Social determinants of leprosy in a hyperendemic State in North Brazil

Monteiro, Lorena Dias; Mota, Rosa Maria Salani; Martins-Melo, Francisco Rogerlândio; Alencar, Carlos Henrique; Heukelbach, Jorg

doi:10.1590/S1518-8787.2017051006655

Brasil

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Original Articles • Rev. Saúde Pública 51 • 2017 • https://doi.org/10.1590/S1518-8787.2017051006655 linkcopy

Social determinants of leprosy in a hyperendemic State in North Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE To identify the socioeconomic, demographic, operational, and health service-related factors associated with the occurrence of leprosy in a hyperendemic State in North Brazil.

METHODS This is an ecological study based on secondary data from the Sistema de Informações de Agravos de Notificação in municipalities of the State of Tocantins from 2001 to 2012. Units of analysis were the 139 municipalities of the State. Negative binomial log linear regression models were used to estimate incidence rate ratios.

RESULTS In bivariate analysis, the incidence rate ratios were significantly higher for municipalities with higher income ratio of the poorest 20.0% (1.47; 95%CI 1.19–1.81) and better Municipal Human Development Index (1.53; 95%CI 1.14–2.06). In multivariate analysis, the incidence rate ratios were significantly higher in municipalities with higher proportion of immigrants (1.31; 95%CI 1.11–1.55) and higher proportion of households with waste collection (1.37; 95%CI 1.11–1.69). There was a significant reduction in the incidence rate ratio with increased coverage of the Bolsa Família Program (0.98; 95%CI 0.96–0.99).

CONCLUSIONS Control programs need to focus on activities in municipalities of greater social vulnerability with intersectoral investment for the improvement of the living conditions of the population.

Leprosy, epidemiology; Socioeconomic Factors; Neglected Diseases, prevention & control; Health Inequalities

Variable	Smoothed detection rate of leprosy per 100,000 inhabitants

	Median	Minimum	Maximum	IRR	95%CI	p
Proportion of households with two or more persons per bedroom
< 25.6	92.8	21.9	250.5	1	-	-
25.6 to 39.9	82.6	25.0	177.1	0.850	0.712–1.014	0.071
> 39.9	61.8	22.7	125.5	0.668	0.544–0.821	< 0.001
Income per capita of up to R$70.00 per household
< 24.7	95.8	42.1	175.4	1.216	0.962–1.536	0.102
24.7 to 32.9	71.8	21.9	250.5	0.933	0.771–1.129	0.477
> 32.9	76.5	22.7	158.7	1	-	-
Income per capita of up to half minimum wage (R$255.00) per household
< 130.9	71.8	21.9	138.8	0.672	0.565–0.799	< 0.001
130.9 to 146.6	88.0	25.0	155.4	0.841	0.689–1.027	0.089
> 146.6	88.4	24.2	250.5	1	-	-
Proportion of illiterates aged 15 or more per household
< 15.2	85.3	31.9	250.5	1	-	-
15.2 to 20.7	81.3	21.9	181.4	0.827	0.693–0.987	0.036
> 20.7	56.1	22.7	125.5	0.600	0.488–0.737	< 0.001
Proportion of unemployed persons aged 16 or more per household
< 5.4	84.9	22.7	223.3	1	-	-
5.4 to 9.6	83.1	21.9	250.5	1.009	0.829–1.229	0.926
> 9.6	68.5	25.0	155.4	0.844	0.669–1.065	0.153
Income ratio (20%–20%)
< 18.5	91.8	24.2	223.3	1	-	-
18.5 to 25.9	80.4	25.0	250.5	0.788	0.655–0.949	0.012
> 25.9	74.7	22.7	177.1	0.715	0.577–0.885	0.002
Income ration of the poorest 20%
< 1.7	74.2	21.9	120.7	1	-	-
1.7 to 3.4	78.0	22.7	250.5	1.129	0.940–1.356	0.194
> 3.4	95.2	24.2	223.3	1.472	1.194–1.813	< 0.001
Average income per capita per household
< 293.5	66.7	22.7	125.5	0.689	0.561–0.846	< 0.001
293.5 to 423.4	80.9	21.9	181.4	0.781	0.654–0.934	0.007
> 423.4	93.2	31.9	250.5	1	-	-
Gini index
< 0.5	83.4	24.2	223.3	1.262	0.976–1.631	0.076
0.5 to 0.6	81.4	22.7	177.1	1.075	0.879-1.315	0.480
> 0.6	74.8	21.9	250.5	1	-	-
Municipal Human Development Index
< 0.6	66.7	22.7	125.5	1	-	-
0.6 to 0.7	82.2	21.9	181.4	1.168	1.142–2.061	0.114
> 0.7	81.7	31.9	250.5	1.534	1.142–2.061	0.004
Men to women ratio in the household
< 104.6	74.8	24.2	250.5	1	-	-
104.6 to 111.8	79.1	21.9	181.4	0.932	0.768–1.13	0.471
> 111.8	85.3	22.7	155.1	0.962	0.773–1.196	0.725
Proportion of households in the urban area
< 54.2	84.9	30.1	141.7	1	-	-
54.2 to 80.1	79.1	21.9	181.4	0.977	0.810–1.178	0.805
> 80.1	81.8	24.2	250.5	1.149	0.924–1.428	0.212
Proportion of immigrants with fixed residence per municipality in the last 10 years
< 17.8	74.7	21.9	175.4	1
17.8 to 23.9	92.6	30.1	250.5	1.306	1.089–1.565	0.003
> 23.9	96.7	31.2	181.4	1.323	1.103–1.586	0.004
Proportion of households with inadequate water supply and sanitation
< 5.2	78.2	21.9	250.5	1	-	-
5.2 to 14.1	87.0	29.0	177.1	1.015	0.837–1.230	0.883
> 14.1	82.2	22.7	175.4	0.902	0.723–1.126	0.364
Proportion of household with running water and bathroom
< 61.7	64.1	22.7	138.8	0.627	0.512–0.769	< 0.001
61.7 to 84.2	78.3	21.9	181.4	0.734	0.616–0.874	0.001
> 84.2	94.5	31.9	250.5	1	-	-
Proportion of households with waste collection
> 97.7	98.6	97.8	99.8	1.583	1.284–1.952	0.000
88.8 to 97.7	95.3	89.3	97.7	1.432	1.196–1.714	0.000
> 88.8	81.2	32.3	88.8	1	-	-
Proportion of cases with grade 2 disability among those assessed
< 5.0	85.7	21.9	250.5	1.383	1.067–1.794	0.014
5.0 to 10.0	81.3	29.1	158.7	1.329	1.002–1.761	0.048
> 10.0	62.9	30.2	120.5	1	-	-
Percentage of contacts examined among those assessed
< 57.6	78.2	22.7	181.4	1	-	-
57.6 to 82.5	80.8	21.9	223.3	1.013	0.838–1.224	0.894
> 82.5	93.2	39.4	250.5	0.869	0.697–1.082	0.209
Average percentage of population covered by the Family Health Strategy per municipality
< 73.3	74.6	25.0	175.4	1	-	-
73.3 to 90.6	81.2	21.9	250.5	1.175	0.968–1.425	0.103
> 90.6	85.1	31.9	181.4	1.213	0.973–1.513	0.086
Percentage of population covered by the Bolsa Família Program
< 25.1	104.7	24.2	250.5	1.658	1.036–2.022	< 0.001
25.1 to 33.9	78.0	21.9	181.4	1.182	0.995–1.405	0.057
> 33.9	59.8	22.7	125.5	1	-	-

Variable	Coefficient	Standard error	IRR	95%CI	p
Distal variables – Level 1 adjustment

Proportion of households with waste collection
< 88.8	-	-	1	-	-
88.8 to 97.7	0.207	0.095	1.230	1.021–1.482	0.030
> 97.7	0.314	0.107	1.369	1.11–1.69	0.003
Proportion of immigrants with residence in the State during the last 10 years
< 17.8	-	-	1	-	-
17.8 to 23.9	0.149	0.088	1.161	0.977–1.38	0.090
> 23.9	0.273	0.084	1.314	1.114–1.551	0.001
Unemployment rate per household in the population aged 16 years or more	-0.021	0.010	0.980	0.961–0.998	0.033
Proportion of municipalities with available potable water and bathroom	0.008	0.003	1.008	1.000–1.013	0.005

Proximal variables – Level 2 adjustment

Proportion of persons registered in the Bolsa Família Program per household	-0.021	0.007	0.980	0.967–0.993	0.002

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