Geographical barriers and multimorbidity in quilombola territories of the amazon region.

BackgroundQuilombos are settlements founded by descendants of runaway slaves in Brazil, typically located in remote rural areas. Quilombola communities typically present poor basic sanitation and health, high levels of illiteracy, and limited access to social and health services, especially among older adults. Therefore, the Quilombola population is socially vulnerable and likely to present an increased risk for dementia, although underrepresented in aging/dementia research. Future research is needed to map dementia risk factors in this population. The present study aims to investigate the association between cognition and socio‐cultural engagement, potentially protective for dementia.MethodThis study is part of the Population Survey of the Living Conditions and Health Status of Older Persons Living in Quilombola Communities in the Baixada Maranhense (IQUIBEq) project, a cross‐sectional household survey conducted in 11 Quilombola communities in Maranhão (Brazil). The study comprised 221 older adults (60‐104 years), selected in partnership with local social services and community health workers. Participants completed a health survey and a cognitive screening (Mini‐Mental State Examination). Demographics, cardiovascular risk factors (waist‐to‐hip ratio and BMI), cognitive performance, and social engagement were described. Regression analysis examined the association between social engagement and cognition. Our models controlled for age, sex, race, education, family income, and cardiovascular risk factors. We also examined if sex and age moderated the association observed.ResultHigher social engagement is associated with better cognition (p <.001) above and beyond demographics and cardiovascular risk factors. We observed the social activities that mostly drove our results were attending community meetings (e.g., community movements or resident associations) and attending religious/faith services. Moreover, age and sex did not moderate the association between social engagement and cognition.ConclusionSocial engagement may be a key aspect of cognitive/brain health in the Quilombola population, a group that faces poor life conditions. Social engagement may not only provide social/emotional support among the community members but can facilitate access to basic needs (e.g., housing, sanitation). Other potential mechanisms are the cognitive stimulation present in social interactions and the effects of spiritual/faith/religious engagement. Although the results are limited by the cross‐sectional design and survival bias, they may inform public health strategies in underserved populations.

<b>Introduction:</b> Brazil is a low-and-medium income country with a nationwide public health system. Despite the efforts to offer quality health services to the population, several access barriers can be observed. <b>Objective:</b> To generate evidence regarding the spatial distribution of all pulmonary arterial hypertension (PAH) to identify the country9s regions facing a lack of access to emergency care in Brazlian public health system (SUS). <b>Methods:</b> We conducted an ecological, time-series study. Our analysis unit was the admitted patients with the PAH in Brazil9s hospital emergency services (ICD code I27) from 2008 up to 2020. All hospital admissions were geolocated to assess the presence of geographical access barriers. The resulting points were analyzed through the kernel density estimator. <b>Results:</b> A total of 3056 hospital admissions were performed in analyzed period (Figure 1). The total cost associated with the admission was US$4.236.761, with an average value of US$1,386 per admission. The geographical distribution of the admissions due to PAH highlighted a clustering pattern in the most developed regions of the country (Figure 2), in states in the south and southeast portions, that present a higher income level and a better emergency care network. It9s possible to observe a lack of admissions in the northern part of the country, suggesting the existence of geographical access barriers. <b>Conclusions:</b> Redistribution of health providers may be considered to increase the equity in access to PAH care in SUS.&nbsp;The spatial analysis investigated here can be useful for decisions by public health officials.

Socioeconomic inequalities in cancer incidence and access to health services among children and adolescents in China: a cross-sectional study

This article aimed to map therapeutic itineraries in health care within rural Quilombola communities in the north of Minas Gerais, Brazil. This is a section of a qualitative research conducted in six visited communities. The data was collected through 18 individual interviews, analyzed using the theoretical-methodological framework of Therapeutic Itineraries, and organized into three empirical themes. The narratives allowed for understanding the paths taken in health care by the Quilombola population, identifying the components of the popular subsystem (natural resources, the use of teas and home remedies), the family subsystem (transmission of knowledge and cultural heritage of care), and the professional subsystem (hospital level, medical care, primary and specialized attention). The difficulties of access are not only due to geographical distances, but also broader aspects of social determination, such as institutional racism, low availability of services, the need for payment for transportation and medical procedures. In this sense, it is necessary to have an approach and interventions from public policies to address ethnic-racial, economic, and access inequalities in health care services.

Este artigo investiga como a Justiça Digital pode aprimorar o acesso à Justiça e a efetivação de direitos para comunidades quilombolas no Brasil, com ênfase particular na sustentabilidade social e cultural. A metodologia empregada inclui uma revisão de literatura centrada em comunidades quilombolas, inclusão digital e acesso à Justiça. Posteriormente, adotou-se uma abordagem de estudo de caso, incorporando análise documental, observação participante e grupos focais com membros da comunidade. A análise documental permitiu compreender o contexto histórico e cultural das comunidades quilombolas no Brasil. A observação participante de campo foi conduzida pelos pesquisadores na Comunidade Quilombola do Remanso, localizada no município de Lençóis, no interior da Bahia, Brasil. Por fim, foram realizados dois grupos focais, cada um composto por cinco membros da comunidade quilombola local. Como resultados, foram identificados seis dimensões-chave associadas às barreiras à justiça e aos fatores facilitadores da Justiça Digital: (i) usabilidade da tecnologia para acesso à Justiça e aos direitos; (ii) facilitadores comunitários para integração de sistemas jurídicos e tecnológicos; (iii) recursos e infraestrutura disponíveis para uso da tecnologia; (iv) barreiras geográficas; (v) comunicação para conscientização sobre direitos; e (vi) educação e letramento. O estudo conclui que essas seis dimensões são cruciais para promover a inclusão digital e o acesso equitativo à Justiça para as comunidades quilombolas.

Access to eye care remains a major global public health challenge, particularly in low- and middle-income countries and rural areas. Financial constraints, geographic inaccessibility, and limited awareness continue to hinder timely utilization of eye care services, leading to preventable vision loss and blindness. This systematic review and meta-analysis followed PRISMA 2020 guidelines and synthesized evidence from PubMed, Scopus, and Google Scholar for studies published between 2000 and March 2024. A total of 45 studies across 28 countries involving approximately 1,200,000 adults were included. Data were analyzed using a random-effects model to estimate pooled prevalence of financial, geographic, and awareness-related barriers. Subgroup analyses and odds ratios assessed differences by income level, geography, and gender. Heterogeneity was evaluated using the I 2 statistic, and publication bias using Egger’s test and funnel plots. Financial barriers showed the highest pooled prevalence at 58.7%, followed by geographic barriers at 41.2% and awareness-related barriers at 39.8%. Individuals in LMICs had significantly higher odds of barriers compared to high-income settings. Women experienced greater financial, geographic, and awareness barriers than men, with statistically significant differences. High heterogeneity was observed across studies. These findings highlight persistent and overlapping inequities in access to eye care. Targeted interventions such as telemedicine, mobile eye units, and community-based education are essential to improve access and support global initiatives including Vision 2030 and the Sustainable Development Goals. Strengthening health systems, reducing financial burden, and addressing gender and rural disparities should be prioritized to ensure equitable and timely eye care delivery worldwide for all populations globally.

The comprehensive insurance coverage afforded low-income elders with both Medicare and Medicaid coverage (dual enrollees) has substantially reduced financial barriers to care. However, other studies show reduced and less appropriate utilization patterns among dual enrollees compared to Medicare beneficiaries with private supplemental insurance, suggesting access barriers remain. This study found that 59 percent of elderly dual enrollees needed an ambulatory medical or long-term care service in a 1-year period. One third of these individuals experienced barriers to access; organizational and geographic barriers were more prevalent than financial barriers. African American race, trouble paying basic living expenses, fair or poor health status, and an unfavorable assessment of physician information giving were significantly associated with an increased likelihood of organizational and geographic access barriers among elderly dual enrollees.

Surveillance, territory, and interculturality: Challenges in managing a rabies outbreak among the Maxakali.

e18633 Background: The National Health Service Corps (NHSC) has created a shortage designation to identify medically underserved communities. HPSA (Health Professional Shortage Areas) designation identifies an area, population, or facility with inadequate access to healthcare resources such as primary care. Rural-urban continuum codes (RUCC) classify U.S. census tracts using urbanization, population density, and daily commuting. Additionally, there are racial, ethnic, and geographic disparities in enrollment on therapeutic cancer clinical trials. Chimeric antigen receptor T cell (CAR T) therapy has been at the forefront of immune effector cell therapy (IEC) for lymphoma and myeloma. However, it is delivered at specialized centers, and access to specialty centers is known to be a challenge due to financial and geographic barriers. At our institution, trials for CAR-T cell therapy in lymphoma and myeloma are conducted by the IEC disease working group (DWG), while non-IEC trials are conducted by the lymphoma/myeloma DWG. We hypothesized that patients from HPSA and rural communities and HPSA had lower access to IEC and non-IEC trials for lymphoma and myeloma . Methods: Patients enrolled between 1/1/2015 – 2/6/2023 on IEC and non-IEC interventional trials with treatment were included. Disease types included lymphoma (Follicular lymphoma, high-grade B cell lymphoma, diffuse large B cell lymphoma) and myeloma were included. The hypothesis was tested through a t-test. Results: There were 667 total subjects. 503 (75.4%) were non-IEC and 96 (14.3%) were IEC clinical trial participants. The majority in both groups were male (52.7%), White (74.8%), non-Hispanic (86%) .Only 69 (10.3%) pts were from rural areas and 223 (38.9%) were from HPSA communities When stratifying based on RUCC (Table), there is significantly higher rural accrual for IEC trials compared to non-IEC trials. Hispanics from rural areas were lower. There were no African Americans (AA) from rural areas. Conclusions: There is low representation of patients from HPSA and rural communities for IEC and non-IEC lymphoma and myeloma clinical trials. The ethnic and racial inequity in access and enrollment to lymphoma/myeloma trials are pronounced in rural and HPSA communities. Strategies to improve clinical trial enrollment of the underserved rural and HPSA populations is an area of unmet need and will benefit minorities and patients from lower socioeconomic status. [Table: see text]

This thesis assesses the effects of having pluralistic systems of health financing and service provision on universal healthcare coverage with a case study on maternal health in Kenya. Through five research papers using a mix of systematic literature review, qualitative, and quasi-experimental quantitative methods, this thesis answers three primary research questions. First, how do researchers measure the contribution of the private sector to maternal health and family planning service provision and how much care does the private sector provide in sub-Saharan Africa (SSA)? Second, how did Kenya’s pluralistic financing policies and public-private engagement strategies for health arise and evolve over time? Finally, what are the impacts of user fee removals and subsidized vouchers on use, sector, quality, continuity, and equity of maternal care in Kenya? The findings from the systematic review suggest that there is substantial heterogeneity in the way that the private health sector is defined in scientific literature, making it difficult to compare estimates of private sector health provision. The qualitative study reveals that Kenya’s pluralistic health system results from the confluence of many historical, social, political, and economic factors and effective lobbying by the private for-profit sector. Finally, the three quasi-experimental studies highlight a complex set of outcomes resulting from user fee removal policies and the safe motherhood voucher program in Kenya. The 10/20 policy was associated with positive effects on the timing and number of ANC visits; however, these improvements were unrelated to use of the public primary care facilities that the policy targeted. The voucher program increased use of facility-based delivery care among poor women; however, it had no impact on use of four or more ANC visits or postnatal care. After the free maternity services policy was introduced, the voucher program no longer improved use of facility-based delivery among the poor; however, use of the private sector remained much higher in voucher counties. Both the voucher program and insurance coverage had positive impacts on continuity of maternal care for poor women, while introduction of the free maternity services policy did not. Many factors affect women’s use of maternal health services beyond the cost of care. Making services free in the public sector is not sufficient to eliminate disparities in access to health services; policymakers must therefore simultaneously address both financial and nonfinancial barriers to service use. Health financing strategies involving private providers have the potential to equitably increase service use and continuity, provided that the cost of care is subsidized for users with the lowest ability to pay.

Quilombos are settlements founded by descendants of runaway slaves in Brazil, typically located in rural areas. Quilombola communities often present poor basic sanitation, high levels of illiteracy, and limited access to social and health services. Although the Quilombola population is socially vulnerable and likely to present an increased risk for dementia, it is underrepresented in aging research. The present study aims to investigate the association between cognition and socio-cultural engagement, potentially protective for dementia. Method: This cross-sectional study was conducted in 11 Quilombola communities in Maranhão, Brazil. The study comprised 221 older adults (60-104 years), selected in partnership with local services and community health workers. Participants completed a health survey and a cognitive screening. Demographics, cardiovascular risk factors (CRF), cognitive performance, and social engagement were described. Regression analysis examined the association between social engagement and cognition, controlling for age, sex, race, education, family income, and cardiovascular risk factors. We also examined moderation effects of sex and age on the regressions. Results Higher social engagement was associated with better cognition (p &amp;lt;.001) above and beyond demographics and CRF. We observed the social activities that mostly drove the results were attending “community meetings” and “religious/faith services”. Age and sex did not moderate the associations. Conclusion Social engagement may be a key aspect of cognitive/brain health in Quilombola population. Social engagement may not only provide social/emotional support, but also facilitate access to basic needs. Although the results are limited by the cross-sectional design and survival bias, it may inform strategies in underserved populations.

Introduction:Universal health coverage will be guaranteed to all individuals, safeguarding the rights of traditional communities, as in the quilombola population, respecting the dimensions of interculturality, gender and ethnicity.Objective:The aim of this study is to describe the conceptions of health and health care practices of Afro-Brazilian men from a quilombola community.Methods:This was a qualitative descriptive study conducted with Afro-Brazilian men from a quilombola community in Bahia, Brazil, where there is a significant concentration of black people and quilombola communities.Results:This group’s conceptions of health are based on the combination of the individual body with the body that is socially and culturally situated in the community. Health care practices are anchored in cultural knowledge and strengthened by the bonds with nature, friends and religious leaders.Conclusion:The black men from quilombola communities are in a state of vulnerability due to the lack of access to health services.

Background: The experiences of parents and care providers offer valuable insight into the inequities that exist in navigating care for children with complex needs (CCN). Care services for this vulnerable population are provided within fragmented health, social services, and education systems. Navigating care remains predominantly women’s work with both parents and care providers facing significant barriers accessing care for CCN. Who is it for? CCN and their families use a high volume of resources across multiple sectors requiring a coordinated effort by parents (often mothers) and care providers (often women) involved in their care. Who did you involve? This paper provides new insight into the work related to care navigation for CCN by applying an intersectionality health equity lens to a secondary analysis of data collected from semi-structured interviews of parents (n=33) and care providers (n=83) involved in care for CCN in two Maritime Canadian provinces. What did you do? In this secondary analysis, data grouped into ten dominant themes related to care navigation were viewed through an intersectionality health equity lens to identify tensions arising from intersecting relations of inequality with a focus on the implications of sex/gender, geography, and income-level in shaping the lived experiences of parents and care providers navigating care for CCN. What results did you get? This study found that care for CCN continues to be provided in a context of siloed health, social services, and education sectors perpetuating the difficulties experienced by parents and care providers needing to identify and access care services available to CCN within and beyond their community. Parents of CCN initially planned to share caregiving responsibilities equally, but only mothers reported leaving their jobs or not pursuing their careers to care for their CCN. Mothers researched available services, organized care appointments, arranged logistics (e.g. transportation, paperwork, care for other children), and advocated for their child. However, not all parents were equally able to navigate care for CCN due to differences in literacy rates, financial or geographic barriers, and care burdens, contributing to perceived inequities in access to care for CCN. Care providers reported trying to support parents in navigating care for CCN but these professionals experienced a lack of dedicated time, navigation training, and adequate remuneration during their efforts to provide the necessary assistance. What is the learning for the international audience? A dedicated role for paid patient navigators could help ensure meaningful access to care for CCN and their parents but this alone is not sufficient. What are the next steps? In addition to supporting the women involved in care navigation work for CCN, it is essential to address interconnected systemic issues related to a lack of health human resources, unequal access to care in rural areas, and financial barriers to accessing care that falls outside of the publicly insured care mandated in national legislation.

The world is facing unprecedented events because of the coronavirus pandemic. It started in China, went to all continents, arrived in Brazil. It is a virus that acts on a global scale, but has different consequences in the countries where does it go. It is intended here to discuss how the pandemic context is highlighting the traces of the established necropolitics in relation to the black population, especially here about quilombola populations. For such, will be head a description of the concept of necropolitics from the Cameroonian philosopher Achille Mbembe, towards that backdrop to analyze the data about the cases of coronavirus patients in Brazil as a whole and in quilombola communities, realizing a discrepancy about the lethality rates between quilombolas and non-quilombolas, a difference that points out that a sick quilombola with the coronavirus has about 3 times more chance of dying than a non-quilombola person. The data will be extracted from epidemiological bulletins provided by the Ministry of Health and by the National Coordination of Articulation of Black Rural Quilombola Communities (CONAQ). With the visualization of this scenario, some hypotheses about the reason for this difference will be put, but the important is that the necropolitics is present in any of them hypotheses. Thus, the let die that Mbembe concept discussed and applied here in the Brazilian scenario, may represent the biggest genocide of the quilombola population in Brazil since the slave period. Finally, it is intended to present some scenarios for the post-pandemic and how quilombola communities can interact in each scenario displayed.

A health care service is a prerequisite for sustainable development. This requires access to balanced health care facilities and services in different geographic areas. The first step is to identify inequality in access to health services in different areas. This study is a descriptive analytical study was carried out on the cities in Yazd province. The indices were weighted using Shannon entropy, then using the TOPSIS technique and the result were classified into categories in terms of the level of development across towns. The findings revealed that distinct regional disparities in health care services across Yazd province. Taft and Sadoogh cities were ranked as first and the last in terms of access to health care services respectively. Policy makers and managers should consider priority (regional planning, budget and resources allocation) according to the degree of development. Ethical issues should provide a broader perspective to policymakers.