Rural women, intersectionality, and health

Abstract

Rural women are considered a healing resource because they manage health problems of their family and community. On the other hand, their own cares are neglected. Based on the experience of women in rural areas, this study adopts an intersectional perspective to understand the relation between social markers of difference and health vulnerability in rural women in Zona da Mata in Minas Gerais. In total, 20 women aged 18 to 73 years were interviewed in 2022. Data were qualitatively analyzed and categorized by content analysis. This research highlights the inequities regarding access to health in rural areas (including the inadequacy of basic sanitation) and the need for an intersectional approach to collective health analysis.

Keywords:
Rural health; Basic sanitation; Intersectionality

Resumo

Mulheres rurais são consideradas recurso um de cura por encaminharem os problemas de saúde da família e comunidade, mas, por outro lado, acabam sendo negligenciadas do cuidado. Baseado na experiência das mulheres nos territórios rurais, este estudo adota a perspectiva interseccional para entender a relação dos marcadores sociais da diferença e a vulnerabilidade em saúde das mulheres rurais da Zona da Mata de Minas Gerais. Foram entrevistadas 20 mulheres, entre 18 e 73 anos, em 2022. Os dados produzidos foram analisados qualitativamente e categorizados pela metodologia de análise de conteúdo. A pesquisa evidencia a falta de equidade quanto ao acesso à saúde no meio rural, incluindo a pouca adequação do saneamento básico, e a necessidade da abordagem interseccional para análises em saúde coletiva.

Palavras-chave:
Saúde rural; Saneamento básico; Interseccionalidade

Introduction

Rural women have historically played the main role in the care and management of family health problems, as they are the ones who assess the need to provide care to family members, which makes women an important “healing resource” (Oliveira; Moraes, 2010, p.415). However, the designation of care as a feminine task deepens gender inequalities. This gap widens even more when permeated by social class markers, since poor women in remote areas are the least likely to seek and receive adequate healthcare (Lopes; Leal; Cardoso, 2023).

During the new coronavirus pandemic, the role of care has further impacted women’s lives. According to a study done by the organizations Gênero e Número and Sempreviva (SOF, 2020), 50% of Brazilian women started taking care of someone during the pandemic, and among these, 80.6% started taking care of family members, 24% of friends, and 11% of neighbors. In rural areas, women’s excessive responsibility for care is articulated with the context of precariousness of social determinants of health¹, which impairs the health of rural populations, especially due to the characteristics of their work and the time dedicated to working in the field, in addition to the distance from the basic health units (UBS) and the absence of community health agents (CHA). The heterogeneity that exists in rural areas is multiplied by the various intersections of inequality markers, such as race, income, and territory (Crenshaw, 2002).

This study analyzes these inequities in the context of the Zona da Mata of Minas Gerais, the second poorest region of Minas Gerais, which has the least amount of concentrated land structure in the state and is the second with the largest number of family farming establishments in the country (IBGE, 2018). We aim to establish a dialogue between equity and intersectionality as a theoretical-methodological approach, allowing us to analyze the experience of women and the vulnerabilities accentuated by social difference markers (income, race, and territory).

The 20 participants in the research live in the Olga Benário agrarian reform settlement (Visconde do Rio Branco) and in the Palmital neighborhood (which is divided between the municipalities of Viçosa and Coimbra and has no political organization). These rural territories are understood in this study as complementary to the urban one, since they enable circularity in the daily lives and trajectories of rural subjects (Castro, 2016). Despite this, there is a distance-not always spatial-between the possibilities that the countryside and the city offer. The physical dispersion of rural populations, socioeconomic problems combined with the absence or insufficiency of public health and sanitation policies, and the scarcity of resources invested in these communities have contributed to consolidating a serious shortage scenario, characteristic of the Brazilian rural area (Lima et al., 2019).

From the specificities of the rural environment, this article analyzes the relationship between social markers of difference and the health vulnerability of rural women in Zona da Mata, Minas Gerais. We analyzed income, basic sanitation services (garbage collection, access to water, sewage disposal), comorbidities, and access to health services. Knowing the specificities of the territory in relation to pre-existing risks contributes toward public health and communication policies that meet the specific needs of this population.

Dialogue between equity and the intersectional approach

Equity, as one of the principles of the Brazilian National Health System (SUS), refers to differences. The World Health Organization (WHO) understands health equity as minimizing avoidable disparities in health and its determinants, including, but not limited to, healthcare, between groups of people with different levels of underlying social attributes. From this perspective, policies focused on particular social groups, contexts, cultures, and territories aim to promote equity by recognizing these particularities.

One of them is the Política Nacional de Saúde Integral das Populações do Campo, da Floresta e das Águas (PNSIPCFA - National Policy for the Integral Health of the Populations of the Countryside, Forest, and Waters), approved in 2011, from the activism of social movements in rural areas. It aims to meet the health needs and improve the indicators and the quality of life of this population, recognizing the conditions and social determinants of the countryside and the forest in the health/disease process of these groups (LIMA et al., 2019). Ordinance No. 2,866/2011 institutes the policy within the scope of the SUS with the objective of improving the level of health of rural and forest populations via actions and initiatives that recognize specificities of gender, generation, race/color, ethnicity, and sexual orientation (Ministério da Saúde, 2013).

This policy considers the importance of Social Determinants of Health (SDH), which are social, economic, cultural, ethnic/racial, psychological, and behavioral factors, that is, social characteristics within which life takes place, influencing the occurrence of health problems and their risk factors in the population (Buss; Filho, 2007). Thus, according to the PNSIPCFA, basic sanitation service is among the most important social determinants of health, as it contributes to the emergence of waterborne diseases, intestinal parasitosis, and diarrhea.

The physical dispersion of rural populations, socioeconomic problems combined with the absence or insufficiency of public health and sanitation policies, in addition to the scarcity of resources invested in these communities have contributed to consolidating the severe shortages issue, characteristic of the Brazilian rural area (Lima et al., 2019).

The PNSIPCFA also highlights that the health of rural workers (of forest and water regions) is conditioned by social, racial and gender, economic, technological, and organizational factors related to the production and consumption profile, in addition to risk factors of a physical, chemical, biological, mechanical, and ergonomic nature present in private work (Ministério da Saúde, 2013). The major driving forces of the health-disease process in rural Brazil are associated with government policies to encourage certain production chains, such as sugarcane and soybeans, which make use of pesticides, like glyphosate. This policy also notes the incidence of episodes of violence related to conflicts over land ownership and possession, in addition to the injuries resulting from domestic and sexual violence, especially against women.

Therefore, an intersectional approach in health research is necessary for the development of more effective and inclusive policies. The term “intersectionality” expresses the way in which racism, patriarchy, class oppression, and other discriminatory systems create basic inequalities that are associated with each other (Collins, 2017; Crenshaw, 2002). Multiple systems of oppression structure the way individuals relate institutionally and interpersonally, thus producing domination matrices specific to each social context, which are related to worse health outcomes (Oliveira; Bastos; Moretti-Pires, 2021). Studies investigating the intersectional relationship between race, gender, and class with self-rated health, hypertension, violence against women, HIV/AIDS, access to health services, and mental health have shown that groups intersected by multiple axes of marginalization are at further disadvantage (Oliveira; Bastos; Moretti-Pires, 2021).

Crenshaw (2002, p. 177) initially proposed intersectionality, originated in the legal sciences, as an approach to the causes and effects of violence against women in Black communities, examining how specific actions and policies generate oppression that manifests itself along certain axes, contributing to “disempowerment”². Within this understanding, it can be seen that in several points (schooling, sanitation services, health, access to digital technologies, poverty), inequality is a striking factor in rural areas, especially when analyzing the reality of women in these contexts, which suggests that intersectionality is an appropriate approach to think about the situation of rural women.

Since the 1990s, the perspectives of intersectionality, originating from Black feminism, gained strength, based on the reflection about the intersection between gender, race, class, ethnicity, religion, sexual orientation, and others (Díaz-Benítez; Mattos, 2019). According to Crenshaw (2002), the intersectional perspective seeks to perceive the structural and dynamic consequences of the interaction between multiple axes of subordination since disadvantages interact with pre-existing vulnerabilities, producing a different dimension of disempowerment. Research with this approach asks other questions to the phenomena that have historically been studied from a neutral and impartial perspective, imparting the logics of oppression and the conditions of subjectivation to the debate, complexifying their analyses and perspectives (Collins, 2017).

It is necessary, therefore, to think simultaneously regarding domination, so as not to contribute to its perpetuation (Kergoat, 2010). In this sense, intersectionality has also contributed significantly to the field of public health, in which social determinants and health disparities are increasingly addressed from this perspective, assuming that a more comprehensive analysis of social problems can yield more effective actions, which corroborates the fight against oppression and for social justice initiatives (Collins, 2017).

In the pandemic context, COVID-19 had critical effects on areas marked by extreme social inequality and in more vulnerable populations since the particularities of the groups affected by multiple oppression markers demanded measures that were not compartmentalized, but rather interconnected and articulated (Marques et al., 2021).

Methodological aspects

This study is part of the project Mulheres Rurais: do Acesso à Apropriação das Tecnologias da Informação e Comunicação (Rural Women: From Access to the Appropriation of Information and Communication Technologies), developed by the research and extension group Meios (Rural Economics Department of the Federal University of Viçosa). The methodological aspect adopted here has an exploratory character and qualitative aspects. In order to fulfill the general objective, starting from the existing heterogeneity in rural areas multiplied by the various intersections of different inequality markers, we sought to consider the plurality of rural women, considering that there are groups that articulate via social movements.

Thus, semi-structured interviews were used with 20 rural women from the Zona da Mata of Minas Gerais, 10 residents of the Palmital neighborhood (Viçosa, state of Minas Gerais), where there is no political organization, and 10 in the settlement of the Olga Benário Landless Rural Workers Movement (MST), in Visconde do Rio Branco (state of Minas Gerais). The MST is a peasant social movement that results from an structural and historical agrarian issue in Brazil and aims to carry out agrarian reform, produce sustainable food and improve the living conditions in the countryside (Caldart, 2001).

The participants are of different ages, ranging from 18 to 73 years old, as a way of increasing the heterogeneity of rural women; they were selected using the snowball method (Vinuto, 2014). To ensure the privacy of each participant, their names were protected and replaced by code names (the letter “P” referring to residents of the Palmital neighborhood and the letter “O” for Olga Benário settlers). To ratify the intersectional perspective, each code name is added to data on the color and age of the participants.

The data were manually treated using content analysis (Bardin, 1977). This stage was carried out from an intersectional perspective, that is, via a critical analysis of social inequality markers on the studied phenomena, such as race/skin color, income, and territory (Díaz-Benítez; Mattos, 2019). For an intersectional qualitative analysis, it is necessary to define the categories, examine which axes of diversity are included and excluded, and understand which roles these axes fulfill when it comes to inequality. This involves analyzing the most significant intersections and processes in a specific context. Thus, following a path that is still developing in the intersectional methodologies field, we sought to systematize results, as much as possible, within a framework elaborated by the authors called the Intersectional Perspective Framework. Table 2 presents the articulations between the markers and highlights inequities that need to be exposed in order to be understood.

This research followed ethical procedures and was registered in Plataforma Brasil, a national and unified records database of all research involving human beings in the Research Ethics Committee (CEP) system, with a Certificate of Presentation for Ethical Appreciation (CAAE) 39341420.6.0000.5153 and opinion number 4.529.610 favorable to the investigation.

Results and Discussion: The health conditions involving the participating women

Table 1 presents data on the profiles of the women participating in this research, including age, race, education, and income.

Table 1
Description of the group of participants from the rural area of the micro-region of Viçosa and the Olga Benário settlement

Participant	Age	Race	Schooling	Monthly family income (according to the minimum wage)
P1	42	Black	Never attended	equivalent to 1 and 1/2 minimum wages
P2	26	Brown	Incomplete higher education degree	equivalent to 2 minimum wages
P3	73	Brown	Elementary education	equivalent to 2 minimum wages
P4	37	White	Lower secondary school	equivalent to 2 minimum wages
P5	44	White	Elementary education	equivalent to 2 minimum wages
P6	46	Black	Elementary education	equivalent to 1 minimum wage
P7	58	White	Lower secondary education	equivalent to 1 and 1/2 minimum wages
P8	50	Black	Elementary education	equivalent to 2 minimum wages
P9	61	White	Elementary education	equivalent to 2 minimum wages
P10	38	Brown	Incomplete Upper secondary education	equivalent to 2 minimum wages
O1	38	Brown	Lower secondary education	equivalent to 1/2 the minimum wage
O2	28	Brown	lower secondary education	equivalent to 1 minimum wage
O3	43	Brown	Lower secondary education	equivalent to 1/2 the minimum wage
O4	38	Brown	Lower secondary education	equivalent to 3 minimum wages
O5	39	Brown	Elementary education	equivalent to 2 minimum wages
O6	30	White	Lower secondary education	equivalent to 1 minimum wage
O7	60	Brown	Elementary education	equivalent to 2 minimum wages
O8	26	Brown	Incomplete higher education degree	equivalent to 2 minimum wages
O9	62	Brown	Lower secondary education	equivalent to 1/2 the minimum wage
O10	18	Black	Lower secondary education	equivalent to 1 minimum wage

• Source: devised by the authors.

According to the data, 15 participants consider themselves Black (Black and Brown/mixed-race) and five White. Regarding family income, 10 participants (50%) stated that they live monthly on two minimum wages³, three (15%) with one and a half minimum wages, four (20%) with one minimum wage, two (10%) with only half the minimum wage and only one interviewee said that her family earns the equivalent of three minimum wages per month. Among the participants, only six (30%) stated that they were enrolled in the Federal Government’s income transfer programs.

The expressive majority of Black women (75%) in the surveyed field who live with a small income (less than two minimum wages per month) portray the fruits of an extremely unequal society, in which Black people have historically been marginalized and excluded. Thus, this extreme and persistent inequality produces asymmetries in the occupation of spaces, which leads to other social inequalities, always to the detriment of the discriminated group.

The education levels of the participants are varied, from women (2) who are studying at a public federal university to those (1) who have never attended school (Participant P1). Seven participants studied up to elementary school, four up to lower secondary school, five completed upper secondary school, and one has not completed upper secondary school. To understand the low education level of some participants, it is important to consider the difficulties faced by many residents of rural areas in attending schools, such as distances and difficulties with transportation, combined with a heavy work routine. It is worth noting that the only illiterate participant is Black, which is in line with data from the Continuous National Household Sample Survey (PNAD). According to the PNAD (IBGE, 2019), illiteracy among the Black population is almost three times that of the White population.

Basic sanitation services

The main perspective of public health is thinking and prioritizing collective health, so it follows that among the SDH-which include the socioeconomic, cultural, and environmental state of a society-sanitation services are a direct strategy for promoting health and preventing disease(File; Oliveira; Pagotto, 2020). Thus, the association between water supply and sewage disposal (or lack thereof) with overall health and its influence on specific indicators (like diarrhea) was highlighted, as well as its relation with broader health indicators (like infant mortality or life expectancy) and with the transmission of diseases due to the inadequate disposal of solid waste (Lima; Oliveira; Pagotto, 2020).

Sanitation law No. 11,445 of January 5, 2007, establishes that public sanitation services must be universal and adapted to local and regional characteristics. It considers sanitation services as a set of services that include water supply, sewage disposal, urban cleanliness, and solid waste management, all essential for public health and environmental protection.

The supply of drinking water implies a set of activities, infrastructures, and facilities, from collection to connection to public water systems and the respective measuring devices; however the distance, however, between rural properties hinder the infrastructure and make it more expensive (Scalize; Bezerra, 2020). The forms of water collection utilized by these rural women are presented in Graph 1.

Graph 1
Water collection

The participants use individual solutions for water collection (Graph 1), which is considered by Scalize and Bezerra (2020) to be a form of precarious access. Among the participants, most (10) use water from semi artesian wells, which are shallow, up to 20 meters, with water collection from the water table very close to the surface.

Another five participants get their supply from artesian wells, with more than 60 meters, in which the extracted water comes from a layer of rock, and not from the ground. This type of well requires professional construction, being more expensive than the semi artesian one. Among these women, three live in the Palmital neighborhood and two in the MST settlement.

Four participants, all residents in the Olga Benário settlement, use spring water, which, although it comes from underground sources, can present instabilities and is not always suitable for human consumption, due to the possibility of presenting physical, chemical, and biological contaminants. Only one, also from the settlement, said that her water comes from a cistern. A cistern, tank, or reservoir that collects rainwater, provides water without sanitary safety and/or in insufficient quantities for health protection (Scalize; Bezerra, 2020)⁴.

Thus, the potable instability of the water consumed by many of these rural women, and, consequently, their families, ratifies the perspective that the health and disease process of the rural population is impacted by social inequalities (Lima; Oliveira; Pagotto, 2020). Water supply is also an important factor in the context of a health crisis such as COVID-19, which required constant hygiene, as mentioned by participant O9 (Brown, 62 years old), who “washed everything, washed shopping bags, all the clothes, because we didn’t enter the house with clothes worn outside, the clothes were too dirty.”

As for sewage disposal (Graph 2), none of the participants has household sewage disposal systems followed by treatment:

Graph 2
Sanitary sewage

Among the women participating in the research, 10 stated that they use a septic tank, or according to P8 (Black, 50 years old) the “tank recommended by the Autonomous Water and Sewage Service (SAAE).” The septic tank mentioned, used by 21% of the Brazilian population (IBGE, 2016), is considered adequate (Scalize; Bezerra, 2020) because it consists of an enclosure buried underground for the purification of household waste compounds (solids and liquids), not contaminating the environment. In addition, it is very widespread for its efficiency and practicality, associated with a low cost and easy installation.

Four participants also stated that they made use of a so-called “rudimentary cesspit,” a precarious sewage that consists of a hole without any type of lining that presents great risks of contamination to the environment and the water table. Among them, one is a resident of the Palmital neighborhood and three live in the Olga Benário settlement.

This modality increases the risk of transmitting diseases like diarrhea, cholera, and hepatitis, among others. A circumstance that also compromises four other participants (three from Palmital and one from Olga Benário), who stated that they do not have any sewage disposal system, which is considered detrimental (Scalize; Bezerra, 2020). According to P2 (Brown, 26 years old), “Everything goes straight to the swamp,” which can contaminate the entire surroundings of the property. It is evident that the universalization of sanitation services is still far from the reality of many rural women, constraining them to unhealthy conditions.

Two participants in the settlement stated that they use an evapotranspiration tank, an environmentally friendly solution that consists of a system that does not generate effluents, as human waste is transformed into nutrients for plants and the water only comes out by evaporation. This solution is considered a social technology, a set of techniques developed and/or applied in the interaction with the population and appropriated by it, enabling social inclusion and improvement of living conditions (Dagnino, 2014).

The development of this social technology took place in the Olga Benário settlement, from an extension project of the Department of Civil Engineering (UFV), in 2011, with the intention of designing and building a sewage system appropriate for the local reality in a participatory manner with settled families (Pires, 2012). However, despite the efforts, according to the interviews, there are still houses in the settlement with rudimentary and open cesspits, demonstrating the resistance to alternative solutions proposed by the settlers and the little control and instruction offered by sanitation companies.

Graph 3 shows the participants’ access to garbage or solid waste collection.

Graph 3
Garbage collection

Among the participants, 15 stated that they did not have access to this service. Among these, four live in the Palmital neighborhood, in the section that belongs to the municipality of Viçosa, because the municipal government does not provide service to the rural neighborhood, causing those who live in this municipality to be without garbage collection. According to P9 (White, 61 years old), “You have to take it to the paved area.” The other 10 women are Olga Benário settlers, as is O3 (Brown, 43 years old), who states that she “Takes it to the city or burns it” and O10 (Black, 18 years old), who “Puts it in a hole and burns it.”

The participants who mentioned receiving waste collection services (five) are residents of the Palmital neighborhood, in the area of the municipality of Coimbra, which provides the service. According to P10 (Brown, 38 years old), the municipality of Coimbra “collects it once a week.”

Many of the determinants presented here contribute, directly or indirectly, to the emergence of waterborne diseases, which may be responsible for the increase in insalubrity, a reflection of a scenario of inequality resulting from restricted access to goods and services indispensable to life (Lima; Oliveira; Pagotto, 2020).

When mapping for the intersectional perspective, all the data presented in this subtopic were systematized (Table 2). For this systematization, the following was considered:

(1) Adequate sanitation services: the presence of three sanitation factors considered adequate as determinants of health (Lima; Oliveira; Pagotto, 2020). Based on the above, this category includes water collection via an artesian well, adequate sewage disposal (septic tank or evapotranspiration tank), and garbage collection services.

(2) Regular/below expectations sanitation services: considers the presence of only two adequate determinants mentioned above.

(3) Inadequate sanitation services: all other cases apply.

Table 2
The conditions of the participants’ sanitation services

The conditions of the participants’ sanitation services
Age bracket	Palmital neighborhood	Olga Benário	Legend
Less than 30 years			Black
31 to 40 years			White
41 to 50 years			Adequate sanitation services
51 to 60 years			Regular/below expectations sanitation services
Over 61 years			Inadequate sanitation services

• Source: devised by the authors.

According to Chart 2, none of the participants had all the basic sanitation conditions considered adequate. This result is in line with research that identifies that the lack of sanitation structures and services in rural areas contributes to consolidating a scenario that compromises health promotion (Lima et al., 2019; Scalize; Bezerra, 2020).

When considering that the total number of participants belong to territories divided into three municipalities, namely Viçosa, Coimbra, and Visconde do Rio Branco, located in the Zona da Mata of Minas Gerais, the infrastructure offered by the three municipal entities is still insufficient to ensure ideal health standards. In this sense, sanitation companies in the region do not seem to prioritize the perspective of sanitation services as a social determinant of health (Lima; Oliveira; Pagotto, 2020) with regard to the rural environment.

The participants who have regular/below expectations sanitation services, which is considered by this study to be better than the inadequate category, prevail in the Palmital neighborhood (five); in Olga settlement only one participant fit this classification. The sanitation conditions of the MST participants suggest that the municipal management’s attention to the settlement is flawed, which can be triggered by political, ideological, or strategic factors.

Notably, among the five residents of Palmital who have regular/below expectations sanitation services, most (three) are White. Thus, most Black participants (12) have inadequate sanitation conditions, ratifying the perspective that the Black population lives, on a greater proportion, in households that are in worse conditions than the White population (Gomes, 2020).

Access to health services and comorbidities

The Basic Health Units (UBS) are the entry points to SUS, where 80% of the population’s health problems are treated free of charge, without needing referrals to other services, like emergencies rooms and hospitals. UBSs offer services that encompass primary care, prevention, and health promotion care, with the performance of routine exams and consultations with multiprofessional teams. They are allocated in neighborhoods, and maintenance is shared between federal, state, and municipal governments (Brasil, 2006). Among the participants, 15 said they go to the SUS health center in a nearby municipality when they need healthcare.

Among Palmital neighborhood residents, five said they sought care at health centers in Coimbra, as they live in the part of the neighborhood known as Marreco, which belongs to this municipality. The city has more than one UBS in the center, located approximately eight kilometers away from the aforementioned neighborhood, in addition to a rural unit that serves a distinct area from the one adjacent to the Palmital neighborhood.

Two participants (P3, Brown, 73 years old; P5, White, 44 years old) commented that they use the central UBS (former Polyclinic of Viçosa), as it is the one responsible for servicing the residents of this rural neighborhood. These participants, who do not have a health center in a nearby rural area, need to travel about eight kilometers of paved road and approximately three kilometers of unpaved road to receive care. Additionally, many depend on public transport with limited schedule for their area.

As for the women who live in Olga, six participants reported that they seek care at the health center of the Sementeira community, managed by the municipality and community, which, according to O4 (Brown, 38 years old), “is nearby, two kilometers away from the settlement.” The organization of rural healthcare is strengthened when there is community-based management because external logic, generally designed for urban areas, is not imposed on the diverse realities of rural and remote territories, as more appropriate and resolutive results are achieved by their own context (Frank; File; Giovanella, 2021). Although the distance is considered close by the participants, the Sementeira Support Center⁵ only works in the morning, limiting the possibilities of these women to access health care.

Two participants from the settlement preferred to receive care at the UBS of Visconde do Rio Branco, located 2.8 kilometers from the settlement, as there are several health centers in the city center.

Three participants who live in Palmital said they use private care, despite not having health insurance. Participant P1 (Black, 42 years old) justifies the option due to her chronic health problems and P7 (White, 58 years old) because “her children take her.” Participant P5 (White, 44 years old), while she also seeks care in the public network, says she uses private services because she has recently overcome cancer. O9 (brown, 62 years old), who is retired and from the settlement, has private health insurance from the National Confederation of Medical Cooperatives (Unimed)⁶, preferring to receive care in the municipality of Ubá (state of Minas Gerais), which is larger and has more services, in addition to stating that there “I have a trusted doctor.”

Only participant P9 (White, 61 years old) seeks the Health Division (DSA) of UFV for medical care, as her husband is an employee of the institution. This DSA⁷ is located within the UFV campus in Viçosa, offers pre-scheduled appointments for different specializations, laboratory services, and outpatient care and provides service to professors, employees, family members, and students. In this sense, although the DSA is not private, it does not offer services to the general public.

When considering an intersectional perspective, in which race is a marker of inequality that reinforces barriers to access healthcare (Caldwell; Araújo, 2020), it is possible to notice that among the participants who choose to receive care from a private health service (or to use UFV services), most are White women, even though they represent a smaller number of the total of women surveyed.

Fifteen participants reported that they do not receive home visits from health agents. In loco services from these professionals, who are part of the primary healthcare team, involve the participation of health promotion actions, including education, and disease prevention (Brasil, 2018).

The four residents of the Palmital neighborhood who responded positively are assisted by health agents from the municipality of Coimbra (since they live in this part of Palmital). Thus, it can be seen that there is greater attention to the rural population on the part of this municipality, compared to Viçosa. Notably, despite home visits from health agents, two of these participants stated that they did not have access to any sewage disposal systems, sending their waste to the “swamp” (P2, Brown, 26 years old). The only settlement participant who reported receiving a visit from a health agent was O9 (Brown, 62 years old), the oldest participant from Olga Benário.

During the new coronavirus pandemic, it became necessary to pay attention to comorbidities, associated chronic diseases, as a screening factor in health services (Feitoza et al., 2020). Thus, according to the authors, identifying the main risk groups is crucial, as patients with chronic diseases may have a worse prognosis when infected with SARS-CoV-2. In addition, COVID-19 can destabilize chronic diseases that were under control, increasing the patient’s susceptibility to infection, which can be influenced by the supply and demand of oxygen.

Among the research participants, four said they had comorbidities. P1 (Black, 42 years old) stated that she had a liver hemangioma, a type of benign tumor; P10 (Brown, 38 years old) is obese; and P9 (White, 61 years old) has high blood pressure; all are residents of the Palmital neighborhood. In Olga, participant O9 (Brown, 62 years old) reported having diabetes, one of the most critical comorbidities (Feitoza et al., 2020).

Considering the gender issue, Vilella et al. (2009) point out that SUS care for women who have hypertension and diabetes is not part of comprehensive women’s healthcare, as the protocols do not consider gender differences in the presentation of chronic diseases. In a pandemic context, gender inequality can increase the vulnerability of rural women.

The research reinforces the view held by Caldwell and Araújo (2020) that Black Brazilians have higher rates of chronic diseases, including diabetes, hypertension, and respiratory and kidney problems. These conditions are attributed to social inequities, which can lead to food insecurity and inadequate access to medicine and prescriptions. As presented in this topic, situations related to sanitation services further aggravate their conditions.

Older adults, such as P3 (Brown, 73 years old) and O7 (Brown, 60 years old), also make up the risk group, since, according to the authors, older adults are more likely to die when affected by COVID-19. Authors like Guinancio et al. (2020) highlight that there are other groups that can be seen as at risk in events such as the COVID-19 pandemic, including family members who live in the same household as people with comorbidities. Here, we highlight the case of the participants O4 (Brown, 38 years old), whose husband has “serious lung problems due to an accident”; and O9 (Brown, 62 years old), who lives with her brother, who is a person with disabilities.

Furthermore, adults with less schooling have double the risk of developing health problems since education favors the adoption of healthy behaviors, like healthy eating habits and good hygiene practices (Feitoza et al., 2020). Additionally, the relation between health, communication, and education, which are fundamental for the mitigation of risk situations like the new coronavirus, are imbricated in the concept of citizenship (Stevanim; Murtinho 2021).

Considering all segments that make up the risk groups, eight of the participants are a part of this total. By articulating this data with the inequalities in access to healthcare present in rural areas and the tensions that originated from the pandemic, it is possible to reflect on the difficulties encountered by the participants during this period.

Final Considerations

The research shows that the overlapping of different social markers generate vulnerability that is reinforced by obstacles and inequalities, whether sanitary or in public services access, which hinders access to health promotion, especially in the context of a pandemic. The race marker focuses on scenarios of lower access to health promotion, like inadequate sanitation services rates and higher rates of chronic illnesses.

When considering an intersectional perspective, in which race is a marker of inequality that reinforces barriers in access to healthcare (Caldwell; Araújo, 2020), it is possible to notice that among the participants who choose to receive private health services (or use UFV services), most were White women, even though they represent a smaller number of the total of women surveyed. Choosing to be assisted by a private network can mean less waiting time in queues and greater agility in service.

In the comparative analysis between the territories studied, the Palmital neighborhood and the Olga Benário settlement, the latter presents greater vulnerability in relation to social determinants of health. However, the settlement is a space that is transformed by strategies of social organization where new perspectives can emerge, especially in the search for collective solutions.

Although this work highlights women located in a specific territory, the Zona da Mata Mineira, we believe that intersectional analysis can provide a diversity of interpretations and formulations in the field of collective health, stimulating debates that take complex realities into account.

References

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• 1
  Social determinants of health are social, economic, cultural, ethnic/racial, psychological, and behavioral factors that influence the occurrence of health problems and their risk factors in the population.
• 2
  For Crenshaw (2002), the subordination axes intersect, creating complex intersections that increase vulnerability and marginalization, articulations she calls the “disempowerment” network.
• 3
  The minimum wage in Brazil in 2020 was R$ 1.039,00, which is equivalent to US$ 202.50.
• 4
  Although there are limiting factors in terms of ensuring the quality of the water collected from the roof, this social technology is of significant importance for rural realities, especially for semi-arid realities.
• 5
  Available at: https://www.infosaude.com.br/ubs/18960-centro-de-apoio-da-sementeira. Accessed date:
• 6
  Unimed is a Brazilian system of medical cooperatives that acts as a health plan operator.
• 7
  Available at: https://www.dsa.ufv.br/. Accessed date: 13 Aug. 2022.

Publication Dates

• Publication in this collection
  27 June 2025
• Date of issue
  2025

History

• Received
  08 Aug 2024
• Accepted
  09 Oct 2024