Introduction

Social markers are considered structuring factors in society, so that they interfere in the health, disease, morbidity and mortality outcomes of the general population, since social inequality is demarcated by race, gender, ethnicity and social condition in the capitalist mode of production^1,2. As an inflection of social inequality, made possible and perpetuated by social markers in society, we consider prejudice as one of the main (and most disturbing) causes of inequities in access to health services^3,4. In addition to dealing with the invisibilization of the most frequent diseases of black and indigenous people, the non-inclusion of racial, gender and class discussions in training devices, the difficulty of accessing health services, the quality of health care, and the differentiated access to supplies, determine significant causes, often avoidable, in the differentiated profiles of illness and death between whites and non-whites, as well as between the poor and the wealthy⁵.

It is from this perspective that we conceptualize health care as the ultimate and fundamental expression of professional practice in the health area, since it plays an essential role in contributing to the reduction or worsening of inequality in health services. Currently, there are many and welcome references that advocate for competent professional practice to deal with demands and emotional trials inherent to people’s ethnic, racial and gender conditions^6,7. There are different ways to contribute to the fight against prejudice, racial and gender discrimination and structural racism and to promote racial equality in Brazil. Education, culture and science play a fundamental role in the construction of a more egalitarian world, with universities being a key element in this process, especially due to their potential in the creation of proposals for public policies of affirmative action, as well as because they are considered an important locus where social practices are constructed. In this sense, the curricula represent the expression of the balance of interests and forces that engender the educational system in a given historical period, which is why it is full of values and assumptions that must be deciphered and analyzed⁸.

Aware of this situation, since the 1990s, Black Movements have been fighting for the recognition of ethnic-racial diversity and the right to education with equity. These movements highlight the need to create educational mechanisms aimed at implementing social justice and affirmative actions that enable the overcoming of ethnic-racial, gender, educational and other inequalities for people affected by racism⁹. Measures such as reserving places on university courses or granting scholarships can be taken to guarantee access to university for vulnerable students. However, these measures do not seem to be sufficient if one starts from the idea that “access and inclusion do not necessarily mean addressing processes and pluralities based on the principles of equality, equity and quality”¹⁰. Gairín and Suaréz¹¹ highlight the persistence of stereotypes and discriminatory practices among the main barriers to the success and retention of this student body, which, according to these authors, are those that most directly affect students belonging to indigenous or Afro-descendant peoples. This is a condition that permeates the student experience at the university. The need for the University to recognize the cultural diversity present in societies has led to the demand for a more plural curriculum in higher education, which is currently shared by different minority groups who call for the decolonization of academia and the end of white privilege in this area^12,13.

There are initiatives to overcome this problem in several countries and continents. We have seen advances in the field of Brazilian public policies achieved through these movements, such as the amendment to Law 9,394/1996, responsible for establishing guidelines and bases for national education, which now includes the mandatory topic of Afro-Brazilian history and culture in the official curriculum of the school system through Law 10,693/2003. Subsequently, the publication of Law 11,645/2008 added the topics of history and culture of the indigenous population to the first one. Another highlight in the support of educational policies were the National Curricular Guidelines (DCN, Diretrizes Curriculares Nacionais) for the Education of Ethnic-Racial Relations for the Teaching of Afro-Brazilian and African History and Culture in 2004 (CNE/CP Resolution No. 01, 2004), the DCN for Indigenous School Education in Elementary Education (CNE/CEB Resolution No. 5, 2012) and the DCN for the Training of Indigenous Teachers in Higher Education and High School Education courses (CNE/CP Resolution No. 1, 2015). Furthermore, it is worth highlighting Law 12,228/2010, which established as a function of the Federal Executive Branch the incentive for higher education institutions to incorporate topics such as ethnic and cultural plurality of Brazilian society into the curricula of higher education courses in Brazil¹⁴.

To comply with these laws, Universidade Federal da Bahia (UFBA) published Resolution N. 04, of May 31, 2023, which establishes norms for the implementation of the National Curricular Guidelines (DCN) regarding Education on Ethnic-Racial Relations and for the Teaching of Afro-Brazilian and African History and Culture, Education in Human Rights, and Environmental Education in the Pedagogical Course Projects (PCP) of undergraduate courses at UFBA, in line with the Resolutions of the National Education Council/Full Council No. 01/2004, No. 01/2012, and No. 02/2012. Therefore, as of 2023, the presence of ethnic-racial, environmental health, and human rights discussions became mandatory in all undergraduate courses.

Correlating health care to the educational process puts pressure on the process of educating sharp eyes in relation to the health problems faced by the population; creating spaces for reflection to raise questions and solutions to the challenges of health care; and stimulate creative processes, amidst technical and scientific aspects related to this area of knowledge.

Therefore, in order to unveil the complexities of social markers (race, gender and class) in the health training process, identify gaps and inspire transformative actions that promote equity and diversity in academic and professional training, we ask: how has Universidade Federal da Bahia (UFBA) addressed the social markers of gender, race and class in the syllabuses of its courses in the Health area?

For this research, it is appropriate to use the concept of Intersectionality which, according to Akotirene¹⁵, “aims to provide theoretical and methodological instrumentality to the structural inseparability of racism, capitalism and cisheteropatriarchy”. Therefore, we start from the assumption that the influence of the social markers of race, gender and class in the training of health professionals needs to be understood in a joint and intersectional manner. The concept of intersectionality represents a fertile perspective for the analysis of power relations that produce inequalities and oppression, promoting critical research that questions educational practices and political interventions, which are incapable of responding to non-hegemonic realities¹⁶.

Method

This exploratory documentary study with a qualitative approach presents the results obtained after the analysis of 1,090 mandatory curricular components of the 22 courses in the Health area of Universidade Federal da Bahia (UFBA), on the Salvador and Vitória da Conquista campuses. The main objective was to identify the approach to social markers of gender, class and race in the syllabuses of these courses. Of the curricular components analyzed, such approaches were identified in only 37 syllabuses, which corresponds to 3.4% of the total analyzed. The documents used as data sources in this analysis are available for public consultation on the official websites of the institutions.

Pimentel¹⁷ explains that the documentary analysis consists of a type of study that uses documents as primary material and extracts the analysis from them through their organization and interpretation, according to the objectives of the ongoing research. Based on this, Kripka et al.¹⁸ complement by pointing out that the challenge of this method lies in the researcher’s ability to select, process and interpret information, because it is precisely through the understanding of the interaction with their primary data source that they can achieve significant results.

In this sense, it is worth highlighting that documentary analysis is related to Sousa’s et al.¹⁹ qualitative approach and this, in turn, was quite pertinent in the present investigation, considering that qualitative research “[...] works with the universe of meanings, motives, aspirations, beliefs, values and attitudes”²⁰. Therefore, from this perspective, we believe that it would be possible to interpret the main topics related to ethnic-racial, gender and class issues in the implemented curricula and what their presence (or absence) means. This occurs with the support of the software, and with a consistent theoretical approach around the idea of intersectionality.

Exploratory studies seek to provide an overview of a given fact²¹. These are usually developed when there is little knowledge about the subject of interest and, from this, the aim is to understand the topic in greater depth, so that it becomes more evident or allows the construction of relevant questions for the development of the research²². Therefore, this design was chosen considering the scarcity of studies that have focused on this investigation of the health course curricula.

Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) used to support the data analysis in this research, consists of a free, open-source software, developed in the Python programming language and that uses the R software for statistical analysis of textual data²³. Its use allows performing simpler statistical analyses, up to multivariate analyses. Among its possibilities are textual statistics, Correspondence Factor Analysis (CFA), Descending Hierarchical Classification (DHC), Similarity Analysis and Word Cloud^19,24.

In this research, as support for the documentary analysis, and with the aim of presenting the results in a systematic manner, we chose to use DHC. In this type of analysis, the software performs the lexical analysis of the textual corpus and divides it into hierarchical classes, which are identified by the program based on the text segments that share similar vocabulary among themselves and different from the segments of the other classes, which makes it easier for the researcher to understand their content^19,23,24.

The result of this classification is presented as a dendrogram, in which the most representative words of each class are highlighted and the font size and order of the words are proportional to their hierarchy within the class. This hierarchical arrangement of the terms in the dendrogram occurs according to their importance in the set and in decreasing order of the chi-square value, reflecting the strength of the word’s connection with the class. This is described by the p-value that expresses the level of confidence associated with the chi-square, which indicates the level of significance of the association of the text segment containing the word with the class^23,24. If p<0.05, there is significant evidence of the correlation of a word or variable with a class, whereas p<0.001, describes extremely significant evidence of such correlation.

Results and discussion

This study analyzed 1,090 syllabuses from 22 undergraduate health courses at UFBA, assessing the presence of content related to social markers of gender, class and race (Table 1).

We observed that courses such as Pharmaceutical Sciences (day course and night course), Bachelor’s Degree in Natural Sciences, Veterinary Medicine and Animal Science, all located on the Salvador campus, do not include these topics in their mandatory syllabuses. However, the other courses address, directly or indirectly, at least one of these markers in specific disciplines.

It is worth noting that within the scope of this study, a direct approach means the explicit inclusion of content related to the social markers of gender, class and race in the syllabuses of the disciplines. In contrast, an indirect approach suggests that these topics are addressed implicitly, whether through discussions on social determinants of health, public policies or in interdisciplinary contexts that touch on these issues. In this scenario, the DHC (Descending Hierarchical Classification) analysis conducted by the Iramuteq software was essential, as it allowed the identification of thematic patterns in the syllabuses. Through the resulting word classes, it is possible to understand how these social markers are represented, either directly or indirectly. Figure 1 shows the dendrogram generated in the analysis with the software.

The 37 texts, corresponding to each of the analyzed syllabuses, comprised the textual corpus submitted to the software. From this, Iramuteq generated 49 text segments (TS), of which 29 were used in the descending hierarchical classification produced, corresponding to 78.38%. The analysis revealed 4,567 occurrences (words, forms or terms), of which 1,296 were distinct words and 627 had a single occurrence. The analyzed content gave rise to six classes: Class 1, with 4 TS (13.79%), Class 2, with 5 TS (17.24%), Class 3, with 4 TS (13.79%), Class 4, with 5 TS (17.24%), Class 5, with 5 TS (17.24%), and Class 6, with 6 TS (20.69%), as shown in the dendrogram (Figure 1).

The formation of six terminal classes indicates that five partitions occurred in the construction of the dendrogram. The first one divided the corpus into two distinct blocks; the second occurred in the block to the left and gave rise to Class 1; the third, in turn, separated classes 2 and 6. In the fourth partition, in the block to the right, class 5 was separated; and finally, in the fifth partition, classes 3 and 4 were divided.

When interpreting the dendrogram, it is necessary to understand that the classes that are grouped together in the same block have greater similarity in vocabulary among themselves, and the more they are aggregated in the branches of a block, the greater this similarity. At the same time, when a class separates from the others in a partition, it indicates that there is unity in that set of text segments that compose it in such a way as to constitute a unique meaning that is distinct from the other analyzed segments. This reveals that classes 1, 2 and 6 and classes 5, 4 and 3 have great similarity among them. However, there is even greater proximity between classes 2 and 6 and between classes 3 and 4.

The analysis of the study results requires an in-depth understanding of the concepts of gender, race, and class, which are fundamental for reflecting on the social disparities present in higher education, especially in courses focused on the health area. For this reason, we understand gender according to Scott²⁵: as a social construct that permeates individual identities and power relations in society, directly influencing the opportunities and challenges faced by men, women, and other gender identities. Race, on the other hand, as discussed by Hall²⁶, is a socially constructed category that reflects the structures of power and privilege operating in a given society, made evident in social and institutional interactions. Finally, social class represents the relative position of an individual in the socioeconomic structure, determining their access to resources and other opportunities²⁷.

Class 1 (13.8%): This class evidenced discussions that explore the intersection between class and gender, especially in the context of health policies. The Medicine course at the Vitória da Conquista campus stands out for its strong association with this approach (p<0.0237), presenting in its textual body objective literature on how class and gender inequalities impact individual and collective health. This suggests that the course offers training that goes beyond technical knowledge, promoting a critical understanding of the social conditions that influence public health in Brazil.

In contrast, the syllabuses of the Nursing and Biological Sciences courses at the Salvador campus reveal a more indirect approach to these issues (p<0.0406). Although class and gender issues are not discussed explicitly, they are integrated into other topics, such as care practices, bioethics, and public health.

Class 2 (17.2%): The syllabuses that comprise this class discuss the influence of social stratum and race on cultural diversity and social representations, focused on health and citizenship. These analyses broaden the students’ understanding of social and racial inequalities and their impacts on health and citizen participation. Courses such as Biotechnology and Physical Therapy stand out for their strong correlation with this approach (p<0.0257), indicating a significant curricular emphasis on preparing undergraduate students to deal with these issues in a critical and practical manner.

On the other hand, in the Nutrition course at the Vitória da Conquista campus, the approach to these topics is more indirect (p<0.00928). Although relevant, topics related to social strata and race are treated within a broader context, probably integrated into other areas, such as public health and nutritional practices.

Class 3 (13.8%): The syllabuses offer a comprehensive view of ethnic-racial and gender relations, highlighting how these social markers condition health, particularly in the context of diseases. The discussions also cover topics related to human rights and environmental preservation, reflecting a holistic perspective on health that considers social and environmental factors as critical determinants.

In this sense, the Nursing course at the Vitória da Conquista campus stands out for its strong correlation with this approach (p<0.0109), evidencing an emphasis on the integration of these topics into the curriculum. The predominance of the direct approach (p<0.0991) suggests that the course not only introduces these topics, but also explores them in depth, encouraging a critical analysis of the social determinants of health and their interconnection with human rights and environmental sustainability.

Class 4 (17.2%): In this category, the syllabuses investigate how gender and race issues shape the socio-political aspects of health, epidemiological patterns, and the organization of hospital care. The discussions focus on how gender and race impact access to health services and care experiences, reflecting a concern with understanding the social factors that shape health and nursing practice.

The Nursing course at the Vitória da Conquista campus stands out in this category, with a significant emphasis on gender aspects (p<0.0374). This emphasis suggests a strong association with the approach to gender and race issues in the curriculum, indicating that the course integrates these issues prominently into the nurses’ training.

Class 5 (17.2%): In this class, the syllabuses analyze the intersections between race and gender in the context of health demands, lifelong care, and disease prevention strategies. The Nursing course at the Salvador campus stands out for its direct approach to the three social markers (p<0.0175), indicating a significant association with this perspective. This shows that the curriculum of this course explicitly integrates race and gender issues into discussions about health and prevention, reflecting a commitment to the training of professionals able to understand and address the complexities of health demands influenced by these social factors.

Class 6 (20.7%): The syllabuses of this class directly address the interconnection between the social markers of gender, social class, and race with topics such as modernity, epistemology, poverty, and globalization. The courses in Biological Sciences (p<0.0038), Speech-language Pathology (p<0.0463) and Occupational Therapy (p<0.0463) stand out for a significant integration of these topics in the syllabuses. In particular, the discipline “Introduction to Sociology I” (p<0.0041) demonstrates a strong association with this perspective, indicating that the curriculum includes a detailed and critical analysis of the intersections between social markers and contemporary issues.

The analysis of the disciplines revealed a significant diversity of approaches in relation to the social markers considered, reflecting the different emphases and contexts of the courses offered. Considering this significant variation, it became clear that some syllabuses incorporate these contents directly, while others address them indirectly or omit them completely. This discrepancy may reflect different pedagogical and ideological perspectives of those responsible for developing the curricula²⁸. In this regard, Silva²⁹ highlights that curricula have the power to legitimize and validate certain types of knowledges to the detriment of others. In view of this, we present below some of the specificities observed between the courses.

In the Biological Sciences courses, both in the daytime and evening periods at the Salvador campus and at the Vitória da Conquista campus, there is a significant emphasis on directly addressing class issues, demonstrating a commitment to the critical analysis of socioeconomic inequalities. In several disciplines, students are exposed to in-depth discussions on how class inequalities affect access to education, health, and natural resources, in addition to influencing opportunities for scientific and technological advancement. In contrast, the social markers of gender and race are treated more indirectly, appearing less explicitly in different disciplines.

On the Salvador campus, the Nursing course stands out for its comprehensive and direct approach to the social markers of race, gender and class, with several disciplines exploring these topics in a clear manner. This same approach is observed on the Vitória da Conquista campus, where the curriculum also reflects a commitment to the critical analysis of these social markers. However, in the Physical Therapy course, the class issue is addressed in a more indirect manner. Disciplines such as Anthropology of Health and Introduction to Public Health address aspects related to class, but in a subtle way. In the Speech-language Pathology course, the discipline Introduction to Sociology I offers a direct approach to the social marker of race, providing students with a broad understanding of racial issues. In contrast, the discipline Society, Culture and Health I addresses the same marker in a more indirect manner, integrating it into discussions about society and health in a less focused manner.

In the Biotechnology course in Salvador, the Bioethics discipline addresses the social marker of race indirectly, including discussions on ethical dilemmas that, although relevant, do not directly explore the implications of racism in scientific practices and biotechnology. Also on the Salvador campus, in the Gastronomy course, the discipline Studies on Contemporaneity I addresses the class issue indirectly, inserting this topic into a broader and less focused context. In the Medicine course, the disciplines Bioethics and Medical Ethics II, as well as Pediatrics II, discuss the social markers of gender and class indirectly, addressing these topics tangentially in their respective areas of study.

On the Vitória da Conquista campus, the Medicine course presents a more direct approach to class through the discipline GEAC (Population Groups and Confronting Inequities), which dedicates an explicit focus to the analysis of socioeconomic inequalities and their implications for health. However, other disciplines in the course deal with the social markers of race and gender in a more indirect way, addressing these topics in a dispersed manner throughout the curriculum.

In the Biotechnology course, on the same campus, the mandatory subject Citizenship and Public Policies adopts a more direct and structured approach to class issues, analyzing how public policies unequally affect different social groups and how class inequalities are rooted in social and economic structures.

In Nutrition (Salvador campus), the subject Introduction to Sociology stands out for directly addressing the social markers of gender, class and race. This approach allows future health professionals to broaden their understanding of the complex intersections between these aspects and their influence on the population’s health. For instance, by discussing disparities in access to food and dietary patterns in different social groups, undergraduate students are able to recognize how factors such as gender, socioeconomic class and race influence food choices and, consequently, the health of communities.

Moreover, in the same course, but at the Vitória da Conquista campus, the Ethnic-Racial Relations course offers a particularly meaningful perspective by focusing on race and class. This approach focuses on analyzing the social and economic dynamics that permeate racial issues in the region. By understanding the relationships between social class and race, students can further examine how economic inequality intertwines with racial discrimination, affecting access to health resources and services.

In the Dentistry course, the discipline Social Sciences Applied to Dentistry addresses the social marker of gender indirectly, integrating the topic into a more general context without specifically delving into its implications for dental practice. In the Public Health course at the Salvador campus, the discipline Society, Culture and Health II offers a more direct and comprehensive approach to the social markers of gender, class and race. This discipline explores in detail how these social dimensions influence health practices and the populations’ experience, providing university students with a critical and integrated understanding of social inequalities and their implications for public health.

Finally, in the context of the Occupational Therapy course at the Salvador campus, the discipline Introduction to Sociology I directly addresses the social markers of gender, class and race, providing an in-depth analysis of these social dimensions. However, the discipline Social Occupational Therapy I deals with the social marker of race more indirectly, inserting it into a more general and less detailed context.

When analyzing how the social marker of race is addressed in the syllabuses and reflected in social indicators such as income, employment, education and health, it is evident that the training process must recognize the inequalities faced by people’s racial affiliation. Historically, Brazilian society was formed with the stratification and hierarchization of people according to race as the root of racism³⁰. The result of this reverberates to the present day and black people still often have limited access to well-paid employment opportunities and are more exposed to polluted environments and face barriers to quality health care access. Therefore, understanding the complexity of the racial marker is essential to fight racism in its various forms, promoting the fight for equity policies and the deconstruction of oppressive structures^31-33.

Critical theories, such as Marxism and feminism, offer a fundamental theoretical framework for the understanding of issues related to gender and class, as well as power structures and social relations. This understanding empowers professionals to identify and address inequalities in the health field³³. Furthermore, intersectionality plays a fundamental role in professional training, providing a comprehensive perspective on the interactions between race, gender, class and other identities, and how these interactions shape health experiences³⁴.

In this sense, the adoption of varied methodologies, such as ethnography and critical analysis, is essential to explore the complexity of experiences associated with social markers. This methodological diversity deepens the understanding of social dynamics and empowers professionals to more effectively address the realities of the populations they serve³⁵.

Therefore, since education plays a fundamental role in perpetuating or transforming the existing power structures, the inclusion of content on gender, race, and class in academic curricula is essential to train professionals who are more aware and sensitive to the social disparities that affect clinical practice and the provision of health services³⁶. Thus, the curricula should offer university students a critical view of the social relations and inequalities that permeate the health field, preparing them to face the complex demands of contemporary clinical practice and recognize the structural inequalities that determine access to health and health outcomes for marginalized populations.

Final considerations

Most health courses at UFBA have not yet included into their curricula the discussion of the main social markers directly or even indirectly; only a few already address differential discussions that problematize them as constituents for the understanding of health. It was possible to identify, in the textual analysis of such syllabuses, a diversity of terms and concepts associated with the social markers of gender, race and class, which already correspond to the requirements of the Resolutions mentioned in the introduction, as an essential guidance policy in university education aimed at overcoming inequalities and inequities in the field of health.

It is clear that the depth and scope with which these topics are addressed can vary between courses, suggesting the need for greater attention to the inclusion of critical and reflective content in academic curricula, based on a careful and urgent review of curricular matrices. Hence, to include this discussion in the curricula, it is necessary to consider not only its individual manifestations, but also its interconnections and systemic impacts. This means that a holistic and inclusive approach must take into account not only a single social marker, but rather the complex interaction of several of them in specific contexts, which can be favored by adopting the idea of intersectionality used in the analysis. It is necessary that the training be focused on building a critical understanding of the complexities that permeate social inequalities and cultural identities in contemporary society. In this sense, the results suggest a careful and urgent review of the curricular matrices.

The limitations of the present study are therefore related to the documentary nature of the research, since the existence of “hidden curricula” and other expressions of university education, in the teaching-research and extension tripod, is known, which are not revealed in this type of documentary analysis of syllabuses. In this sense, it is also necessary to investigate the positions of students and teachers who are part of the higher education institution regarding the presence or absence of these markers in academic training.

References

Publication Dates

History