Prevalence and Factors Associated with Food Insecurity in Indigenous Families in the State of Alagoas (Northeast Brazil): A Population-Based Cross-Sectional Study

1. Introduction

Food insecurity (FI) represents a severe violation of the Human Right to Adequate Food, a condition guaranteed by the Federal Constitution of Brazil and various international treaties to which the country is a signatory. FI undermines the dignity and well-being of a significant portion of Brazilian families, particularly those in a state of social vulnerability. The lack of regular and permanent access to quality food in sufficient quantities perpetuates a cycle of poverty and exclusion, limiting social and economic development, exacerbating existing inequalities, and hindering the creation of a more just and equitable society [1,2].

FI is a multifactorial condition that affects traditional peoples and communities differently. For Indigenous peoples, the prevalence of FI is invariably higher compared to other population segments and is associated with greater social, economic, and demographic vulnerability [3,4]. Factors such as low educational attainment and changes in production methods, often imposed by territorial conflicts, further highlight the vulnerability of this population [3,4,5].

Indigenous peoples represent approximately 1.7 million individuals in Brazil. With an estimated population of 520,000 people, the Northeast region holds the second largest Indigenous population in the country, with approximately 25,000 of them residing specifically in the state of Alagoas [3].

The situation of FI among Brazilian Indigenous peoples has been little investigated, and there is even less research on the factors associated with this condition. The limited studies available reveal a concerning reality that reflects the social and economic inequalities faced by these peoples in Brazil [4]. The Brazilian Food Insecurity Scale (EBIA), the primary tool for assessing FI in families across the country, has also been used among Indigenous peoples, but it increasingly highlights the need for adaptations to suit the diverse realities of Brazil’s Indigenous populations [6].

The population of Alagoas has historically faced significant issues such as high illiteracy rates, low income, and inadequate public infrastructure. These conditions directly impact the fulfillment of essential rights such as food, basic sanitation, and access to healthcare. Moreover, the vast cultural diversity within the same territory, as seen in Alagoas, highlights the need for carefully designed and culturally appropriate policies to address the real needs of these communities [7].

Considering the historical social vulnerability of Indigenous peoples in Brazil, and specifically in Alagoas [7], and the lack of studies focused specifically on food insecurity and understanding the factors contributing to its prevalence, this study aimed to assess the prevalence and factors associated with food insecurity in Indigenous families in the state of Alagoas. The information produced may contribute to the planning, implementation, and evaluation of actions and public policies aimed at promoting Food and Nutrition Security and ensuring the Right to Adequate Food for these peoples.

2. Materials and Methods

2.1. Study Design, Population, and Sampling

This study is a cross-sectional, population-based survey derived from the Study on Nutrition, Health, and Food Security of Indigenous Peoples in the State of Alagoas (ENSSAIA). It assessed the 11 Indigenous ethnic groups present in Alagoas, distributed across 29 villages, most of which are located between the Agreste region and the Alto Sertão region of the state (Table 1).

To address the various objectives proposed in ENSSAIA, a sample prevalence of 50% was adopted in the sampling plan. This prevalence maximizes the sample size, providing sufficient power to assess any other outcome beyond food insecurity. The sample error calculation for this study was performed retrospectively: Considering a population of 8,575 families [3], an observed prevalence of 69.1%, a significance level of 5.0%, and a 95% confidence interval, the analyzed sample of 1,270 families is associated with a sample error of approximately 2.4%.

For the selection of the Indigenous communities included in the sample, all 11 ethnic groups in the state were represented. For the Aconã, Kariri-Xokó, Katokinn, and Wassú peoples, which have only one community, this community was selected with a probability of 1. For the other ethnic groups, simple random sampling was used to select one of their villages. However, if the selected village had a population exceeding 2,000 people, sectors within the coverage area of an Indigenous Health Agent were randomly selected to cover approximately one-third of the village's population. Conversely, if the selected village had fewer than 150 inhabitants, additional sectors from another village of the same ethnic group, and closer in proximity to the selected village, were included to reach at least one-third of the Indigenous population of the respective ethnic group.

All families residing in the selected communities were eligible for the study. Family identification was based on a registry provided by the local coordination of the Family Health Strategy, and data collection was conducted with the support and supervision of the responsible Indigenous Health Agent. The Family Health Strategy is the foundation of primary healthcare in Brazil. It utilizes multidisciplinary teams to provide continuous care to families in defined territories, with a focus on prevention and health promotion.

2.2. Data Collection

Data collection took place from September 2022 to December 2023 through home visits using structured forms, which were previously tested in a pilot study. The forms were developed electronically using the Epicollect5 app, version 4.0.0, installed on tablets with Android operating systems. At the end of each interview (or at the end of the morning/afternoon shift, depending on internet availability), the completed forms were uploaded, saved in the Google account linked to each tablet. Subsequently, the spreadsheets generated by the software were transferred to a computer for the creation of the research database.

Since the project aimed to include all Indigenous ethnic groups in the state, the pilot study was conducted in one of the communities (Cocal of the Wassú ethnicity), chosen for convenience (being closer to the municipality of Maceió, the capital of the state of Alagoas).

The field team consisted of 14 researchers. Considering the cultural particularities of the Indigenous peoples and to facilitate communication and participation, the team was supported by an Indigenous Health Agents, who was responsible for identifying households with registered Indigenous people in the Family Health Strategy. Additionally, an Indigenous collaborator from the village assisted the anthropometrist in transporting the equipment. Field activities were coordinated and supervised by a faculty member and a post-doctoral student with extensive experience in epidemiological surveys.

2.3. Variables and Data Collection Instruments

2.3.1. Dependent Variable

Food insecurity (FI) was defined according to the Brazilian Food Insecurity Scale (EBIA). The current version of the EBIA consists of a form with 14 closed-ended questions, with positive or negative responses regarding the family's food experience over the past three months. Based on the number of positive responses, the scale categorizes food insecurity from concerns about potential food shortages to experiencing a full day without eating [9].

Given the cultural specifics of the target population, a version of the EBIA adapted for the Terena Indigenous population was adopted [10].

Operationally, each affirmative response on the form represents 1 point. The classification of the scale is based on the total score, ranging from 0 to 14 points in households with individuals under 18 years old, and from 0 to 8 points in households without individuals in this age group (the last 6 questions pertain to individuals under 18).

2.3.2. Independent Variables

The independent variables related to demographic and socioeconomic conditions evaluated were: the head of household's gender (male; female); number of people in the household (≤ 4; > 4); head of household's education level in years of schooling (≤ 4; 5 to 8; ≥ 9); head of household's employment status (formal employment; informal employment; retired; unemployed); total family income in number of national minimum wages (0 to 1; > 1 to 2; > 2); and family participation in a direct income transfer social program, Bolsa Família Program - BFP (yes; no).

Regarding environmental conditions, the variables analyzed were: type of housing (masonry; mud/wood); total number of rooms (≤ 4; > 4); garbage destination (public collection; other); source of drinking water (adequate; inadequate); and waste disposal method (adequate; inadequate).

For the source of drinking water, "adequate" conditions were considered to be: public water supply network and mineral water; while sources such as cisterns, wells, small ponds, rivers, streams, springs, trucks, or other were classified as "inadequate." For waste disposal, "adequate" was classified as a septic tank or public sewage system, and "inadequate" was classified as a rudimentary pit, ditch, river, or other.

2.4. Data Processing and Analysis

The spreadsheets generated by the Epicollect5 software, version 4.0.0, were imported into Stata®, version 18.0, where the database was created (combine datasets) and all statistical analysis procedures were conducted. The database was initially checked for consistency, and when issues were identified, the information was reviewed to correct errors (e.g., typographical errors) or to exclude data when correction was not possible.

To enhance international comparability, the recommendations of the Food and Agriculture Organization of the United Nations (FAO) regarding food security (FS) assessment were adopted. The sum of moderate and severe food insecurity (MSFI) cases was considered as the outcome for analysis in identifying associated factors, thereby increasing the specificity of this indicator [11].

The unadjusted analysis was performed by comparing the prevalence of MSFI across different categories of independent variables (demographic, socioeconomic, and environmental). The chi-square test was used for this comparison. The measure of association was the prevalence ratio (PR) and its 95% confidence interval (CI), calculated using Poisson regression with robust variance adjustment, for both crude and adjusted analyses. Associations that showed significance at the unadjusted level of up to 20% (p<0.2) were subjected to multivariable analysis, following the hierarchical conceptual model adapted from Victora et al. [12] (Figure 1).

The hierarchical analysis began with the distal level, followed by the subsequent levels according to their proximity to the outcome of the investigation. For each analysis level, variables without statistical significance were successively eliminated using backward stepwise elimination, retaining only those with p<0.05. Therefore, all variables that showed p<0.05 at their respective level, even if they exceeded the significance level in the next level, were retained in the final model.

The ENSSAIA was approved by the National Research Ethics Commission (CONEP: 29121120.0.0000.5013), and all legal requirements related to ethical procedures for conducting research involving Indigenous peoples were observed [13,14,15]. All heads of households or eligible adults for the study, or those responsible for children or adolescents, were fully informed about the study's objectives, risks, benefits, and other details provided in the Informed Consent Form. Participation was only allowed for those who signed the consent form.

3. Results

A total of 1,296 families were assessed, with 26 (2.0%) excluded from the analysis due to incomplete data on the EBIA, resulting in a final sample of 1,270 families. Most of these families were headed by men (55.5%) and consisted of up to four members (75.6%). According to the EBIA, 69.1% of the families experienced some degree of FI, with 29.5% experiencing moderate (23.2%) and severe (6.3%) FI (Figure 2).

Regarding the hierarchical analysis (Table 2), the factors associated with MSFI at the distal level were: female-headed households (PR=1.38; 95% CI: 1.16-1.63), residing in houses made of mud or wood (PR=1.69; 95% CI: 1.25-2.28), and households with 4 or fewer rooms (PR=1.47; 95% CI: 1.18-1.84). At the intermediate level, factors included households headed by individuals with lower educational attainment: 5 to 8 years of schooling (PR=1.80; 95% CI: 1.38-2.34) and up to 4 years of schooling (PR=2.02; 95% CI: 1.61-2.53). Proximal variables independently associated with MSFI included households headed by retired (PR=1.73; 95% CI: 1.10-2.73) and unemployed individuals (PR=1.62; 95% CI: 1.03-2.54), as well as those with a total national family income equal to or less than two National Minimum Wage - NMW (≤ 1 NMW: PR=2.00; 95% CI: 1.44-2.76; >1 to 2 NMW: PR=1.69; 95% CI: 1.22-2.33). At the time of data collection, the NMW in Brazil was R$ 1,320.00, approximately $275.00 USD as of July 2023.

4. Discussion

Food insecurity is a concerning reality among Indigenous peoples in Alagoas and reflects the context of inequities in which their families are situated, underscoring the need for the development and implementation of effective cross-sectoral strategies to address the current situation. Most indigenous peoples in Alagoas are characterized by significant social vulnerability, a persistent struggle for land demarcation, and the preservation of their traditions, culture, and way of life [7]. These conflicts are part of the historical experience of these peoples and are associated with structural, demographic, socioeconomic, environmental, health, and educational challenges in their communities [16,17]. Given this context, the high prevalence of FI reported is not surprising, as living conditions in households can directly or indirectly affect FI status [18].

In the observed scenario, about 40% of families showed concern or uncertainty about regular access to food, indicating a mild form of FI. Regarding more severe forms of FI (moderate and severe), nearly 30% of families faced quantitative or qualitative restrictions in their food and nutritional needs. These restrictions suggest a real possibility of these families experiencing hunger [9].

The scarcity of data in the literature on FI among Brazilian indigenous peoples, especially concerning its associated factors, contributes to the invisibility of the issues faced, perpetuating disparities and inequities compared to the rest of society. Furthermore, this lack of knowledge hampers the implementation of actions aimed at improving the quality of life for this population [4].

The comparability of this study with results reported for other indigenous communities in the country is limited due to significant cultural differences related to the concept of food security for each group, particularly regarding food access methods such as agriculture, extraction, and financial access in local markets. Additionally, comparability is also affected by differences between studies, such as participant age and data collection timing, which are strongly influenced by political processes and established public health priorities.

Among the available studies similar to this one, a notable study was conducted in the state of Mato Grosso do Sul involving families from the Terena ethnic group, which identified moderate to severe food insecurity (MSFI) in 53.1% of households [10]. Another recently published study [4] involved indigenous families in Dourados, also in Mato Grosso do Sul, and found a total food insecurity prevalence of 64.1%%, similar to the prevalence observed in the present study. It is important to highlight that there is a significant time gap between the publication of the first study and the current one, and the second study employed a different tool for defining food insecurity, known as the Short Food Security Scale.

Worldwide, households headed by women and ethnic-racial minorities are at higher risk of food insecurity [19]. Although most indigenous households in Alagoas are headed by men, the situation of MSFI in female-headed households was comparatively higher (34.9% vs. 25.1%), maintaining a higher prevalence ratio at all levels in the hierarchical analysis. These results align with national and international data showing that, although most non-indigenous households are male-headed, MSFI is more prevalent in female-headed households [20,21,22].

In addition to gender and ethnic-racial differences, factors such as housing type, the disparity between the number of residents and rooms or living spaces, lower education of the head of the household, employment status, monthly family income, and rural versus urban housing locations have been associated with higher levels of household food insecurity in general populations. In this regard, the association between food insecurity and the factors presented in this study is consistent with what is observed in the general population, such as the association with housing quality observed in various studies [23,24,25].

Regarding the factors related to the environment where families live, this study points to concerning indicators of vulnerability, such as a large proportion of people without adequate access to drinking water, waste collection, and sanitation. In this context, Raupp et al. [26] confirmed the poor basic sanitation infrastructure of indigenous households in the country and reaffirmed inadequate sanitary conditions in indigenous homes in a comparative analysis between the 2000 and 2010 censuses, as well as the persistent significant racial and color inequalities in the country [25,26].

The education level of the household head proved to be an important factor for understanding associations with food insecurity, especially when this level is below 4 or up to 8 years of schooling. In this classification, the indigenous population of Alagoas shows that over 65% of household heads fall into this category, and this variable is independently associated with FI. Similar associations have also been confirmed in the non-indigenous population with comparable numbers [27,28]. Specifically, among indigenous populations, this association was also observed among the Terena, Ñandeva, and Kaiowá in Mato Grosso do Sul and the Kaingang in the Terra de Guarita in Rio Grande do Sul [4,29].

The association of MSFI with the absence of formal employment and lower total family income highlights the difficulties faced by this population. Bacarrin et al. [18] point out that, similar to the relationship between employment status and FI, inflation experienced by a country with high unemployment rates results in increased indicators related to FI.

In this context, and supporting the data on the income of the indigenous population in Alagoas, Brito et al. [30] found that an income below one minimum wage was associated with FI in a socially vulnerable community in São Luís, Maranhão [30]. As presented in our results, nearly 60% of the families were enrolled in the PBF, a group that was significantly more exposed to food insecurity compared to families not linked to the Program. This fact underscores the effective targeting of the PBF and its importance in addressing the vulnerability situation [31].

Studies show that lower family incomes directly impact the acquisition of food in terms of quantity and quality, raising concerns about families' access to food and compromising food security [23,28,30]. Similarly, lower educational levels can affect financial management, ensure adequate food intake, and, more importantly, the quality of food choices for the household [27,29]. Additionally, compromised access to quality water, coupled with inadequate sanitation and waste collection services, exacerbates the conditions of families already facing a history of social vulnerability and other determinants worsening their FI [25,26].

Due to factors such as the real increase in average worker income, the decline in the unemployment rate, and the reinstatement of effective social policies like the Bolsa Família Program, Brazil experienced a 40% reduction in the extreme poverty rate between 2022 and 2023 [32] This positively impacts purchasing power and food choices within families, establishing a favorable scenario for reducing the prevalence of food insecurity [18], However, it’s essential to recognize that socially vulnerable populations, such as Indigenous communities, Quilombolas, riverine groups, and other minority segments, still require significant attention to effectively address the persistent issue of food insecurity.

In this regard, the importance and need for studies like this one for epidemiological understanding of FI are emphasized. As the first study to assess this outcome in the indigenous population of Alagoas, it serves as a baseline for future evaluations and aids in the development and formulation of public policies that help understand and improve food security conditions in this population.

A critical issue in food insecurity scenarios is the increased exposure to conditions leading to malnutrition. Within such a context, there's a higher likelihood of individuals experiencing malnutrition early in life, which can have lifelong consequences. This phenomenon is explained by the Developmental Origins of Health and Disease (DOHaD) theory. According to this theory, adverse exposures during the first 1000 days of life, starting from conception, can alter a child's growth trajectory, prioritizing immediate survival but increasing the risk of diseases later in life. Therefore, populations facing food insecurity not only confront the immediate challenges of hunger but also an elevated risk of developing chronic diseases in adulthood, the roots of which originate in the early stages of their lives [33,34].

Regarding the limitations of this study, the cross-sectional design is notable, as it does not allow for the establishment of the incidence of the problem or direct cause-and-effect relationships between variables. Additionally, the data do not permit a qualitative assessment of the specific contexts of the indigenous communities studied.

Another significant limitation is the absence of a validated measurement tool for the target population. This issue is challenging to overcome, given the great diversity of indigenous ethnicities in Brazil, each with its distinct cultures, characteristics, and different ways of accessing food.

While the data presented facilitate the understanding of the epidemiological profile of FI among these populations, they highlight the need for the development of strategies to address the issue. It is essential to adopt approaches that consider their perspectives, traditions, cultures, and ways of life, including strengthening territorial rights and sustainable family agriculture to improve food access and the quality of life for Indigenous peoples.

5. Conclusions

The prevalence of FI among Alagoan Indigenous people is considerably high and associated with worse demographic, socioeconomic, and environmental conditions. This highlights the social inequities they face and underscores the need for intersectoral public policies to reverse this situation.