Rheumatic diseases are a frequent cause of disability, deterioration in quality of life, and high health costs. The objective of the study was to estimate the prevalence of rheumatic diseases using COPCORD methodology in the Indigenous Misak people of the Guambia - Cauca reservation, over 18 years of age.
Materials and methodsA community-based cross-sectional study was carried out using systematic random sampling, in 3 stages: (1) selection of participants house by house following the main rural road of each village of the Guambia reservation. (2) Application of the COPCORD questionnaire, Spanish version or version adapted and validated to Wam, Misak language), by standardized bilingual interviewers. (3) Confirmation of the diagnosis was made by rheumatologists with access to all the information. Descriptive statistics were performed.
ResultsOf a total of 624 people surveyed, 67% were women, the average age was 44 years, 49.2% had basic primary education, and 79.4% spoke Spanish. Pain in the last 7 days and/or history was reported in 366 respondents (58.6%). One hundred and ninety-two patients received medical evaluation, of which 27 (4.33%) had a diagnosis of rheumatic disease and particularly 21 (3.36%) of rheumatoid arthritis.
ConclusionThe prevalence of rheumatic diseases was lower than reported, however the prevalence of rheumatoid arthritis (3.36%) was higher than that reported in the rest of the country and in other Indigenous communities in Latin America. Rheumatic diseases represent a public health problem and specific information on Indigenous groups is necessary for the design of specific interventions.
Las enfermedades reumáticas son causa frecuente de discapacidad, deterioro de la calidad de vida y altos costos en salud. El objetivo del estudio fue estimar la prevalencia de dichas enfermedades usando metodología COPCORD en el pueblo indígena misak del resguardo Guambia (Cauca), mayor de 18 años.
Materiales y métodosSe realizó un estudio transversal de base comunitario utilizando un muestreo aleatorio sistemático, en tres etapas: (1) selección de participantes casa por casa siguiendo la vía rural principal de cada vereda del resguardo de Guambia; (2) aplicación del cuestionario COPCORD, versión en español o versión adaptada y validada al wam, lengua misak), por entrevistadores bilingües estandarizados; y (3) confirmación del diagnóstico por reumatólogos con acceso a toda la información. Se realizó estadística descriptiva.
ResultadosDe un total de 624 personas encuestadas, el 67% fueron mujeres, la media de edad fue 44 años, el 49,2% tenía educación básica primaria y el 79,4% hablaba español. El dolor en los últimos siete días y/o histórico fue reportado en 366 encuestados (58,6%). Recibieron valoración médica 192 pacientes, de los cuales 27 (4,33%) tuvieron diagnóstico de enfermedad reumática y 21 (3,36%) de artritis reumatoide.
ConclusiónLa prevalencia de enfermedades reumáticas fue menor a lo reportado, sin embargo, la prevalencia de artritis reumatoide (3,36 %) fue mayor a la reportada en el resto del país y en otras comunidades indígenas de Latinoamérica. Las enfermedades reumáticas representan un problema de salud pública y la información particular en grupos indígenas es necesaria para el diseño de intervenciones específicas.
Rheumatic diseases (RD) have a significant impact on the general population, but this Influence is even more pronounced in Indigenous communities.1 These populations often remain invisible to healthcare programs in Latin America, where they face limited access to medical care. This disparity results in the coexistence of infectious and chronic diseases that cause high levels of disability, socioeconomic burdens, family stress, and low quality of life. Epidemiological data on the impact of these diseases on Indigenous peoples are urgently needed, especially considering the comorbidities they experience, unequal access to healthcare, geographic and linguistic barriers, discrimination, limited social support, and a lack of health policies that offer culturally sensitive care.1 This situation has been described as "syndemic," a theoretical framework that suggests that “the interaction of two or more biological diseases within different sociocultural contexts and healthcare systems exacerbates their detrimental effects on individuals, communities, and societies”.2
While there is fragmented information on the impact of RD on quality of life—such as pain, suffering, progressive deformity, and the inability to perform daily activities—, there are other more complex variables to consider. These include social isolation, loss of work opportunities, limited job promotions or educational prospects, economic dependence, and unwanted changes to life plans. Given these considerations, the study of RD prevalence and its impact on quality of life must be prioritized in healthcare agendas. This is especially important for vulnerable groups such as indigenous communities, due to the profound effects RD has on individuals, families, work, and sociocultural aspects of society.
Rheumatoid arthritis (RA) is one such RD with a significant morbidity burden. Since 2009, the Latin American Group for the Study of RD in Indigenous Populations (Gladerpo) has been exploring the prevalence of RD using the Community Oriented Program for Control of Rheumatic Diseases (COPCORD) strategy. Studies have been conducted with various indigenous groups, such as the Qom3 and Wichi4 peoples in Argentina, the Warao, Kari'ña, and Chaima5 peoples in Venezuela, and the Mayan-Yucatecan,6 Mixtec, Chontal,7 and Raramuri8 peoples in Mexico. In these studies, the prevalence of RA has ranged from 0.5% to 3.2%. In other regions, much higher prevalence rates have been found, such as in the Chippewa people in the USA (6.8%), Australian Aborigines (2.7%), and the Ratahuana people in New Zealand (3.3%).9
In Colombia, RA has an estimated prevalence of 1.49%, according to a COPCORD study; however, this research did not include the indigenous population.10 Therefore, the objective of this study was to estimate the prevalence of musculoskeletal disorders (MSD) and the main RD in the Misak indigenous population of the Guambia reservation in the department of Cauca, using stage I of the COPCORD strategy.11 Additionally, the study aimed to assess the impact of MSD and RD on the quality of life of this population, providing valuable data for the development of future culturally sensitive community interventions (stages 2 and 3 of the COPCORD strategy). These interventions will contribute to the early detection of RD and the prevention of disability caused by MSD in vulnerable groups.
MethodsDesign: community-based cross-sectional studyThe methodology and validated questionnaire of the Colombian version of COPCORD were used to identify MSD and RD.11 Adults aged 18 and older, who had been residing in the surveyed household for at least six months and were mentally fit to complete the questionnaires, were invited to participate.
SampleA systematic random sampling method was applied in several stages: the primary unit was villages, and the secondary unit was households. The Guambia reservation is located approximately 60km from Popayán, the capital of the department of Cauca, and is divided into eight zones: Cacique, Cofre, Campana, Pueblito, Michambe, Tranal, Chiman, and Purachak. Each zone consists of several villages, totaling 39 villages, which extend over approximately 400 km². Population data from the 2018 National Administrative Department of Statistics (DANE) were used to gather information on the reservation’s inhabitants, grouped by zones and villages, totaling 7,870 residents. A representative sample percentage was calculated for each zone and village, resulting in a target of 367 people to be interviewed, with a margin of error of 5% and a confidence interval of 95%. Families were visited at every third house along the main access route to each village until the designated number of participants for each village was reached (Fig. 1).
Recruitment
The interviewers, referred to as "Filter 1”, were three trained nursing assistants who used structured and validated questionnaires for the Misak population.11 They administered the questionnaires in person or face-to-face at participants' homes. Various variables were collected, including sociodemographic (age, sex, educational level, marital status, religion, literacy in Wam or Spanish) and socioeconomic data (indirect indicators of income and, type of health insurance). Quality of life was assessed using the EQ-5D-3L questionnaire,12 a generic and multidimensional instrument that evaluates five dimensions (mobility, self-care, daily activities, pain/discomfort, and anxiety/depression) on three response levels (1=no problems, 2=moderate problems, 3=extreme problems). Additionally, a scale was used to measure the health status "today" (EQ-5D-VAS), ranging from 0 (the best imaginable health status) to 100 (the worst imaginable health status).13 Physical function was assessed using the Health Assessment Questionnaire (HAQ), which consists of 20 items organized into eight categories, scored from 0 to 3. These two questionnaires have been previously validated in Spanish and within the Colombian population. Information was also collected on self-reported chronic non-communicable diseases (such as chronic hypertension, diabetes mellitus, heart disease, cancer, tuberculosis, mental illness, obesity, lower limb venous insufficiency, cerebrovascular disease, epilepsy, and headaches), as well as exposure to wood smoke, smoking, alcohol, and other psychoactive substances.
The COPCORD questionnaire, which has been validated in the Misak population,11 identifies individuals with rheumatic symptoms through an interrogation with trained interviewers. It includes questions about symptoms (pain and stiffness), disability, treatment, and adaptation to the problem. The instrument also contains a section on help-seeking behavior and a list of non-conventional remedies. Individuals who reported pain, swelling, or stiffness in the past seven days, at any point in their life, and whose symptoms were not trauma-related, were classified as COPCORD-positive. These individuals were then assessed at Mama Dominga Hospital by "Filter 2": internal medicine fellows and trained internists from the Internal Medicine program at the Universidad del Cauca, as well as a student and a physical therapist professor from the Physiotherapy program at the Universidad del Cauca, who conducted medical histories and physical exams. Those with suspected rheumatic diseases were further evaluated by "Filter 3": rheumatology specialists. Participants who were classified as COPCORD-positive but did not attend the assessment after seven attempts were excluded from the assessment process.
The definitive diagnosis was determined using the American College of Rheumatology classification criteria for osteoarthritis (OA),14–16 fibromyalgia (FM),17 rheumatoid arthritis (RA),18 systemic lupus erythematosus (SLE),19 gout,20 Sjögren syndrome,21 dermatomyositis,22 and systemic sclerosis.23 For spondyloarthritis (SpA), the criteria proposed by the European Group for the Study of Spondyloarthritis24 were applied, focusing on clinical criteria due to the inability to access supplementary immunological or imaging tests.
For the classification of soft tissue rheumatism, the definition of appendicular regional pain syndrome (ARDS) proposed by Alvaréz-Nemegyei was used, encompassing tendinopathies, bursopathies, entrapment neuropathies, and enthesopathies not associated with systemic disease.25 For pain, inflammation, or stiffness in any musculoskeletal structure not classifiable under these categories, the term non-specific musculoskeletal disorder (MSD) was used, and non-rheumatic diseases were classified according to the ICD-10 registry.26
Statistical analysisA univariate analysis was performed using descriptive statistics, reporting proportions for nominal variables and measures of central tendency or dispersion for discrete or ratio variables, depending on their symmetrical or asymmetrical distribution. For bivariate analysis, the Chi-square test was applied, with a p-value < 0.05. Data analysis was conducted using STATA 16 software (VeriSign Class 3 Code Signing 2010 CA).
Ethical considerationsThe ethical principles guiding this research were based on the Declaration of Helsinki27 and Resolution 008430 of 1993 from the Ministry of Health of Colombia. Approval was obtained from the ethics committee of the University del Cauca (internal code ID: 5083). Endorsement was also received from the indigenous authority (the Cabildo), and individual consent was obtained from each participant, who signed informed consent forms to participate in the study. To uphold confidentiality, each participant was assigned a code.
ResultsA total of 789 participants were interviewed by Filter 1 from a population of 7,870 eligible local inhabitants. Of these, 165 were excluded due to incomplete information, resulting in a final sample of 624 participants. Of the 366 (58.65%) individuals who were COPCORD-positive, 192 (52.45%) were assessed by Filter 2, with confirmation by Filter 3 in 53 (27.60%) (Fig. 2).
Table 1 presents the demographic and socioeconomic characteristics. All participants were enrolled in the subsidized health regime as stratum 0; however, economic disparities were evident based on household appliance ownership, homeownership, and access to public services. The most common occupations were domestic work (97.80% of women and 90.78% of men) and agricultural work (59.57% of women and 68.93% of men).
General characteristics of the population.
| Population | n=622an=(%) |
|---|---|
| Age, years, mean (SD) | 44.90 (16.73) |
| Gender (Female) | 418 (67) |
| Marital status | |
| With a partner (married, free union) | 426 (68.49) |
| Without a partner (single, separated) | 196 (31.51) |
| Educational level | |
| Elementary | 307 (49.20) |
| Middle | 170 (27.24) |
| Technical | 30 (4.81) |
| Professional | 20 (3,21) |
| None | 95 (15.22) |
| Literacy (reading and writing) | n=622 |
| Wam (native language) | 321 (48.24) |
| Spanish | 496 (79.49) |
| Religion | n=622 |
| Catholic | 318 (50.96) |
| Evangelical, Jehovah's Witness, Protestant | 282 (45.33) |
| None | 12 (1.92) |
| Pishimisak (Misak Spirit) | 9 (1.44) |
| Other | 1 (0.16) |
| Occupation | |
| Employee | 41 (6.57) |
| Domestic jobs | 596 (95.51) |
| Farmer/Day Laborer | 391 (62.66) |
| Student | 46 (7.37) |
| Hawker | 36 (5.77) |
| Employers | 251 (40.22) |
| Public services and goods | |
| Electrical energy | 600 (96.15) |
| Sewerage | 2 (0.32) |
| Aqueduct | 474 (75.96) |
| Telephone (landline or mobile) | 520 (83.33) |
| Own means of transport, fuel | 235 (37.66) |
| Gas/electric stove | 304 (48.72) |
| Radio | 578 (92.63) |
| Sewing machine | 21 (3.37) |
| Television | 446 (71.47) |
| DVD | 137 (21.96) |
| Computer | 92 (14.74) |
| Bicycle | 88 (14,10) |
| Fridge | 105 (16.83) |
| Washing machine | 26 (4,17) |
| Heater | 45 (7.21) |
| Own home | 568 (91.03) |
According to the COPCORD questionnaire, 294 (47.12%) respondents reported musculoskeletal pain in the last seven days, with 150 (51.19%) describing the pain as "severe." Additionally, 258 (41.35%) reported musculoskeletal pain at some point in their life, of whom 122 (46.39%) described the pain as "severe." The most common sites of pain in the past seven days or over the lifetime were the lumbar spine (35.30%), hands (33.33%), knees (26.50%), and shoulders (12.59%) (Fig. 3).
Regarding musculoskeletal pain, 345 (57.5%) participants sought medical care, with 137 (39.7%) seeking traditional medicine, 117 (33.91%) opting for Western medicine, and 53 (15.36%) using alternative medicine. The most commonly used medications for pain relief were nonsteroidal anti-inflammatory drugs (NSAIDs) (44/172, 25.58%), paracetamol (26/172, 15.1%), steroids (14/172, 8.1%), and herbal formulas (107/172, 62.2%). Physiotherapy was provided to 94 (26.1%) participants, with 80 (85.1%) reporting effectiveness.
In assessing static and dynamic biomechanical stress, it was significantly found that COPCORD-negative individuals tolerated greater loads than COPCORD-positive individuals, particularly regarding walking (87.6% vs. 77%) and standing for more than half an hour (85.5% vs. 71.3%) (Table 2).
Positive biomechanical load in positive and negative COPCORD population.
| In your work or routine tasks, have you had difficulty doing the following activities? | COPCORD positive n=366 (58.65%) | COPCORD negative n=258 (41.35%) | Total, n (%) n=624 (100%) | p |
|---|---|---|---|---|
| Spinning or weaving >1h | 252 (68.85) | 187 (72.48) | 439 (70.35) | 0.3200 |
| Load >25 kg | 234 (63.93) | 215 (83.33) | 449 (71.96) | 0.0000 |
| Pushing things >25 kg | 243 (66.39) | 2.217 (84.11) | 460 (73.72) | 0.0000 |
| Going up or down slopes all the time | 202 (55.19) | 165 (63.95) | 367 (58.81) | 0.0290 |
| Standing for more than half an hour | 261 (71.31) | 221 (85.66) | 482 (77.24) | 0.0000 |
| Being crouched for more than half an hour | 258 (70.49) | 208 (80.62) | 466 (74.68) | 0.0040 |
| Walk more than half an hour | 285 (77.87) | 226 (87.60) | 511 (81.89) | 0.0020 |
| Standing up and sitting down all the time | 252 (68.85) | 183 (70.93) | 435 (69.71) | 0.5780 |
Functional assessment using the HAQ questionnaire revealed that COPCORD-positive individuals had limitations, particularly in tasks such as housework (washing, dishwashing, cooking, farming), bending over and picking up items, climbing five steps, opening a bottle, and getting in or out of bed. In 42 (6.73%) cases, the calculated HAQ score was >0.8, and in 14 (2.24%) cases, it was >1.5. Among these, 50% were RA patients with more than one year of disease. Twelve participants (1.92%) required assistive devices (cane, wheelchair, crutches, or walker).
Regarding quality of life, COPCORD-positive participants reported more significant problems than COPCORD-negative participants in the following areas: mobility (22.68% vs. 1.94%), personal care (10.93% vs. 0.76%), daily activities (23.22% vs. 1.55%), moderate anxiety/depression (18.85% vs. 2.33%), and a mean health status of 74.67 vs. 89.73 (p=0.028).
The primary diagnoses following medical assessments by Filters 2 and 3 are presented in Table 3. Twenty-one (3.36%) individuals were diagnosed with RA, 18 (85.7%) of whom were women, with a mean age of 44 years, and 12 (51.14%) had advanced disease. Seven patients (33.33%) had a first-degree family history of RA. Overall, the average disease duration was 10 years, with symptom onset around the age of 34. Eight (38%) were treated with methotrexate (four with monotherapy, three with chloroquine, and one with leflunomide), 12 (57.14%) received steroids, and the remaining patients had no treatment.
Prevalence of rheumatic disease in the Misak population of the Guambia reservation.
| Disease | Point estimate (%) | 95% Confidence Interval |
|---|---|---|
| Osteoarthritis | 60 (9.64) | 7,44−12,24 |
| Mechanical low back pain | 50 (8.01) | 6,11−10,42 |
| Rheumatic regional pain syndrome | 47 (7.53) | 5.69−9.88 |
| Rheumatoid arthritis | 21 (3.36) | 2,18−5,11 |
| Undifferentiated arthritis | 3 (0.48) | 0.09−1.47 |
| Juvenile idiopathic arthritis | 1 (0.16) | 0−0.09 |
| Fibromyalgia | 1 (0.16) | 0−0.09 |
| Sjögren syndrome | 1 (0.16) | 0−0.09 |
| Systemic lupus erythematosus | 1 (0.16) | 0−0.09 |
The main self-reported comorbidities are shown in Fig. 4. A total of 97.20% of the population reported exposure to wood smoke.
Discussion
This is the first study using the COPCORD strategy in indigenous communities in Colombia. One of the most notable findings was the high prevalence of RA at 3.36%, which is higher than that reported in the rest of the country and in other indigenous communities in Latin America. With the use of other assessment methods, similar prevalence rates have been found in some Native American populations, with the Chippewa (6.8–7.1%) and Yakima (3.4% in women)9 communities being the most representative examples. Table 4 presents a comparison of the prevalence of RD and MSD between this study, COPCORD Colombia, and other indigenous peoples in Latin America.
Comparison of prevalence of rheumatic diseases and musculoskeletal disorders.
| COPCORD | Misak (Colombia) | Colombia | Wichi (Argentina) | Saraguro (Ecuador) | Maya-Yucatecan (Mexico) | Qom (Argentina) | Warao, kari'ña, Chaima (Venezuela) | Mixtec/Chontal (Mexico) | Raramuris (Mexico) |
|---|---|---|---|---|---|---|---|---|---|
| Prevalence (%) | 2023 | 2018 | 2020 | 2019 | 2016 | 2016 | 2016 | 2016 | 2016 |
| Osteoarthritis | 9.6 | 10.81 | 3.2 | 7.2a | 9.4 | 4 | 14.1 | 14.7 | 6.6 |
| Mechanical low back pain | 8.01 | 7.24 | 19 | 9.3 | 10 | 20.1 | 12.4 | 16 | 1.6 |
| Rheumatic regional pain syndrome | 7.53 | 9.73 | 5.2 | 5.8 | 10.8 | 2.9 | 9.7 | 4.9 | 0.3 |
| Rheumatoid arthritis | 3.36 | 1.49 | 3.2 | 1.3 | 1.1 | 2.4 | 1.1 | 0.3 | 0.5 |
| Undifferentiated arthritis | 0.48 | 0.15 | 0.3 | – | 0.5 | 0.3 | 1.5 | – | – |
| Fibromyalgia | 0.16 | 0.72 | 0.15 | 1.8 | 2.2 | 0.1 | 0.5 | – | 0.3 |
| Systemic lupus erythematosus | 0.16 | 0.05 | – | – | – | 0.06 | 0.06 | 0.09 | – |
Regarding RA, the disease exhibited an aggressive progression among the Misak community, with 51% of individuals showing pathognomonic deformities, which is consistent with other indigenous communities. For example, in the Wichi people, the disease was evidenced by an average DAS28 (ESR) of 5.1 (indicating high activity), 75% had a positive rheumatoid factor, 100% tested positive for anticitrulline antibodies, and 66.7% showed erosions.4 In the Saraguro community, individuals with RA reported a greater impact on quality of life in areas such as mobility, self-care, pain, and daily activities.28 The severity of RA in these groups may partly be explained by a strong genetic component, as indicated by the high frequency of family history of RA among those affected. In the Misak population, 33% had at least one first-degree relative with RA, while the prevalence of family history in the Wichi community was 42.9%.4 This phenomenon may be facilitated by the persistence of endogamous relationships in these populations.29 However, environmental factors, such as the high frequency of periodontal disease30 and exposure to wood smoke,31 likely play a key role in the high RA prevalence observed in the Misak group.
A delay in diagnosis and treatment is a significant issue. Several studies conducted in Latin American countries show delays ranging from a minimum of one year in Argentina to nearly six years in Venezuela.32–35 Additionally, there are cultural, economic, and geographic barriers to accessing healthcare, which result in inadequate pharmacological treatment regimens. Among Misak patients with RA, only 38% received a disease-modifying drug, which mirrors the situation in the Wichi population. This is reflected in the increased use of NSAIDs, which reached 47.6% in the Wichi group, and steroids, used by 57.1% and 28% of the Misak and Wichi communities, respectively.4
Under these circumstances, there was a notable trend towards traditional medicine compared to Western medicine (39.7% vs. 33.9%). This indicates that the Misak community either seeks one or the other or creates syncretism between both, with a stronger inclination toward their knowledge. However, it is important to promote cultural competency in healthcare, so Western physicians can provide culturally sensitive care that facilitates timely interventions and improves patient adherence to treatment.36
The prevalence of mechanical low back pain in the Misak population was 8.01%, which aligns with the 7.3% prevalence reported in the COPCORD study in Colombia, as well as the 9.3% and 10% prevalence in the Saraguro and Maya-Yucatecan indigenous populations, respectively.6,28 However, communities such as Qom, Wichi, and Mixtec-Chontal report much higher prevalence rates (20.1%, 19%, and 16%, respectively).3,4,7 Mechanical lower back pain is common in Latin American populations, resembling the Misak, who are often engaged in physically demanding tasks such as agriculture.
The syndemic approach, which considers the interaction of genetic, biological, psychological, social, and political factors, suggests that the vulnerability of Indigenous populations to rheumatic diseases is largely a result of inequalities in access to healthcare in rural areas, low educational levels, and comorbidities, particularly mental health issues.37 This finding aligns with our study, as patients with RD reported a higher frequency of comorbidities compared to those without RD, as shown in Fig. 4.
The prevalence of OA in this study was like that found in COPCORD Colombia, Yucatecan Maya, and Saraguro studies (10.8%, 9.6%, 9.4%, and 7.2%, respectively).6,10,28 In the Misak population, the prevalence of OA was higher than in the Warao/Kari'ña/Chaima and Mixtec/Chontal communities (14%)5,7 and lower than in the Wichi and Qom communities (3.2% and 4%, respectively).3,4 The prevalence of pain in the last week varied among indigenous groups in Latin America, with this study reporting 47.12%, which is comparable to the general Colombian population, as well as the Saraguro, Mixtec/Chontal, and Qom indigenous groups (48%, 45.5%, 46.3%, and 52.9%, respectively),3,7,28 but higher than in the Warao-Kari'ña-Chaima, Wichi, and Maya-Yucatecan groups (32.9%, 33.3%, and 38.8%, respectively).4,6 The prevalence of pain at some point in life in the Misak population was comparable to that of the Warao-Kari'ña-Chaima, Wichi, and Saraguro groups (41.35%, 38%, 42.1%, and 44.3%, respectively).4,5,28
A paradoxical effect was observed in the assessment of biomechanical load in this population. Participants without MSD or RD reported being exposed to greater biomechanical stress, a phenomenon known as the "disability paradox".38 This refers to the observation that individuals with long-term rheumatic disease and disability often report better coping mechanisms and a more positive attitude, which reduces the perceived biomechanical impact.
Comorbidities, however, are factors that contribute to the deterioration of quality of life, either due to the progression of musculoskeletal disability or the self-perception of a higher disease burden. This was evident in the load of comorbidities among patients with RD. In our study, anxiety and depression were the most common comorbidities (27.2%), which was significantly higher than what was reported in the 2015 mental health survey of the Colombian population.39 Factors such as displacement due to violence, loss of cultural traits, poverty, limited access to basic health and education services, ethnic discrimination, exposure to family and interpersonal violence, barriers to mental health services, alcoholism, and migration to urban areas may explain this higher rate. These challenges are common across indigenous populations worldwide.39
Obesity was reported in 7.73% of the Misak population, comparable to the 6.8% prevalence in the Qom community,3 but lower than the rates observed in the Maya-Yucatecan and Mixtec/Chontal groups (30.1% and 17.2%, respectively).6,7 Diabetes mellitus was reported by 3.04% of Misak participants, similar to the 2.8% prevalence in the Wichi group, which is among the lowest observed. This contrasts with the higher prevalence in the Maya-Yucatecan and Mixtec/Chontal communities (9.7% and 9.4%, respectively).6,7 The varying prevalence of diabetes mellitus among indigenous groups is likely due to the multifactorial nature of the disease. Lastly, the prevalence of arterial hypertension ranged from 10% in the Misak population to 18% in the Qom community,3 which is much lower than the global adult prevalence of 31.1%.40 This may be related to the significant physical activity associated with rural work.
Limitations of the studyOne of the limitations of this study is the lack of immunological and radiographic data for classifying the different RD. However, the diagnosis of these conditions was based on clinical criteria applied by rheumatology specialists, who, among other things, described pathognomonic features and classified the severity of the diseases.41 It is important to note that accessing paraclinical support required transportation to health facilities in urban areas, which was limited for people with disabilities. This was compounded by the economic constraints of the Misak population, most of whom are classified in socio-economic stratum 0 (low). Residential instability, stress, and the loss of social support networks also made it difficult for individuals to travel to specialized healthcare centers in cities.42
Additionally, during the study's fieldwork, the COVID-19 pandemic occurred, which restricted access to the reservation, and some individuals chose not to engage with our research team due to fear of contagion. After the pandemic, several social protests and road blockades also hindered access to the reservation. Furthermore, part of the initial research team was involved in professional development outside the region, which affected the pace of the project. On the other hand, there were annual changes in the council (leadership group) and in the management of Mama Dominga Hospital (which provided support with location for medical assessments and personnel to assist with the village locations). This required resubmitting the study for approval by the new leadership, which delayed the project's completion.
ConclusionsThe prevalence of musculoskeletal diseases in indigenous communities is high, likely due to the cultural demands and primary socioeconomic activity (agriculture). Rheumatoid arthritis is one of the most prevalent diseases in the Misak indigenous community, potentially linked to genetic factors facilitated by endogamy, the high frequency of periodontal disease, and possibly exposure to wood smoke. Given the disabilities caused by these conditions and the high prevalence observed in our study, we believe these results can help promote interdisciplinary preventive interventions that support early and timely diagnoses, greater adherence to treatment, and improved health outcomes. Lastly, we stress the importance of culturally sensitive healthcare, ensuring that diagnoses and treatments align with the epidemiological and sociocultural characteristics of each population.
Authors’ contributionAna Ospina-Caicedo: Participated in the design, execution, analysis, writing, revision and approval of the final version of the manuscript.
Alex Imbachí-Salamanca: Participated in the design, execution, analysis, writing, revision and approval of the final version of the manuscript.
Ingris Peláez-Ballestas: Participated in the design, analysis, writing, revision and approval of the final version of the manuscript.
María V. Torres-Andrade: Participated in the design, execution, analysis, writing, revision and approval of the final version of the manuscript.
Edgar A. Castro-Franco: Participated in the design, execution, analysis, writing, revision and approval of the final version of the manuscript.
Jaime Coral-Enríquez: Participated in the execution, analysis, writing, revision and approval of the final version of the manuscript.
Diana K. Rodríguez-Cerón: Participated in the design, execution, analysis, writing, revision and approval of the final version of the manuscript.
Jorge Izquierdo-Loaiza: participated in the execution, revision and approved the final version of the manuscript.
FinancingFunding for this study was provided by the Asociación Colombiana de Reumatología (ASOREUMA) under the April 2020 agreement and by the Universidad del Cauca through internal code ID: 5083.
Declaration of competing interestThe authors declare no conflicts of interest.
We would like to extend our special thanks to the Guambia reservation, the local councils that have supported the project year after year, and Mama Dominga Hospital. We are grateful to rheumatologist Jorge Hernán Izquierdo for his support. We also wish to thank Brayan Reyes, Daniel Santiago, Diana Rodríguez, and Jorge Rosero, MDs, as well as physical therapy student Karol Yiseth Jurado Narváez and internal medicine specialist Juan David Orozco for their work in the field and in organizing the data. Our thanks also go to Talía Orozco for her invaluable assistance in data tabulation. Finally, we would like to express our gratitude to the EuroQoL Research Foundation for allowing us to use the EQ-5D-3L instrument to assess the quality of life of the individuals who participated in this research.
Representing the Latin American Study Group on Rheumatic Diseases in Indigenous Peoples (Gladerpo).
