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Health panorama of the Afro-Brazilian population: a systematic review

1 Department of Internal Medicine, Division of Rheumatology, Universidade de São Paulo (USP), São Paulo, Brazil. 2 Post Graduate Program in Ciências da Computação, Universidade Federal de Pernambuco (UFPE), Recife, Brazil. 3 Departament of Nutrition, Universidade Federal do Pernambuco (UFPE), Recife, Brazil. 4 Post Graduate Program in Health Sciences, Faculty of Medicine, Universidade Federal do Cariri (UFCA), Barbalha, Brazil. 5 Post Graduate Program in Desenvolvimento Regional Sustentável, Universidade Federal do Cariri (UFCA), Juazeiro do Norte, Brazil.


Introduction
Afro-brazilian population claims to health system access increased in the second half of the 20th century. They had a strong participation of popular movements and supported the process that originated the Sanitary Reform and the Brazilian Unified Health System (SUS) [1] in the future. However, even though this developing system promoted universality, equity and integrality concepts, an environment of inequalities, differences and iniquities was its real configurations [2].
The Annual Report of Racial Inequalities in Brazil (2009Brazil ( -2010 showed a scenario of inequalities that varied from reproductive health to dental treatment. It emphasized the disregard for the well-being of social groups that are victims of racism, which is designed as a socio and historical determined context [3,4]. Thus, in Brazil of the 21st century, white, Afro-Brazilian (black and pardo) and Indigenous populations still occupy different social spaces, which reflects directly in the most common social indicators like schooling, work and health conditions [5,6]. Thus, race as well as gender and sexual orientation are social markers of difference, i.e. an explanatory variable for inequalities [6].
Based on the government point of view, the Brazilian Department of Health published the Política Nacional de Saúde Integral da População Negra (PNSIPN -Integral Health National Policy of the Black Population) in 2009, approved by the National Health Board in 2006 and that has been discussed since the creation of the Afro-brazilian population Technical Committee of Health in 2004 [7]. São Paulo State was the precursor in this process, because it was the first to incorporate the "race/color" subject in 1990 in health information systems, even though it was done only because of the popular pressure [8]. Nevertheless, the population and health professionals seem to be unaware of how racism impacts on life, access to services and quality of care [9]. It shows the need of a continuous elaboration of studies in order to acquire updated data that reinforce race equality fight. Data were collected in July of 2021. Manuscripts were mainly chosen through the analysis of titles and abstracts.

Data analysis
The articles were analyzed according to the following eligibility criteria ( Figure 1): (1) articles including at least one combination of the terms described in the search strategy in their titles; (2) articles written in English, Portuguese or Spanish; (3) articles that discussed about socioeconomic indicators of the Afro-descendant population that live in Brazil; (4) original studies with full text accessible through the Journal Portal of the Coordination for the Improvement of Higher Education Personnel (CAPES), which is a virtual library created by the Brazilian Department of Health with restricted content to authorized users. We excluded: (1) non-original studies, such as letters to the editor, prefaces, short communications, corrections /errata, comments, editorials, reviews, papers, dissertations, and theses. Manuscripts found in more than one of the databases were accounted only once. To ensure more outcome reliability, data were collected by two researchers individually and divergences were solved by a third senior researcher.
Then, each article of the sample was fully read, and data were added to a spreadsheet that included author and year, title, study sample, study type, main outcomes, and conclusions (Table  1).
Some articles were excluded because they did not provide enough data for a comparison between several ethnic groups, due to the fact they did not divide data into different races, nor they focused on a certain group to the detriment of the others. Articles that considered quilombolas (maroons, in English) as a unique ethnic group are an example, because such fact does not follow the current mixed-race reality of these communities.

Ethics approval
This study followed all the ethical requirements of Helsinki Declaration and Resolution 510/2016 of the Brazilian Health National Council. It is a Literature Review study; therefore, it does not need to be submitted to the Ethics Committee in Research with Human Beings.

Results (Review)
According to the adopted strategy, 65 manuscripts were firstly chosen. After complete analysis of the titles, abstracts and manuscripts, we obtained 19 articles according to the eligibility criteria and, therefore, we excluded 46 ( Figure 1). The sample was divided into two predetermined categories, as follows: Epidemiological aspects of pathologies in the afro-brazilian people; and Health epidemiological aspects of the Afro-Brazilian women.

Epidemiological aspects of pathologies in the afro-brazilian people
Chronic kidney disease -CKD [10], diabetes (DM2) with higher levels of HbA1c [16], and lack of all teeth [15] or tooth decay for Afro-Brazilian people and [13] mulatos (they constitute the Brazilian ethnic groups that are the result of miscegenation between African and European) were more present in comparison with other ethnic-racial groups.
This can be explained by biological aspects, such as higher incidence of resistant hypertension and hard control on Afro-Brazilian people and their refractoriness to medications like angiotensin -converting -enzyme inhibitors (ACE inhibitors), and psychosocial factors, for instance, limited access to services. This population also shows more incidence of infectocontagious diseases like Chagas disease [11] when compared to the European-descendant population, and metabolic diseases like polycystic ovary Syndrome, in which 889 women, in a population studied at paper [24], were assessed and 88.9% were Afro-Brazilian, with an 8.5% disease incidence [24]. However, since this study was conducted in the city of Salvador, Bahia State, in which there is a higher incidence of the Afro-Brazilian population, there is a bias here.
It is noteworthy that in these studies, lower per capita income, low schooling levels and, therefore, level of instruction for the development of health self-care had a higher impact on the prevalence of these diseases than specific biological characteristics of the Afro-Brazilian. A work conducted in Bambuí [12] highlighted that schooling levels (<4 years) were statistically more correlated with high pressure levels (Adjusted β=2.92; 95% confidence interval, 0.85-4.99), whereas polygenic mutations that address African ancestry were not.
An interesting fact is that in a study about health self-assessment from a quilombola population of Vitória da Conquista, Espírito Santo, Brazil Southeast, skin color was pointed out as one of the justifications for those that assessed health condition as negative [14], a similar result also found in other studies [29,30]. Racism has been indicated as one of the reasons for ethnical-racial criteria eligibility as causers of inequalities in the health quality assessment. We also identified the prevalence of food insecurity in quilombos from a Brazilian Northeast rural area, which also have some associations with economic level and quantities of residents per house [19].
In the Afro-Brazilian population, unlike other ethnic-racial groups, there are higher mortality and lower life expectancy with a disparity of around 33 years in the median of deaths between Afro-Brazilian and white individuals according Fiorio et al [18]. Afro-Brazilian people show higher rates of deaths due to mental and behavioral disorders, as well as undefined causes [18]. A study published in 2014 [14] showed a depression incidence of 13.5% in Afro-descendants from the Bahia city Vitória da Conquista, and more than 60% of them had a chronic disease. These statistics are not universal. They even highlight there is no concrete correlation between race and mental health in literature; however, a positive incline has been seen towards this direction.
This group, probably due to their life conditions -more exposure to violence, poverty and insalubrious environments -, is more inclined to developing mental disorders. In addition, due to the lack of multidisciplinary team care in the outskirts of the cities, improper coverage of the Family Health Strategy and efficient public security presence in these places, which show a higher incidence of Afro-Brazilian people, afro-Brazilian people would not have their causa mortis clarified.

Health epidemiological aspects of afrobrazilian women
After the study of HIV female carriers, statistically significant differences were found between Afro-Brazilian and non-afro Brazilian women for variables like schooling; monthly, individual and family per capita income; number of direct dependents, correct knowledge of CD4 and viral load examinations, access to gynecologist and infectious disease specialist, and comprehension of what the infectious disease specialist explains during the medical appointment according Fabian et al [27]. Researches [17] in the city of São Paulo that compared Afro-Brazilian and non-Afro-Brazilian women found that Afro-Brazilian women are considered the group with the highest BMI, especially at the ages of 4 and 23, varying from 1 to 3 kg/m 2 . Thus, they reinforce the multifactorial model that mainly involves social position variables to explain the higher percentage of sick people among Afro-Brazilian people.
In Miranda et al. afro-brazilian women waiting for liver transplant presented lower model for end-stage liver disease -MELD (26.1%) than white women (63.4%) [16], despite the same cirrhosis causes in both groupsalcohol, C and B viruses, respectively. Also, afro-brazilian people are more inclined to kidney dysfunction; therefore, they show a lack of equity among women due to their ethnicity.
According the papers evaluated regarding gynecological and obstetric health issues, these patients presented a higher incidence of uterine fibroids [23] and more aggressive breast neoplasms, because when the values per region were divided, the Brazilian Northeast region, which has higher influence of the black in its constitution, provided higher rates of breast cancer with uncommon and severe mutations [22] and there was more smoking during pregnancy [19,20].
In addition, a study carried out in Maranhão [21] shows that C-section delivery rates are lower in all the ethnic groups in comparison with white women, of whom Afro-Brazilian ones are a minority in hospital deliveries. This disparity becomes even more important in states with lower access to hospitals, and causal factors include more advanced maternal age, high schooling levels, and prenatal followup. Such situation shows that Afrobrazilian women have lower access to health services and undergo procedures that are available in the public health system, but they usually do not have the possibility of choosing how they want to give birth. Such fact is mainly associated with poor financial conditions of Afro-Brazilian pregnant women, even though there are many orientations in literature regarding the best delivery type.
Therefore, the most of these diseases are strictly correlated with poor socioeconomic variables, such as low income, housing in insalubrious places, lack of access to basic sanitation, to quality food, to public security, to health services and to health prevention and promotion media. In parallel, we noticed that the interest for such subject is still new in the country and is shown by the disparity of indicators in different regions of Brazil.
This suggests the need of increasing discussion about racial inequalities in health by promoting public policies of accessibility to services in the four spheres -primary, secondary, tertiary and quaternary attention, as well as a bolder mapping of social indicators divided and compared by regions to subsidize future interventions.