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Geographical barriers and multimorbidity in quilombola territories of the amazon region

Author

Listed:
  • Leanna Silva Aquino
  • Ellen Mara Fernandes da Silva
  • Victoria Valentim Aguiar
  • Cesar Ferreira Fernandes Filho
  • Sheyla Mara Silva de Oliveira
  • Tatiane Costa Quaresma
  • Valney Mara Gomes Conde
  • Nádia Vicência do Nascimento Martins
  • Marcos Manoel Honorato
  • Veridiana Barreto do Nascimento
  • Guilherme Augusto Barros Conde
  • Franciane de Paula Fernandes
  • Lívia de Aguiar Valentim

Abstract

Background: Quilombola communities in the Brazilian Amazon face persistent social and territorial inequities that shape health outcomes and access to care. Geographic isolation, limited transportation, centralization of specialized services, and socioeconomic disadvantages contribute to unequal opportunities for timely diagnosis and treatment. Understanding how these determinants interact with patterns of multimorbidity is essential for guiding equiTable health policies and strengthening primary care in remote territories. Methods: A cross-sectional epidemiological study was conducted with 518 adults from nine quilombola communities in Santarém, Pará. Data were collected through household surveys addressing sociodemographics, self-reported diseases, service utilization and resolvability. Geographic coordinates of communities and health services were mapped to classify accessibility as high, medium or low. Diseases were converted into a binary matrix to estimate prevalence and identify multimorbidity (≥2 conditions). Statistical analyses included chi-square tests, ANOVA, Spearman correlations and heatmap visualization. A Composite Access Index (CAI) integrating geographic distance, epidemiological burden and service-use indicators was developed. A Random Forest model was used to identify conditions most strongly associated with multimorbidity. Results: Communities showed marked territorial heterogeneity. Pérola do Maicá had the highest accessibility, while Ituqui, Tiningu and Murumuru presented substantial geographic and logistical barriers. Service utilization ranged from 42.9% to 95.0%, and most communities relied on care outside their territory (70–95%). Complete problem resolution was reported by 72.5% of participants, though with variation among communities. The CAI identified Ituqui (0.550), Tiningu (0.480) and Murumurutuba (0.331) as the most vulnerable territories. The Random Forest model achieved 93.6% accuracy, with hypertension, diabetes, musculoskeletal diseases, arthritis/rheumatism and heart disease emerging as key predictors of multimorbidity. Discussion: Findings indicate that social and territorial determinants are strongly associated with inequities in access to health services, continuity of care, and disease burden across quilombola communities. Conclusions: Geographic barriers and the distribution of health services are associated with distinct patterns of multimorbidity and health service access among quilombola populations. Strengthening primary care, transportation, and diagnostic support may help mitigate inequities and improve health conditions in remote Amazonian territories.

Suggested Citation

  • Leanna Silva Aquino & Ellen Mara Fernandes da Silva & Victoria Valentim Aguiar & Cesar Ferreira Fernandes Filho & Sheyla Mara Silva de Oliveira & Tatiane Costa Quaresma & Valney Mara Gomes Conde & Nád, 2026. "Geographical barriers and multimorbidity in quilombola territories of the amazon region," PLOS ONE, Public Library of Science, vol. 21(3), pages 1-15, March.
    • Handle: RePEc:plo:pone00:0344043
    DOI: 10.1371/journal.pone.0344043
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    References listed on IDEAS

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    1. Dahlgren, Göran & Whitehead, Margaret, 1991. "Policies and strategies to promote social equity in health. Background document to WHO - Strategy paper for Europe," Arbetsrapport 2007:14, Institute for Futures Studies.
    2. Ellen Mara Fernandes da Silva & Leanna Silva Aquino & Ednaldo Pereira Maranhão & Sheyla Mara Silva de Oliveira & Tatiane Costa Quaresma & Daliane Ferreira Marinho & Valney Mara Gomes Conde & Veridiana, 2026. "Social and environmental determinants of Neglected infectious diseases in quilombola communities of the Brazilian Amazon: An epidemiological and machine learning analysis," PLOS Neglected Tropical Diseases, Public Library of Science, vol. 20(3), pages 1-14, March.
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