP, Molle LF: Good p ac ice o men al heal h p og amming o women in p ison: e aming he pa ame e s. Public Heal h 2009; 123: 431–433. 38 Langne N, Ba on J, McDonagh D, Noel C, Boucha d F: Ra es o p esc ibed medica ion use by women in p ison. Fo um Co ec Res 2002; 14: 10–14. 39 Fe on JM, Paulus D, Tongle R, Lo an V, Pes- iaux D: Subs an ial use o p ima y heal h ca e by p isone s: epidemiological desc ip ion and possible explana ions. J Epidemiol Commu- ni y Heal h 2005; 59: 651–655. 40 Be gh BJ, Ga he e A, F ase A, Molle L: Im- p isonmen and women’s heal h: conce ns abou gende sensi i i y, human igh s and public heal h. Bull Wo ld Heal h O gan 2011; 89: 689–694.