Introduction

Brazil has the third-largest prison population worldwide, with a vertiginous trend of continuous growth [1,2]. However, the Brazilian penitentiary system—being marked by structural and organizational disarray—has been unable to keep pace with this growth [3]. Consequently, the conditions in prison spaces are precarious and the facilities are overcrowded, precipitating unhealthy sanitary conditions; inadequate food; insufficient human resources; improvised work routines; and insufficient legal, educational, and health assistance [4].

In this context, although the right to health in Brazil is universal (including oral health), evidently, the incarcerated population has greater difficulty accessing healthcare [5,6]. Thus, oral diseases that typically become acute complications or generate demands for emergency services are highly prevalent [7,8].

Health care for incarcerated people demands structure and logistics inherent to security, which encompasses escorting by criminal police officers after removal from the cell, supervision, consultation, and accompanied return to the cell [8,9]. These complex logistics have aggravated the problem of access to dental care in the Brazilian context [10]. Prisoners recognize their oral health condition’s precariousness through frequent painful symptoms, difficulty chewing, tooth loss, and a lack of access to oral rehabilitation, in addition to poor hygiene conditions and a lack of health promotion activities [11].

Understanding the particularities of access to health in the prison environment has enabled the development of strategies that can repair violations of the right to health and human dignity [10]. A national policy for oral health care within the Brazilian jail system was proposed. Initially, this support was the obligation of the States, which enacted initiatives within prisons without definitive national directives. In 2014, this support was incorporated into the Unified Health System (SUS) by a public policy known as the National Policy for Comprehensive Health Care for Individuals Deprived of Liberty in the Prison System. Subsequently, health initiatives and services were initiated for jailed individuals, encompassing preventive, curative, and rehabilitative aspects. The primary aim of this program is to guarantee access to healthcare within the jail environment. [9]. Therefore, this study initially assumed that the inclusion (or increase) of dental surgeons in the Brazilian prison system would have been insufficient to guarantee access to health care services. The aim of our study was to formulate a theory concerning access to oral health and the influencing factors, grounded in the perspectives of incarcerated men.

Methodology

Results

Sixteen men serving their sentences in a closed regime in a state prison unit in Minas Gerais State (Brazil) were interviewed. Categories were formed aligning the meanings produced by prisoners during the interviews with the dimensions of the patient-centered access to healthcare conceptual framework [13,14]. The theorization supported by theoretical reference allowed to organize the categories into two domains related to access for incarcerated men.

The first domain grouped patient abilities necessary to access health services. In our study, we named this theme “Prisoners’ Abilities in Accessing Oral Health Care in the Prison System”. The second assembled characteristics of health services related to access. This theme was named “Structural Barriers of the Prison System”.

Table 1 presents the categories, subcategories, and illustrative statements from the theme “Prisoners’ Abilities in Accessing Oral Health Care in the Prison System”.

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Table 1. Categories, subcategories, and illustrative statements constituting of the theme Prisoners’ Abilities in Accessing Oral Health Care in the Prison System.

https://doi.org/10.1371/journal.pone.0335590.t001

Ability to engage

The interviewees understood that dental treatment is limited to invasive and mutilating procedures, in addition to discouraging preventive approaches. However, this curative-mutilating model of care is incompatible with prisoners’ expectations. This population cannot participate in treatment decision-making and faces imposed difficulties (officialism and lack of reference services) in accessing specialized treatments.

Table 2 presents the categories, subcategories, and illustrative statements of the theme “Structural Barriers of the Prison System”.

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Table 2. Categories, subcategories, and exemplifying statements integrating the theme “Structural Barriers of the Prison System”.

https://doi.org/10.1371/journal.pone.0335590.t002

Discussion

To understand the meanings produced by prisoners regarding access to oral healthcare, the results of our study indicate that difficulties in accessing oral health in the prison system are predominantly attributed to state negligence. The form of organization and management of the prison health service and administrative bureaucracy may influence the inequality of access and does not allow the prioritization of oral health, as overcrowding and shortage of professionals resulting from negligence promote micropolitics for access.

Broadly speaking, state negligence begins even before confinement as incarcerated people have a sociodemographic and economic profile closely related to poverty, social vulnerability, and lack of access to healthcare [16]. State negligence can also be identified by the low adherence of states and municipalities to health program in prisons, demonstrating a scant effort to comply with health legislation [4,8,17]. Low adherence to national health program in the prison environment arises from the fact that adherence is not voluntary [8].

One of the themes established in this study highlights characteristics of the prison system and their negative impacts on the access to dental care of incarcerated men. This outcome relates to overcrowding, and insufficient criminal police agents and dental surgeons. Therefore, there is a repressed demand within the prison system that undermines access. Overcrowding in prison units is increasing in all Brazilian states [8]. Overcrowding of prison units is also observed in other countries, which, even after changes in the penal structure, have observed the permanence of this scenario [18]. Statistics from Uruguay suggest that the country’s incarcerated population is growing continuously and that health care for people deprived of their liberty has not reached the minimum level established by international standards [19]. The same was observed in Portugal, where the growth of the prison population remained high even after penal reform measures [20]. To reduce prison overcrowding and a hyperviolent criminal ecosystem, Ecuador sought solutions through the creation of large penitentiary complexes and a review of the indiscriminate use of prison sentences; however, the results obtained were still unsatisfactory [19].

Research results from different Brazilian regions [8,21] have also linked overcrowding to limitations in access to healthcare. A study conducted in the State of Paraíba (Brazilian Northeast Region) indicated that although the number of health teams following the publication of the National Policy for Comprehensive Health Care in the Prison System (PNAISP) increased, the infrastructure of health services did not accompany the progressively expanding population demand [21,22]. The same was observed in the State of Pará (Brazilian North Region), where an increase in the absolute number of health professionals hired and prison infrastructure was still not sufficient to fulfil the labour demand of the prison units [8].

As such, the achievement of equitable access to health depends on overcoming technical and political factors that affect prison reality, configuring themselves as barriers to guaranteeing and maintaining intramural services and negatively impacting the resocialization process [11,23].

The number of health professionals [6], infrastructure, available materials, overcrowding, and precarious sanitary conditions in prison units make it infeasible to provide comprehensive and continuous dental care, even with the existence of laws that ensure access to the population deprived of freedom [11]. There is irregularity in the number of consultations conducted by prison health teams, resulting from a lack of planning and monthly production parameters according to the needs and health profile of the prison population [8,21]. The autonomy provided to states and municipalities in Brazil to implement health program in the prison environment generates disparities in the services offered, resulting in an extremely heterogeneous distribution of consultations and human resources, in addition to insufficient funding, which impairs the system’s organization [11].

Structural restrictions to access oral health care found in our results have also been reported in other prisons, including those of high incomes countries. Evidence from a French study indicated that dental facilities in prisons exhibited considerable structural deficiencies, such as inadequately designed physical areas for dental practice, outdated equipment, and insufficient maintenance [24]. Moreover, challenges in inmate transportation and a lack of personnel limit dental surgeons to addressing only emergency cases [24]. Likewise, the United Kingdom, United States of America, Canada, and Australia presented deficiency of skilled practitioners, inadequate materials and equipment, and an absence of a structured care routine, which constitutes obstacles to dental treatment [25].

Research conducted in the State of Goiás (Brazilian Midwest Region) identified that incarcerated people perceive a restriction on access to oral health, considering the large number of attempts necessary to access dental care in prison units [12]. Consistently, a study conducted in Pará (Brazilian North Region) found that more than half of the prison population did not receive any type of dental care in the prison unit and that the prevalence of missing teeth was significant in all age groups assessed [4]. Difficulties in accessing oral healthcare were also reported in studies conducted in South Korea [26], Pakistan [27], Scotland [28], England [29], Finland [30], Canada [31], India [32,33], Thailand [34], Kosovo [35], and France [36], with the caveat of aggravating factors related to the condition of the incarceration itself. Noteworthily, oral hygiene supplies are insufficient, rendering the prison population dependent on religious institutions or family members to provide toothbrushes and toothpaste because the use of dental floss is almost always prohibited for safety reasons [6].

Our findings suggest that prisoners had the capacity to recognize their oral health issues. However, there is a lack of transparency and of predictability regarding the mechanisms for accessing dental care, even when pain is perceived. In other studies [35,37], incarcerated individuals recognized mechanisms of access to oral health care available in times of severe pain or obvious emergencies. Both results indicate a reactive nature of prison system, without planning of preventive or continuous care.

Even when access to oral health services is obtained, care is highly mutilating regardless of the lack of supplies to conduct rehabilitative procedures in penitentiary offices, and exacerbated medicalization to alleviate painful symptoms is common [6,27,31]. When evaluating the profile of dental service provision in Brazilian prison units, it was possible to observe a high prevalence of tooth extraction compared to other clinical treatments [10]. Despite the high prevalence of dental cavities in Bahia (Brazilian Northeast Region), a low percentage of restored teeth is observed [18].

The global panorama of oral health conditions and dental treatment needs of prisoners indicates that the burden of oral diseases is substantially greater in this group as compared to the general population, with high rates of tooth loss, dental cavities, and periodontal disease [32,34–37]. Although this study’s central aim was to understand access to oral health within the prison environment, incarcerated people did not attribute their oral health conditions solely to the prison context, but also to their life before incarceration. This result aligns with what was observed [4], which indicated that crime, drug use, time, and financial resources to access health services before prison impacted oral health. Before incarceration, the use of medications and illicit drugs is common to reduce pain. However, upon entry into the prison system and deprivation of access to these subterfuges, the perception of pain becomes more evident, which explains the increased demand for dental services [11,27,35,38].

The perspective of the inmates presented in our results indicates access to dental care may be constrained by healthcare professionals’ prejudices against the incarcerated population, which undermines the legitimacy of inmates’ needs. This results in a micro-policy of access that reflects the relevance of interpersonal relationships to access health services (irrespective of the real need for oral health). Per Santos et. al [10], the need for criminal police officers to escort the patient throughout the entire dental treatment process creates an additional challenge, as the number of workers to perform this function amid other diverse escorting and security demands, which negatively impacts both the initial and follow-up consultations, is insufficient. In this context, there is a greater focus on tasks related to custody than on those related to healthcare, despite the existence of regulations to equalize the two functions [39]. Moreover, when inmates exhibit behavior that is considered disrespectful, criminal police officers allow themselves to employ repression, such as preventing access to health care [40].

This conduct may be shaped by ideological beliefs and ethical considerations grounded in a conservative perspective that the prison setting confines individuals who ought to forfeit all their rights, not merely their liberty. These beliefs could affect the dynamics between criminal police officers and inmates, as well as the operation of healthcare services. This scenario may have the potential to stigmatize the incarcerated population and rationalize the denial of rights, including oral health care, since prejudice diminishes the quality of health care and impedes the execution of governmental policies [41,42].

Brazil has a universal healthcare system that includes the provision of dental care to the prison population. However, the provision of health services in the prison system does not meet the demands for dental care [08]. Given the difficulty of obtain oral health care, our results showed that some inmates end up using private external services when they have ability to pay. This finding indicates the challenges of adequate financing the oral health services into the prison system which may also be observed in other countries. In South Korea, prisoners are excluded from the public health insurance system and depend only on services provided by correctional facilities. Nonetheless, the demand for care exceeds the supply [43]. In the United States, which lacks a universal healthcare system, access to dental services is limited. Individuals with a history of incarceration are less likely to keep health insurance coverage. Consequently, efforts are required to enhance health insurance coverage to mitigate the health inequities seen by this population [44].

A limitation of the study is that, for safety reasons, the interviews were conducted with open doors and in the presence of a police escort outside the room. Despite the confidentiality of the interviews, interviewees may have felt less comfortable sharing their opinions regarding the care trajectory.

Conclusion

The meanings produced in the interviews allowed us to understand that the barriers to accessing oral health have been attributed by incarcerated men, mainly, to governmental negligence. This notion stems from the chronic scenario of overcrowding, the shortage of oral health and public safety professionals, which does not seem to be adequately addressed by the government. These problems reinforce inequalities, create a micro-politics of access, and consequently perpetuate inequity in access to oral health care for the incarcerated population.

Our results, as well as the precarious oral health conditions of the prison population, indicate the need to strengthen government policies aimed at health in the prison environment and to address overcrowding. In the realm of public policies, once the legal framework is established, it is up to the government’s responsibility to promote compliance with the defined parameters and to continuously oversee their execution. The legislative definition stipulates that the quantity and working hours of dental surgeons should be appropriate with the incarcerate population, varying from 6 hours per week for up to 300 detainees to 30 hours per week for facilities housing over 1,700 inmates. Ultimately, our findings underscore the necessity to reevaluate incarceration as a punishment for minor offenses and to enhance the training of criminal police officers about human rights, particularly in relation to healthcare access.

Acknowledgments

This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES).