Evaluacíon de los currículos de pregrado em enfermaria sobre salud indígena: distribucíon y relaciones para la diversidade, equidade e inclusion

Fernanda Teixeira Paes1, Eliene Rodrigues Putira Sacuena2, Janis Rodrigues de Souza Way Way1, Nayure Lopes Ribeiro1, Juliana Pereira Pinto Cordeiro1, Inara Mariela da Silva Cavalcante1, Andressa Tavares Parente1, Nádile Juliane Costa de Castro1

1UniversidadeFederal do Pará. Belém (PA), Brazil. 2Ministério da Saúde. Belém (PA), Brazil.

Introduction         

The inclusion of the topic “Indigenous health in nurse education” constitutes a challenge in terms of pedagogical inclusion, especially for training aligned with the principles of the Brazilian Unified Health System (SUS – Sistema Único de Saúde), particularly considering that nursing is the category with the greatest presence in the workforce of the Indigenous Healthcare Subsystem (SASISUS - Subsistema de Atenção à Saúde Indígena)1. SASISUS and the Indigenous Health Department support the objectives of the Brazilian National Policy for the Healthcare of Indigenous Peoples (PNASPI - Política Nacional de Atenção à Saúde dos Povos Indígenas), one of which is to recognize and value the social, cultural, geographic, historical, and political diversity of Indigenous peoples2, through the training of the human resources involved and the strengthening of social control3.

Given this scenario, in order to decentralize the operationalization of SASISUS, 34 Indigenous Health Special Districts (DSEIs - Distritos Sanitários de Saúde Indígena) were created, distributed throughout the Brazilian territory1,2. Each DSEI responds to the territorial dynamics of the Indigenous peoples that compose it1, with geographic distribution, its own organization of services, and health actions carried out by Indigenous multidisciplinary health teams (IMHTs). IMHTs are composed of nurses, nursing technicians, physicians, dentists, and Indigenous health workers. The category of nurses stands out4,5, present in undergraduate programs offered by public and private universities in Brazil and in other countries.

It is therefore evident the importance of training that enables the recognition of the different diversities of the Indigenous population4,5,6, which accounts for 0.83% of the Brazilian population, corresponding to 1,693,535 people distributed across 305 ethnic groups. These groups are characterized by great cultural, linguistic, and organizational diversity, with different cosmovisions and Indigenous technologies7, and their populations are more concentrated in the Legal Amazon (Acre, Amazonas, Amapá, Maranhão, Mato Grosso, Pará, Rondônia, and Roraima), although they are present in all five regions of Brazil, albeit more prominently in the North region8.

In this sense, public universities, state higher education institutions (HEIs) of public and collective interest, with autonomy grounded in the pillar of education, play an important role in strengthening health as a right, in training healthcare professionals as part of the SUS workforce, and in achieving social transformations through institutional support9. On the other hand, in their social and intellectual roles, universities have the responsibility to contribute to responses to the objectives of PNASPI1,4,5. To this end, universities, through actions outlined in their Institutional Multiannual Plan, should indicate the need to include topics related to Indigenous peoples of Brazil in research, teaching, and extension.

Furthermore, for undergraduate nursing programs, emphasis is placed on the training of professionals capable of working at different levels of healthcare, considering cultural diversities and the development of skills that enable culturally appropriate care4,5, as established by the Brazilian National Curriculum Guidelines for Undergraduate Nursing Programs (DCENf - Diretrizes Curriculares Nacionais dos Cursos de Graduação em Enfermagem), reinforcing the importance of including Indigenous health in training to meet social and legal demands.

Such action would enable the construction of training programs that promote the effective inclusion of specific content and mandatory workload in the Pedagogical Course Projects (PPPs) of undergraduate nursing programs at public universities. This perspective supports dialogue between technical knowledge and Indigenous medicines and technologies10, benefiting comprehensive and complex training capable of responding to the research priority agenda in Indigenous health in Brazil.

Thus, due to its social and health relevance and the significant inequalities faced by Indigenous peoples, as well as the misalignment between public policies on health, diversity, and inclusion in higher education11, studies in this area are important tools for qualified professional training. In addition, this research addresses items 3 (Good Health and Well-Being), 4 (Quality Education), and 10 (Reduced Inequalities) of the Sustainable Development Goals.

In the field of nursing, despite advances already observed in studies on curricular characterization, investigations point to persistent gaps regarding Global South12 epistemologies and the inclusion of topics related to Indigenous peoples of Brazil in nursing education. However, these investigations also point to pathways for dialogue on training for diversity, equity, and inclusion13, as well as for inclusive education, based on territories and the challenges faced by PNASPI within DSEIs and the Healthcare Network under SUS.

Due to the central role of Brazilian public HEIs9 in reducing persistent health inequities in SUS through training capable of identifying specific territorial needs and engaging with other epistemological and Global South12 knowledge systems, studies that analyze PPP content represent opportunities to promote revisions in curricular activities of undergraduate nursing programs in regions with significant Indigenous populations, also favoring the allocation of qualified professionals across the different dimensions of PNASPI.

Thus, this study analyzed the characteristics of curricular approaches to Indigenous health and the extent to which curricula include theoretical and practical content that prepare nurses to work with Indigenous populations, aiming to analyze curricular approaches to Indigenous health in undergraduate nursing programs at public universities in Brazil.

Method

This is a descriptive and documentary study with quantitative data, based on analyses of institutional documents and information available on the electronic portals of the Ministry of Education and the Ministry of Health, as well as on the official websites of Brazilian federal and state public universities. Data collection was conducted from November 2023 to June 2024.

The variables of interest included geographic aspects, distribution of programs, ethnic groups, curricular activities, and specific bibliographies on Indigenous peoples. Variables related to program offerings were organized according to the five regions of Brazil and state and federal institutions; the distribution of ethnic groups was represented by DSEIs; curricular activities considered thematic specificities and similarities by region; and specific bibliographies were linked to programs and universities. Municipal higher education institutions were not considered in this investigation.

As inclusion criteria, active undergraduate nursing programs listed on the e-MEC portal were analyzed, including in-person programs offered by federal or state public institutions. Therefore, teaching degree programs in the activation phase, technological programs, and private institutions were excluded, as well as those that did not include content related to ethnic groups and traditional populations in their syllabi or bibliographies with specificities of Indigenous peoples.

Concerning Ministry of Health documents, ethnic groups present in the DSEIs were considered, regardless of the repetition of peoples across different territories. Regarding the municipalities hosting university campuses, geographic regions and their records on the same portal were considered.

Quantitative variables were analyzed using simple descriptive statistics, allowing the characterization of regional and institutional distributions of programs and curricular activities. Qualitative variables, extracted from syllabi and bibliographies, were categorized according to thematic similarities and cultural specificities. For spatial analysis, the cartographic base of the Brazilian Institute of Geography and Statistics (IBGE - Instituto Brasileiro de Geografia e Estatística) was used, enabling visualization of distribution by region and by DSEI.

Initially, the data were organized using Microsoft Word® and Microsoft Excel 365® and later edited in Canva Pro, which was used to support the creation of figures and infographic composition. For this purpose, the regional distribution of nursing programs and curricular activities was considered on IBGE maps, which supported the spatial analysis of this study, along with the application of the previously described variables.

As this is a documentary-based study, approval by a Research Ethics Committee involving Human Beings was not required.

Results

A total of 149 undergraduate nursing programs were identified in federal and state public institutions, three of which were excluded because their curricular pedagogical projects were not available on the respective university websites. There was also no response to our requests for documents via email. Figure 1 presents the distribution of undergraduate nursing programs and the number of campuses by region.

Source: Brasil (2023).

Figure 1 – Distribution of undergraduate nursing programs in state and federal public institutions by campus and region

It can be observed that the Northeast region has a higher concentration of federal and state public institutions offering undergraduate nursing programs, followed by the Southeast, South, Midwest, and North regions. Regarding the distribution of campuses by region, a higher concentration was noted in the Northeast region and a lower concentration in the North region.

Regarding the distribution of ethnic groups by DSEI, it was observed that there is no homogeneity in the number or exclusivity of ethnic groups per DSEI, i.e., different ethnic groups are found across multiple territories, demonstrating a diversified dynamic in terms of ethnic distribution in Brazil (Figure 2).

Source: adapted from Brasil (2024).

Figure 2 – Distribution of ethnic groups by Indigenous Health Special District.

With respect to curricular activities related to Indigenous health or associated topics, the North region presents a higher number of public institutions offering these topics within nursing curricula, as shown in Figure 3. The figure also displays institutions that include syllabi with curricular activities directed toward Indigenous contexts, as well as optional components.

Source: Brasil, 2023. Infographic processed in Canva Pro (https://www.canva.com).

Figure 3 – Distribution of the inclusion of curricular activities on indigenous health and related topics in undergraduate nursing courses in Brazil in 2024.

Greater concentrations of these institutions are also observed in the North, Midwest, and Northeast regions, particularly among federal institutions. Universities in the South region of Brazil, especially state institutions, do not present syllabi with descriptors related to the topic or its associated topics.

The distribution of curricular activities and their characteristics are presented in Figure 4. A total of 13 such activities were identified, located in regions with higher concentrations of Indigenous lands, with varying titles and workloads, and which may or may not include the Indigenous peoples described.

Source: adapted from a map processed in QGIS 3.10.7 (https://qgis.org/); Cadastro Nacional de Cursos e Instituições de Educação Superior.

Figure 4 – Geographic division and characterization of curricular activities in Brazil in 2024.

In relation to the use of curricular activities and specific bibliographies containing the keyword “Indigenous”, 11 were identified, with a higher concentration in the North region, followed by the Midwest and Northeast regions—areas with higher concentrations of self-declared Indigenous populations (Figures 4 and 5). Regarding bibliographies, five universities were identified with specific content from Indigenous authors: Universidade Federal do Amazonas (Coari campus); Universidade Federal do Maranhão (Imperatriz campus); Universidade Federal do Mato Grosso (Pontal do Araguaia campus); Universidade do Estado do Mato Grosso (Diamantino campus); and Universidade do Estado do Mato Grosso (Tangará da Serra campus).


Source: authors, 2024. Infographic processed in Canva Pro (https://www.canva.com).

Figure 5 – Characterization of specific curricular and bibliographical activities on indigenous populations in Brazil in 2024 by region.

The findings highlight the authors Gersem José dos Santos Luciano and Kaká Werá Jecupé. It is noteworthy that, based on these results, the Midwest region—specifically the state of Mato Grosso - makes the greatest use of works by Indigenous authors in curricular structures.

Discussion

Curricular approaches to Indigenous health are essential for the training of nurses who will work with these populations, given the diversity of ethnic groups present in Brazil. This diversity represents a reality that is not supported by traditional Eurocentric curricular epistemology, which is grounded in authors from the Global North.

However, due to the conceptual differences14,15 between Western medicine, based on a biomedical model, and Indigenous medicines, which encompass diverse practices and technologies, it is essential that curricula include both theoretical and practical aspects of this topic from a dialogical perspective, allowing space for other epistemological knowledge systems within educational pathways.

Moreover, adopting a dialogical perspective contributes to the deconstruction of prejudice and stereotypes, fostering mutual respect and valuing different forms of knowledge. It promotes the training of critical and reflective professionals capable of working in multicultural contexts within the perspectives of health and/or intercultural education13, strengthening professional training, the effectiveness of health interventions, and equity in care for Indigenous populations through the ability to identify needs inherent to specific territories4,5.

This curricular movement is necessary to facilitate the identification of different Indigenous territories and alignment with the objectives of PNASPI, which emphasize the importance of differentiated care and the articulation between Indigenous medicines and other knowledge systems. Enabling this connection in academic environments clearly encourages multicultural dialogue and interdisciplinary approaches to Indigenous cosmovisions.

Likewise, this initiative promotes the appreciation of different systems of knowledge and health practices10, as well as creating academic spaces conducive to the sharing of knowledge among different cultures and epistemologies11. In this regard, nursing education becomes broader and more sensitive to cultural specificities16,17,18, promoting professional practice aligned with the principles of equity and comprehensiveness of SUS.

At the institutional level, universities contribute to the training of professionals who strengthen health as a right and are sensitive to addressing the specific challenges of the Indigenous Healthcare Network16,19. From an epistemological perspective, this represents an opportunity to introduce new topics and approaches to Indigenous health, involving the incorporation of Indigenous epistemologies and the understanding of contrasts between these and the Western biomedical perspective predominant in curricula12. This enables the development of care strategies based on the deconstruction of Eurocentric paradigms, such as rationality and objectivity.

An objective approach tends to homogenize practices and knowledge, disregarding cultural diversity and the different ways of understanding health and illness present in other epistemologies, such as Indigenous ones. In nursing education contexts, these paradigms manifest through an exclusive emphasis on Western biomedical models, which fragment care and often fail to consider cultural, spiritual, and social aspects that are fundamental to a comprehensive understanding of Indigenous health. Thus, there is an opportunity for dialogue and articulation between biomedical and Indigenous knowledge systems.

In nursing education, it is essential to promote cultural competencies, foster intercultural dialogue, and integrate care approaches12. Therefore, universities can train competent professionals who are sensitive to Indigenous issues and capable of acting as transformative agents in promoting health equity.

Although biomedical epistemologies still predominate in traditional curricula, the inclusion of Indigenous topics and authors in nursing education highlights the importance of understanding the contrasts between Indigenous and biomedical knowledge systems, as well as the relevance of developing integrative approaches that address the specific needs of Indigenous populations18,19. This is consistent with the principles of PNASPI17, which emphasize differentiated care and the articulation between different knowledge systems in the promotion of Indigenous health20.

As for knowledge production, integrating these values into curricula enables inclusive and interdisciplinary education that values multiple forms of knowledge13, which may foster research, extension, and teaching projects over time, contributing to the qualification of the SASISUS workforce. Furthermore, by incorporating works by Indigenous authors into their bibliographies, universities recognize the importance of authentic voices in knowledge construction, such as those of Indigenous intellectuals from different ethnic groups21. This enriches the learning process and promotes the decolonization of knowledge, allowing previously marginalized perspectives to gain space in academia13,21.

By incorporating and exploring different possibilities, it is also possible to address other challenges identified in studies on the topic4,5,13, including the identification of different ethnic groups by region, diverse native languages, family relationships in the health-disease process, symbolic aspects related to rituals, differentiated dietary practices, among others. Therefore, universities must provide critical training that contributes to social transformation, in which pedagogical and curricular models offer opportunities to understand different realities, values, and processes of vulnerability among groups13,21.

However, insufficient qualification18 and the lack of a deep understanding of the Indigenous context and its diverse dynamics19 hinder nurses’ ability to provide equitable and comprehensive care. Therefore, it is essential that nursing curricula include mandatory courses addressing the cultural, social, and health specificities of Indigenous peoples18, with defined workloads. The absence of these elements weakens education and creates dependence on the epistemological sensitivity of faculty members. When Indigenous epistemologies are not recognized as valid knowledge, faculty may silence the knowledge of ethnic groups that are now part of university territories11, particularly due to the inclusion of Indigenous students in HEIs through affirmative action policies.

From this perspective, by identifying the distribution and concentration of federal and state public institutions, it is possible to understand how training is structured for working with surrounding Indigenous populations. The North region, for instance, concentrates the largest Indigenous population and ethnic diversity, as well as the highest number of DSEIs. This diversity must be considered in the training of nurses in the region, enabling them to understand different cultural realities as opportunities to identify ethnic heterogeneity, distinct individual and collective health issues, and the need for tailored healthcare pathways13.

In contrast, the North region has the lowest number of university campuses relative to its geographic extent, highlighting issues such as the marginalization of higher education in the region, which has the lowest rate of university interiorization compared to other regions of the country13. Despite this, it presents the highest number of specific and related curricular activities, reflecting the reality of 753,780 inhabitants who self-identify as Indigenous22, the highest proportion among Brazilian regions.

These findings demonstrate that, despite the lower presence of campuses and the historical marginalization of higher education in the North region, there is a significant effort by local institutions to incorporate curricular activities related to Indigenous health, reflecting an adaptive response to regional needs.

Such curricular activities are mainly identified in Amazonas, Acre, Roraima, and Tocantins, indicating that universities in these areas are aligning their curricula with local sociocultural realities. Although the state of Pará hosts one of the largest DSEIs in the region—the Guamá-Tocantins—no specific actions were identified, only related ones (notably at Universidade do Estado do Pará, at Universidade Federal Rural da Amazônia, and at Universidade Federal do Amapá). This absence highlights internal disparities within the North region, demonstrating that the curricular inclusion of Indigenous health content is not homogeneous and pointing to the need for broader educational policies to promote standardization and expansion of such activities.

The Northeast region, despite having the largest concentration of undergraduate nursing programs and campuses, as well as the second-largest Indigenous population (approximately 529,128 people8), faces a significant gap in specific training on Indigenous health. The identification of only one specific curricular activity, offered by Universidade Federal do Maranhão, reveals a deficiency in preparing professionals to meet the needs of local Indigenous communities. This contrasts with the available educational infrastructure, indicating that the number of programs does not necessarily translate into adequate training for working with Indigenous populations.

In relation to the Midwest region, which has the second-largest Indigenous population8, a significant number of specific curricular initiatives was identified—the second highest representation. Despite not having a large number of nursing programs or campuses, the region demonstrates a commitment to training professionals to work with Indigenous populations, indicating effective alignment between educational provision and local sociocultural demands.

Furthermore, the inclusion of bibliographies on Indigenous health in local universities contributes to strengthening and valuing Indigenous epistemologies, promoting a decolonial education that recognizes and integrates different knowledge systems21. The reality of the Brazilian Midwest suggests a model to be followed by other regions, highlighting the importance of adapting academic curricula to local needs and to the guidelines of PNASPI.

Concerning the South and Southeast regions, the absence of specific curricular programs was observed, with only some related initiatives identified, indicating the need for further progress. These regions have historically had more isolated Indigenous populations and smaller population contingents compared to other regions8; nevertheless, the presence and importance of these communities cannot be ignored. Studies have shown that Indigenous populations in these regions face specific challenges, such as social invisibility and lack of recognition of rights22, including access to culturally appropriate healthcare services.

A possible explanation for disparities in the inclusion of Indigenous health content among regions lies in the greater or lesser presence of Indigenous populations8. Regional policies tend to emphasize the importance of preparing healthcare professionals to work in Indigenous contexts, encouraging educational institutions to incorporate relevant content into their curricula. Moreover, local initiatives, such as partnerships with Indigenous communities and extension projects, reinforce the inclusion of these topics in nursing education13.

Considering that the South and Southeast regions, where the Indigenous population is smaller and often invisible, exert less social and political pressure for the inclusion of Indigenous health content in HEI curricula, educational policies in these regions tend to prioritize other areas of knowledge considered more urgent or locally relevant. This disparity highlights the need for a national approach to promote the inclusion of Indigenous health in nursing curricula across the country, regardless of the geographic distribution of Indigenous populations.

To overcome these challenges, it is essential to invest in faculty training and establish partnerships with local Indigenous communities that can contribute to the educational process and ensure the relevance of the content taught13. The inclusion of Indigenous faculty in universities is also an effective strategy, as it brings authentic perspectives and contributes to the decolonization of knowledge in HEIs11. Moreover, these initiatives foster epistemological pluralism8,20, cultural competencies, and revisions of DCENf.

In this direction, the continuous implementation of DCENf in educational settings is necessary, while the inclusion of Indigenous students in universities through affirmative action policies intensifies the need for curricular adaptation to ensure an inclusive academic environment11,13. These factors support professional training that is respectful of the ethnic specificities of Indigenous medicine, as has been observed in basic education since 200823.

It is also necessary that these activities be grounded in bibliographies composed of Indigenous authors20,24, as already observed in the state of Mato Grosso and in some universities in the North region, creating an environment in which Indigenous peoples can appropriate their own knowledge25. This is particularly important because the epistemology currently taught in universities does not align with Indigenous medicine, which encompasses broad diversities of cosmologies and worldviews24.

It is also essential to include Indigenous theorists in the bibliographic references of these educational activities so that they can occupy spaces historically denied to them and take ownership of knowledge production rooted in their ancestral traditions21, while also valuing these knowledge systems and enabling changes in how Indigenous health is taught and learned.

Study Limitations

This study is limited to the assessment of federal and state public institutions and does not include data from private institutions, which may not fully represent the national reality of nursing education. Additionally, some institutions did not provide information on their websites (a total of three, as mentioned), resulting in missing data and contradicting the Access to Information Law, which guarantees Brazilians the right to access information.

Final Considerations

This study demonstrated that, despite advances in the inclusion of Indigenous topics in the curricular activities of Brazilian public universities, there is still a long way to go, as this initiative is not homogeneous. Institutional and educational challenges remain for the effective incorporation of this topic into nursing education and its subsequent expansion to other health-related undergraduate programs.

Conversely, the study showed that the inclusion of curricular programs addressing Indigenous topics enables the construction of pathways of belonging for Indigenous students within university environments and fosters intercultural dialogue between Indigenous and non-Indigenous students. Furthermore, this represents a way of ensuring the rights of Indigenous peoples, as established in the 1988 Federal Constitution, serving as a bridge for initiating important discussions on hegemonic epistemologies used in public universities. In summary, this constitutes an important step toward deconstructing the Eurocentric hegemony present in the training of healthcare professionals, particularly nurses.

In other words, the contributions of Indigenous authors to universities enable intercultural sharing of their cosmogonies, seeking to understand health and disease from their lived experiences and the sciences of their territories. This has a significant impact on professional training, particularly in promoting healthcare free from racism. Therefore, the recognition of Indigenous medicines is fundamental to dialogue between interculturalities and intermedical processes, involving the participation of Indigenous actors and specialties within their original territories.

In these terms, pathways are identified for the continuous revision of DCENf, as it is essential that the contents considered fundamental to nursing education be revised in alignment with the inclusion of Indigenous contexts in training processes, especially through the use of bibliographic references that include Indigenous authors, which are equally fundamental.

Authors Contributions

Study conception: Paes FT, Castro NJC. Data collection: Paes FT, Castro NJC. Data analysis and interpretation: Paes FT, Castro NJC. Manuscript writing: Paes FT, Castro NJC.. Critical review of the manuscript: Paes FT, Sacuena ERP, Way JRSW, Ribeiro NL, Cordeiro JPP, Cavalcante IM, Parente AT, Castro NJC. Approval of the final version of the text: Paes FT, Sacuena ERP, Way JRSW, Ribeiro NL, Cordeiro JPP, Cavalcante IM, Parente AT, Castro NJC.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgments

Association of Indigenous Students of the Federal University of Pará

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Corresponding Author

Nádile Juliane Costa de Castro

E-mail: nadiledecastro@hotmail.com

The Author(s) 2026.  This work is licensed under Creative Commons Attribution 4.0 International. License text for use: https://creativecommons.org/licenses/by/4.0/deed.pt_BR