Alcohol misuse by Amerindians with tuberculosis: relations to cash transfer programs in Brazil.

Alcohol misuse is a remarkable risk factor for tuberculosis (TB) and limits access to health services and adherence to medications, especially among socioeconomically disadvantaged populations, such as indigenous people.1 Minimum-income public policies, specifically cash transfer programs (CTPs), have been adopted to improve the social and health indicators of these groups in several countries.2

We conducted a cross-sectional study among Guarani-Kaiowá villages in the state of Mato Grosso do Sul, Brazil, between 2011-2016. Our purpose was to estimate the prevalence of alcohol misuse by indigenous Brazilians undergoing TB treatment and its association with CTPs granted by the Brazilian federal government. Sex, age, place of residence, educational attainment, severity of TB, and CTP were the variables of interest. The study was approved by the research ethics committee of Escola Nacional de Saúde Pública Sergio Arouca (protocol 96/2010) and by the Brazilian National Ethics Commission (protocol 400/2010).

Alcohol misuse was defined as an Alcohol Use Disorders Identification score higher than 8 points for men or 7 for women. In this study, families were considered CTP recipients when they received either rural retirement benefits, the Bolsa Família program, or both. The purpose of the Bolsa Família program is to immediately alleviate poverty in families that are proven to be vulnerable, who commit to conditionalities related to education and health care. To estimate the prevalence ratio, we used the Poisson regression.

Overall, 197 TB cases were reported during the period. Of these, 35.5% (confidence interval: 28.8-42.2) exhibited alcohol misuse. On average, alcohol misuse was 50% (prevalence ratio: 1.5; confidence interval: 1.1-2.0) more frequent in individuals whose families did not have access to CTPs (Table 1).

Table 1

Crude and adjusted factors associated with alcohol misuse among indigenous people with tuberculosis, Mato Grosso do Sul state, Brazil, 2011-2016

Variable	Crude PR (80%CI)	p-value	Adjusted PR (95%CI)	p-value
Gender
Male	2.0 (1.5-2.7)	< 0.001	1.4 (1.1-2.0)	0.075
Female	1
Age group
10-24 years	1
25-49 years	1.5 (1.1-2.1)	0.099	--	--
50 or older	0.9 (0.6-1.5)	0.842	--	--
Cash transfer programs*
Yes	1
No	1.7 (1.4-2.1)	< 0.001	1.5 (1.1-2.0)	0.005
Smoking (≥10 cigarettes/day)
Yes	5.1 (3.8-6.7)	< 0.001	4.6 (3.0-7.1)	< 0.001
No	1		1
Severity of tuberculosis
Severe	1.6 (1.2-2.1)	0.046	--	--
Other	1		1

CI = confidence interval; PR = prevalence ratio.

Bolsa Família program or rural retirement benefits.

The prevalence of alcohol misuse among indigenous people undergoing TB treatment in this sample was close to that observed in TB patients from India (38.8%),3 as well in admittedly vulnerable groups, such as homeless and transgender individuals.1

The inverse association between CTPs and alcohol misuse in indigenous people, as shown here, occurs in a context marked by precarious housing, low education and income levels, and food insecurity.4 We believe the majority of the indigenous population living in the investigated villages would meet the criteria to receive at least one of the CTPs here investigated. However, recent studies4,5 revealed that these especially vulnerable groups have faced major difficulties in accessing CTPs in Brazil.

Even if access to CTPs does not ensure protection against alcohol misuse, our data show that individuals undergoing TB treatment and suffering from alcohol misuse, and thus bearing a double burden of vulnerability, were more likely to not have access to CTPs. Despite meeting the criteria and being eligible, part of these individuals had limited access to CTPs and/or faced troubles remaining enrolled in the social programs.

In settings of great socioeconomic vulnerability, such as among indigenous people in Mato Grosso do Sul state, people who should have access to CTPs but who, for various reasons, are unable to achieve access or remain enrolled in these programs should receive special attention, not only from social security and social assistance but also from the health authorities. Limiting the access of these individuals to CTPs seems inadequate from a public health viewpoint, since it can deepen social inequalities as well hinder tuberculosis control among indigenous people.

Disclosure

The authors report no conflicts of interest.