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A Look at Vulnerability: Analysis of the Lack of Access to Health Care For www. jhgd.com.br ORIGINAL ARTICLE A look at vulnerability: analysis of the lack of access to health care for quilombolas in Brazil Alyne Nunes Motaa,b, Erika da Silva Macielc, Fernando Rodrigues Peixoto Quaresmac, Francisco Albino de Araújod, Luiz Vinícius de Alcântara Sousaa, Hugo Macedo Juniord, Fernando Luiz Affonso Fonsecad, Fernando Adamia Open acess Abstract aLaboratório de Epidemiologia e Análise de Dados. Centro Introduction: In Brazil, access to health care is a constitutional Universitário FMABC, Santo right guaranteed by the Unified Health System that provides, André, São Paulo, SP 09060- in its guiding principles, universality, and equity of access to 870, Brazil; health services. bSecretaria de Estado da Saúde do Tocantins SES/TO, Palmas, Objective: To analyze the factors associated with the Tocantins, TO 77015-212, Brazil; quilombola population’s access to health services. cUniversidade Federal do Methods: Cross-sectional study with 91,085 quilombolas. Tocantins UFT/TO; To measure the absence of access to health, the variables sex, ethnicity, work, disability, age group, illiteracy, place of dLaboratório de Delineamento de Estudos e Escrita Científica. residence, and average family income were used. The lack of Centro Universitário FMABC, access to health services was due to the identification of health Santo André, São Paulo, SP care establishments by quilombola families in the Cadastro 09060-870, Brazil. Único database. The association between socioeconomic Corresponding author characteristics and the lack of access to health services [email protected] were assessed using the chi-square test and the measures Manuscript received: March 2021 Manuscript accepted: June 2021 of magnitude of the association and respective confidence Version of record online: July 2021 intervals were estimated by Poisson Regression with robust variance. Results: Among the factors associated with access to health services for the quilombola population, it is observed that the group with the highest risk is the elderly quilombolas, who declare themselves indigenous and who reside in the central west region It is noted that in 2004 there was a reduction in the lack of access to health by quilombolas to health services, however, between 2005 and 2015, there is an increase in the lack of access to health by quilombolas, after that period there is an ascendancy of access to health by this population. Conclusion: Several factors are associated with access to health by quilombola populations, which, related to the inequalities experienced by this population, directly impact government actions. Keywords: vulnerable populations, access to health services, information systems. Suggested citation: Mota AN, Maciel ES, Quaresma FRP, de Araújo FA, Sousa LVA, Junior HM, Fonseca FLA, Adami F. A look at vulnerability: analysis of the lack of access to health care for quilombolas in Brazil. J Hum Growth Dev. 2021; 31(2):302-309. DOI: 10.36311/jhgd.v31.11404 J Hum Growth Dev. 2021; 31(2):302-309. DOI: 10.36311/jhgd.v31.11404 302 www. jhgd.com.br Authors summary Why was this study done? Access to health services is a constitutional right, but there are still barriers to access by Brazilians. The scarcity of information about the factors that are associated with this access is a challenge to be overcome in the Unified Health System, as it is from this information that public policies are created.Our objective was to analyze the factors that are associated with the quilombola population’s access to health services. What did the researchers do and find? This study identified information about quilombolas in the Cadastro Único database. In this database, it was also possible to identify the name of the health care establishment that these quilombolas used. The results indicated that the group at greatest risk for access to health services are the elderly quilombolas, who declare themselves indigenous and who live in the central west region of the country. What do these findings mean? These findings suggest that the factors associated with access to health services by the quilombola population are age group, ethnicity, and region of residence. This type of study can contribute to the construction of public policies aimed at guaranteeing access to health services, in particular, the prevention and health promotion of vulnerable populations, especially quilombolas. INTRODUCTION In Brazil, access to health is a constitutional presence of the idea that they are a group of “fugitives”. right provided by the Unified Health System (SUS) to This group tends to suffer materially and socially, and all Brazilians, with universality and equity being the psychologically from the effects of exclusion, whether for fundamental principles for implementing health actions. religious, health, ethnicity, physical or mental disabilities, Although SUS has experienced a significant and even access to education16. advance over the years since its creation, there are still Thus, the objective is to analyze the factors geographic and social inequalities regarding access to associated with the quilombola population’s access to health services, especially among people who declare health services. themselves to be mixed, black, and indigenous1. The concept of access to health is broad and METHODS complex. Access refers to the “offer and the ability to Study design produce services” based on the needs of the population, This is a cross-sectional study17 carried out taking into account the individual factors of each user2. according to the guidelines of STROBE - Strengthening Equity of access, especially to vulnerable populations, the Reporting of Observational Studies in Epidemiology18, is something that has been sought since the early 1970s with using secondary data collected through the database of the the Brazilian Health Reform. The development of social Single Registry of the Ministry of Social Development movements, the consolidation of the democratic process, (MDS). and the federal government’s effort to guarantee the rights of vulnerable groups over the years resulted in the construction Study location and period of public policies for the Promotion of Equity. This policy We used the unidentified database of the Cadastro aims to reduce health inequities3,4. Único with marking of the Bolsa Família program in a As for the construction of public policies for section from the years 2002 to 2017. vulnerable populations such as quilombolas, one of The Cadastro Único (CadÚnico) “is an instrument the main problems highlighted is the invisibility of for the identification and socioeconomic characterization these populations in the existing information systems, of low-income Brazilian families, which must be used information is an essential tool for access to health services, to select beneficiaries and integrate federal government this information about this population in an accessible way social programs aimed at serving this public”19. is a challenge1,5-7. Quilombolas are black people who live in rural Studied Population and Eligibility Criteria communities formed by descendants of enslaved Africans, The target population consisted of members of the then called Quilombola Remaining Communities8-10. families registered in CadÚnico identified as quilombolas Known as ethnic-racial groups with a historical trajectory in the database. In this system, quilombola families are of pain and oppression experienced by black ancestors, they registered as individuals who compose “ethnic-racial live scattered throughout Brazil; in remote communities groups, according to criteria of self-attribution, with their formed by a strong kinship bond, they are marked by the own historical trajectory, endowed with specific territorial stigma of social-historical exclusion11,12. relations, with a presumption of black ancestry related This population is considered a vulnerable group to the resistance to historical oppression”11 and who because of its cultural heritage, susceptibility to risks, self-determine belonging to that group. As an eligibility social disparities, ethnic discrimination, and this group criterion, only data from years showing family registration is more sensitive to inequalities in access to health1,13,14. in all months of the year were used. Vulnerable populations are those with limited capacity Inclusion criteria were the family identifying itself or freedom to consent or refuse, unable to protect their as quilombola and the identification of the name health own interests15. Quilombolas are considered a vulnerable care establishment. Data on vulnerable populations with population, suffering historical oppression due to the the exception of quilombolas are considered losses. J Hum Growth Dev. 2021; 31(2):302-309. DOI: 10.36311/jhgd.v31.11404 303 www. jhgd.com.br Sample or less as the income considered by WHO as the necessary The total sample was 91,085 quilombolas after the income for the survival of the individual, for the calculation statistical adjustment. it was used as a basis the value of the US dollar of R$4.05, requiring a monthly income of R$230.85. Data analysis Qualitative variables were described by absolute and The analyzed outcome was the lack of access to relative frequency. The association between socioeconomic health by quilombolas. The characteristics and profile of characteristics and non-access to health services was the population that does not have access to health were assessed using the chi-square test. The measures of described using the variables: sex, race,
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