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PREVENTION AND CONTROL OF CHRONIC DISEASES IN
VULNERABLE POPULATIONS: APPROACHES IN FAMILY MEDICINE
Maria Antônia Rocha Fiorott1
Ingrid Brandão Coelho2
Elza Dadalto Scarpati3
Lara Martins Eller4
Alice Sarlo Pinheiro5
José Siqueira Neto6
Ivelize Altoé Pipa Silva7
Ricardo Maia Cruz Brazuna8
Alex Cesar Ferreira9
Nicolle Lofêgo Olmo10
Marcelle Maria Moreno Lobo11
Jessica Castro Narduci12
Julia Vita de Sa13
Mariana de Assis Miranda14
1 EMESCAM
2 Iguaçu University, Campus V
3 EMESCAM
4 Vila Velha University
5 Vila Velha University
6 Serra dos Órgãos University Center - Unifeso
7 EMESCAM
8 Serra dos Órgãos University Center - Unifeso
9 Serra dos Órgãos University Center - Unifeso
10 Vila Velha University
11 Multivix College
12 UniRedentor College - Itaperuna
13 Federal University of Espírito Santo
14 Multivix College
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Jaís Monteiro Cordeiro de Alvarenga15
Abstract: Chronic diseases such as diabetes, hypertension and cardiovascular diseases are prevalent
in vulnerable populations, who often face difculties in accessing adequate medical care. Primary
care, especially family medicine, plays a central role in the prevention and control of these diseases,
as it offers continuous, comprehensive and personalized care, focused on health promotion and the
prevention of complications. This model of care is especially effective in communities that face
economic, social and cultural barriers, allowing for early intervention and appropriate management
of chronic conditions. The aim of this study is to analyze strategies for the prevention and control of
chronic diseases in vulnerable populations, with a focus on family medicine. The aim is to identify
effective approaches that can be used to improve the quality of life of these populations and reduce
the incidence and progression of chronic diseases. The research was carried out through a qualitative
literature review, focusing on articles published between 2017 and 2022. The aim was to explore the
advances and challenges in the management of chronic diseases, with an emphasis on primary health
practices, the impact of social determinants of health, and the role of technologies such as telemedicine
in the management of these conditions. By providing continuous and comprehensive care, family
medicine uses various strategies to prevent and control chronic diseases. These include regular patient
follow-up, early screening for conditions such as hypertension and diabetes, and health education,
which guides individuals on healthy behaviors and self-care. In addition, disease monitoring programs
and interventions such as modifying eating habits and promoting physical activity have shown positive
results in the management of chronic diseases. However, there are still signicant challenges, such as
the scarcity of resources and the lack of qualied professionals, which limit the effectiveness of these
approaches in certain regions and social groups. Overcoming these barriers requires a joint effort
between health professionals, managers and public policies. It is concluded that family medicine is
a fundamental approach to the control and prevention of chronic diseases, especially in vulnerable
15 Iguaçu University, Campus V
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populations. The strategies adopted in this model of care, such as continuous monitoring, health
education and early intervention, have shown signicant results in improving quality of life and
reducing complications associated with chronic diseases. However, in order to optimize the results,
it is necessary to overcome challenges related to access and the training of professionals, as well as
ensuring adequate support for the implementation of public health programs that favour the population
in situations of vulnerability. Implementing efcient public policies and expanding access to primary
health care are essential to achieving effective control of chronic diseases.
Keywords: Chronic Diseases; Social Vulnerability; Family and Community Health.
INTRODUCTION
The prevention and control of chronic non-communicable diseases (NCDs), such as diabetes,
high blood pressure, and cardiovascular diseases, are priority issues for health systems globally,
especially when it comes to vulnerable populations. These populations include people who face
nancial difculties, language and cultural barriers, or live in remote areas with limited access to
medical care. The World Health Organization (WHO) highlights that NCDs account for more than
70% of annual deaths worldwide, with a disproportionate impact on marginalized communities,
requiring tailored interventions that take into account social inequalities (WHO, 2022).
In the context of Primary Health Care (PHC), Family Medicine emerges as a crucial
component in the management of NCDs. This model of care is based on principles of continuity,
comprehensiveness, and coordination of care, offering a holistic approach that addresses not only
medical conditions but also social determinants of health. Studies indicate that the presence of
family physicians is associated with better clinical outcomes in patients with NCDs, especially when
care is organized around the family and community. This is particularly important in vulnerable
communities, where the connection between patients and health professionals must be strong and
grounded in mutual trust for treatment strategies to be effective (Pinto et al., 2018).
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In addition to the importance of the Family Medicine model, it is essential to consider the
structural barriers faced by vulnerable populations. Factors such as food insecurity, inadequate
housing, low levels of health literacy, and social stigma can affect an individual’s ability to manage their
chronic conditions effectively. Recent research indicates that strategies that go beyond conventional
clinical care, such as community engagement programs and interventions that promote access to
necessary resources, have a positive impact on the management of NCDs. In addition, cross-sectoral
collaboration between health, education, and social services has shown to be a promising avenue for
addressing the complexities of the social context affecting health (Marmot and Allen, 2020).
Technology has also played a signicant role in increasing the reach and effectiveness of
chronic disease prevention and control. Telemedicine, for example, has been shown to be an effective
tool in overcoming geographical barriers, especially during and after the COVID-19 pandemic.
Mobile applications that monitor the patient’s health status, such as blood glucose control in diabetics
or blood pressure measurement, have facilitated self-care and health education. However, for these
technologies to be effective, inclusive design is needed that considers the technological limitations
of vulnerable populations, ensuring that all patients can benet from these innovations (Bauer et al.,
2017).
Therefore, the analysis of the prevention and control of NCDs in vulnerable populations from
the perspective of Family Medicine is essential to move towards a more equitable and sustainable health
system. The integration of community-based approaches, effective public policies, and technological
innovations, coupled with a deep understanding of patients’ social and cultural needs, is essential
to mitigate the impacts of NCDs and promote a better quality of life for these communities (Smith,
Thomas, and Lee, 2020).
The objective of this study is to analyze the strategies for the prevention and control of chronic
diseases in vulnerable populations, with a focus on the performance of family medicine. It seeks to
identify effective approaches that can be used to improve the quality of life of these populations and
reduce the incidence and progression of chronic diseases.
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MATERIALS AND METHODS
The research was carried out through a qualitative literature review, focusing on articles
published between 2017 and 2022. The objective was to explore the advances and challenges in the
management of chronic diseases, with an emphasis on primary health practices, the impact of social
determinants of health, and the role of technologies such as telemedicine in the management of these
conditions.
Inclusion Criteria:
- Peer-reviewed articles published between 2017 and 2022.
- Studies that address the management of chronic diseases in contexts of vulnerable
populations.
- Articles that discuss the impact of social determinants of health, the implementation of
public policies for the prevention of chronic diseases, and the use of health technologies such as
telemedicine and mHealth.
Exclusion Criteria:
- Studies that do not directly address chronic diseases or that focus on acute conditions.
- Papers without peer review or publications in journals with a low impact factor.
- Articles that do not provide data or analysis on the management of chronic diseases in
vulnerable populations or on the use of technologies in the context of health.
Search Strategy and Boolean Markers:
- A N D: to associate related topics (e.g., “ch ronic disease management” AND “telemedicine”).
- OR: to cover synonymous terms (e.g., “social determinants” OR “health equity”).
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- NOT: to exclude irrelevant topics (e.g. “acute diseases” NOT “chronic conditions”).
Guiding Question:
- What are the challenges and opportunities in the management of chronic diseases
in vulnerable populations, considering the social determinants of health and the integration of
technologies such as telemedicine?
THEORETICAL FOUNDATION
Approaches in Family Medicine involve a detailed analysis of primary care strategies and
their ability to directly impact the management of chronic diseases, in addition to considering the
social determinants and inequalities that interfere with treatment adherence. Family Medicine, as a
patient-centered care model and continuous bond with the health team, is one of the most effective
approaches in preventing chronic diseases and reducing their complications in the long term. The
literature has shown that, by offering comprehensive and accessible care, with a focus on health
promotion and prevention, Family Medicine can signicantly reduce morbidity and mortality rates in
vulnerable populations (Pereira et al., 2021).
Primary Health Care (PHC), within this context, is a strategy that aims at the early approach
of health conditions, especially chronic non-communicable diseases (NCDs), such as diabetes
mellitus, hypertension, chronic respiratory diseases, among others. Through regular consultations
and ongoing follow-up, Family Medicine professionals can detect early signs of chronic diseases and
implement preventive interventions. In addition, they play an essential role in educating patients,
promoting adherence to treatment, and advising on lifestyle changes, such as healthy eating, regular
physical exercise, and stress management. The personalized approach that Family Medicine offers
allows health professionals to build a care plan tailored to the individual needs of each patient, taking
into account their socioeconomic, cultural, and psychological conditions (Browne et al., 2019).
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However, vulnerable populations face a number of barriers that make it difcult to control
their health conditions. As a result, poverty, lack of access to quality health services, low education,
and food insecurity are factors that contribute to the high prevalence of chronic diseases among
these populations. Accessibility to care and knowledge about health conditions are directly affected
by these social determinants. Studies reveal that adherence to treatment for chronic diseases is often
low among vulnerable populations due to difculty in accessing medicines, medical appointments,
and often lack of trust in the health system. Therefore, the integration of interdisciplinary actions and
attention focused on the social determinants of health are fundamental for the effectiveness of chronic
disease control in these communities (Costa et al., 2021).
In this scenario, Family Medicine needs to go beyond conventional consultations and offer
continuous support. Strategies involving the use of community health agents, who act as a link between
families and health services, have been shown to be effective in promoting health in vulnerable
communities. The active participation of these professionals, who know people’s living conditions
closely, helps in the early identication of risks and in continuous education about the importance
of self-care and adherence to treatment. Thus, the work of community agents has been essential in
the implementation of chronic disease prevention programs, especially in peripheral or rural areas,
where access to doctors and hospitals is limited. In addition, these professionals play a crucial role in
reducing the stigma associated with chronic diseases, such as diabetes and hypertension, which are
often seen as disabling and difcult to treat (Silva et al., 2021).
In addition, the implementation of digital technologies, such as mobile applications and
remote monitoring of chronic conditions, can expand the reach of care provided in Primary Health
Care. During the COVID-19 pandemic, telehealth and the use of mobile devices have become
indispensable tools for monitoring patients with chronic diseases. The use of technologies such as
these devices allows patients in distant areas or in vulnerable situations to have constant access to
health professionals, even without the need for face-to-face consultations. However, for these tools
to be effective, it is essential that the population has access to technologies and that there is a digital
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inclusion strategy to overcome barriers such as the low level of digital literacy. The combination
of mobile technologies with the performance of family health teams can ensure broader and more
efcient coverage in the management of chronic diseases, providing patients with continuous and
personalized follow-up (Fernandes et al., 2020).
The integration of prevention strategies with the treatment of chronic diseases in vulnerable
populations also depends on the creation of public policies that promote health equity. Public health
initiatives that promote healthy eating, physical exercise, and self-care education are essential to
reduce the impacts of chronic diseases. In this sense, the implementation of policies that guarantee
access to medicines, routine exams, and basic health care are essential to improve the quality of life
of vulnerable populations and, consequently, control the advance of chronic diseases. Such policies
should be supported by a continuum of care approach, in which PHC, through its professionals, serves
as a gateway to the health system and as a care coordinator in several other areas (Pereira et al., 2021).
Therefore, the prevention and control of chronic diseases in vulnerable populations require
a joint effort involving health professionals, effective public policies, and community mobilization.
Family Medicine plays a central role in this process, not only because of its ability to identify and treat
chronic conditions, but also because of its role in health promotion and prevention, especially when
working in an integrated way with the community (Marmot and Allen, 2020).
CONCLUSION
Therefore, the prevention and control of chronic diseases in vulnerable populations are
complex challenges, which require an integrated approach focused on the specic needs of these
groups. Family Medicine, with its focus on continuous and personalized care, emerges as an effective
strategy to address these challenges by offering affordable and quality primary care. The combination
of regular medical care, health education, and social support are key to reducing disparities in the
treatment of chronic diseases among vulnerable populations.
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Although socioeconomic barriers, such as lack of access to health services, medicines,
and adequate information, are still a considerable obstacle, the work of community health agents
and the use of digital technologies can complement traditional strategies, expanding the reach and
effectiveness of treatment. The support of public policies that ensure equity in access to health and
promote the integration of care is crucial for interventions to be sustainable and effective in the long
term.
Therefore, by focusing on prevention, education, and continuous care strategies, Family
Medicine has the potential to transform the management of chronic diseases in vulnerable populations,
not only improving the quality of life of patients, but also contributing to the reduction of the burden
of chronic diseases in the health system. The implementation of public policies aimed at expanding
access and promoting health is an essential step to ensure that the benets of this care model reach
all segments of the population.
REFERENCES
WHO. (2022). Noncommunicable diseases. Retrieved from [World Health Organization](https://www.
who.int/news-room/fact-sheets/detail/noncommunicable-diseases)
Pinto, R. J., Campos, M. R., & Maia, M. M. (2018). Family Medicine and the impact on chronic
disease management: A comprehensive review. Primary Health Care Research & Development, 19(3),
299 –311.
Marmot, M., & Allen, J. (2020). Social determinants of health equity. American Journal of Public
Health, 110(S2), S140–S142.
Smith, A., Thomas, E., & Lee, M. (2020). The role of technology in chronic disease management:
Telemedicine and beyond. Journal of Medical Systems, 44(8), 1–12.
Bauer, A. M., Rue, T., Keppel, G. A., & Cole, A. M. (2017). Mobile health (mHealth) technologies and
the digital divide: Access among the underserved. Journal of Health Communication, 22(4), 279–287.
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Browne, A. J., et al. (2019). The role of primary care in the prevention of chronic diseases: a review of
strategies and challenges. BMC Public Health, 19(1), 1234.
Costa, A. L., et al. (2021). The impact of social determinants on chronic disease management in
vulnerable populations. J Epidemiol Community Health, 75(4), 287-295.
Costa, A. L., et al. (2021). The impact of social determinants on chronic disease management in
vulnerable populations. J Epidemiol Community Health, 75(4), 287-295.
Silva, L. C., et al. (2021). The role of community health agents in managing chronic diseases in
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Fernandes, S. A., et al. (2020). Telemedicine as a tool for managing chronic diseases: Opportunities
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Pereira, L. M., et al. (2021). Public health policies for chronic disease prevention in underserved
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