Abstract

Objective:

to investigate access to health services for tuberculosis (TB) diagnosis and treatment among indigenous peoples in Rondônia State, Brazil, 2009-2011.

Methods:

we conducted a cross-sectional study with indigenous people attending Indigenous Health Care Units (Casai) between October 2009 and February 2011; geographical, economical and functional dimensions of access to TB services were evaluated through interviews and then described.

Results:

52 indigenous people with TB were interviewed; in the geographical dimension, lack of transportation, distance and lack of health professionals were the main obstacles; in the economic dimension, 15 indigenous people reported cost/expense as a barrier to access; in the functional dimension, 21 arrived at the Casai using their own means; 24 reported that the time between first symptoms and arriving at the Casai was > 30days; 25 reported that time between first consultation and starting treatment was >30 days; treatment was supervised in 22 cases.

Conclusion:

the difficulties found in accessing health services in the dimensions we analyzed can contribute to TB continuing to be transmitted in indigenous villages.

Keywords:
Tuberculosis; Health of Indigenous Peoples; Health Systems; Public Health Surveillance; Health Services Accessibility

Introduction

Interest in tuberculosis among indigenous peoples has been increasing since 1990.¹1. Tollefson D, Bloss E, Fanning A, Redd JT, Barker K, McCray E. Burden of tuberculosis in indigenous peoples globally: a systematic review. Int J Tuberc Lung Dis [Internet]. 2013 Sep [cited 2019 Jun 26];17(9):1139-50. Available from: Available from: https://www.ingentaconnect.com/content/iuatld/ijtld/2013/00000017/00000009/art00005%3bjsessionid=3o9pe62dan63f.x-ic-live-03 . doi: 10.5588/ijtld.12.0385
https://www.ingentaconnect.com/content/i... ^,22. Viana PVS, Gonçalves MJF, Basta PC. Ethnic and racial inequalities i notified cases of tuberculosis in Brazil. PLoS One [Internet]. 2016 May [cited 2019 Jun 26];11(5):e0154658. Available from: Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0154658 . doi: 10.1371/journal.pone.0154658
https://journals.plos.org/plosone/articl... In Brazil there are reports of active tuberculosis incidence rates three times higher than the national averages,²2. Viana PVS, Gonçalves MJF, Basta PC. Ethnic and racial inequalities i notified cases of tuberculosis in Brazil. PLoS One [Internet]. 2016 May [cited 2019 Jun 26];11(5):e0154658. Available from: Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0154658 . doi: 10.1371/journal.pone.0154658
https://journals.plos.org/plosone/articl... ^,33. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. O controle da tuberculose na população indígena. Bol Epidemiol [Internet]. 2013 [citado 2019 jun 26];44(13):1-13. Disponível em: Disponível em: http://portalarquivos2.saude.gov.br/images/pdf/2014/junho/11/BE-2013-44--13----TB.pdf
http://portalarquivos2.saude.gov.br/imag... prevalence of latent infection in excess of 40% in the Northern region,⁴4. Basta PC, Camacho LAB. Teste tuberculínico na estimativa da prevalência de infecção por Mycobacterium tuberculosis em populações indígenas do continente americano: uma revisão da literatura. Cad Saúde Pública [Internet]. 2006 fev [citado 2019 jun 26];22(2):245-54. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v22n2/02.pdf . doi: 10.1590/S0102-311X2006000200002
http://www.scielo.br/pdf/csp/v22n2/02.pd...

5. Malacarne J, Rios DPG, Silva CMFP, Braga JU, Camacho LAB, Basta PC. Prevalence and factors associated with latent tuberculosis infection in an indigenous population in the Brazilian Amazon. Rev Soc Bras Med Trop [Internet]. 2016 Aug [cited 2019 Jun 26];49(4):456-64. Available from: Available from: http://www.scielo.br/pdf/rsbmt/v49n4/1678-9849-rsbmt-49-04-00456.pdf . doi: 10.1590/0037-8682-0220-2016
http://www.scielo.br/pdf/rsbmt/v49n4/167... ^-66. Rios DPG, Malacarne J, Alves LC, Sant’Anna CC, Camacho LA, Basta PC. Tuberculosis in indigenous peoples in the Brazilian Amazon: an epidemiological study in the Upper Rio Negro region. Rev Panam Salud Pública [Internet]. 2013 Jan [cited 2019 Jun 26];33(1):22-9. Available from: Available from: https://www.ncbi.nlm.nih.gov/pubmed/23440154 . doi: 10.1590/s1020-49892013000100004
https://www.ncbi.nlm.nih.gov/pubmed/2344... considerable concentration of cases in border regions,⁷7. Belo EN, Orellana JDY, Levino A, Basta PC. Tuberculosis in Amazonian municipalities of the Brazil-Colombia-Peru-Venezuela border: epidemiological situation and risk factors associated with treatment default. Pan Am J Public Health [Internet]. 2013 Nov [cited 2019 Jun 26];34(5):321-9. Available from: Available from: https://www.ncbi.nlm.nih.gov/pubmed/24553759
https://www.ncbi.nlm.nih.gov/pubmed/2455... ^,88. Marques M, Cunha EAT, Evangelista MSN, Basta PC, Marques AMC, Croda J, Andrade SMO. Resistência às drogas antituberculose na fronteira do Brasil com Paraguai e Bolívia. Rev Pan-Am Saúde Pública [Internet]. 2017 abr [citado 2019 jun 26];41:e9. Disponível em: Disponível em: https://scielosp.org/pdf/rpsp/2017.v41/e9/pt
https://scielosp.org/pdf/rpsp/2017.v41/e... a drug resistance emergency⁸8. Marques M, Cunha EAT, Evangelista MSN, Basta PC, Marques AMC, Croda J, Andrade SMO. Resistência às drogas antituberculose na fronteira do Brasil com Paraguai e Bolívia. Rev Pan-Am Saúde Pública [Internet]. 2017 abr [citado 2019 jun 26];41:e9. Disponível em: Disponível em: https://scielosp.org/pdf/rpsp/2017.v41/e9/pt
https://scielosp.org/pdf/rpsp/2017.v41/e... ^,99. Basta PC, Oelemann MAC, Oelemann WMR, Fonseca LS, Coimbra CEA. Detection of mycobacterium tuberculosis in sputum from Suruí Indian subjects, Brazilian Amazon. Mem Inst Oswaldo Cruz [Internet]. 2006 Sep [cited 2019 Jun 26];101(6):581-4. Available from: Available from: http://www.scielo.br/pdf/mioc/v101n6/v101n6a01.pdf . doi: 10.1590/S0074-02762006000600001
http://www.scielo.br/pdf/mioc/v101n6/v10... and patterns of recent transmission in 63.5% of cases in Mato Grosso do Sul state (1999-2001).¹⁰10. Cunha EA, Ferrazoli L, Riley LW, Basta PC, Honer MR, Maia R, et al. Incidence and transmission patterns of tuberculosis among indigenous populations in Brazil. Mem Inst Oswaldo Cruz [Internet]. 2014 Feb [cited 2019 Jun 26];109(1):108-13. Available from: Available from: https://www.ncbi.nlm.nih.gov/pubmed/24270999 . doi: 10.1590/0074-0276130082
https://www.ncbi.nlm.nih.gov/pubmed/2427... The level of these indicators is a result of socio-economic disadvantages, discrimination, prejudice and indigenous people having difficulty in accessing health services.¹¹11. Massignam FM, Bastos JLD, Nedel FB. Discriminação e saúde: um problema de acesso. Epidemiol Serv Saúde [Internet]. 2015 jul-set [citado 2019 jun 26];24(3):541-44. Disponível em: Disponível em: http://scielo.iec.gov.br/pdf/ess/v24n3/v24n3a20.pdf . doi: 10.5123/S1679-49742015000300020
http://scielo.iec.gov.br/pdf/ess/v24n3/v...

Little is known about the problems related to access to diagnosis and treatment services and control actions in indigenous areas. According to some authors,¹²12. Donabedian A. Aspects of medical care administration. Boston: Harvard University Press; 1973.

13. Penchansky DBA, Thomas JW. The concept of access - definition and relationship to consumer satisfaction. Med Care [Internet]. 1981 Feb [cited 2019 Jun 26];19(2):127-40. Available from: Available from: https://www.jstor.org/stable/pdf/3764310.pdf?seq=1#page_scan_tab_contents
https://www.jstor.org/stable/pdf/3764310...

14. Unglert CVS. O enfoque da acessibilidade no planejamento da localização e dimensão de serviços de saúde. Rev Saúde Pública [Internet]. 1990 dez [citado 2019 jun 26];24(6):445-52. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v24n6/02.pdf . doi: 10.1590/S0034-89101990000600002
http://www.scielo.br/pdf/rsp/v24n6/02.pd... ^-1515. Travassos C, Matins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública [Internet]. 2004 [citado 2019 jun 26];20(Suppl 2):190-8. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v20s2/14.pdf . doi: 10.1590/S0102-311X2004000800014
http://www.scielo.br/pdf/csp/v20s2/14.pd... access depends on the availability, structure and organization of local systems, as well as overcoming barriers of a geographic, economic and functional nature in order for actions developed by services to meet the needs of the population.

This study aimed to investigate access to health services for tuberculosis (TB) diagnosis and treatment among indigenous peoples in Rondônia state, Brazil, between 2009 and 2011.

Methods

We conducted a cross-sectional study collecting primary data and monitoring indigenous people being treated for TB in Indigenous Health Support Shelters (Casai) in Rondônia state. The study did not use probabilistic sampling; we included all indigenous people cared for between October 2009 and February 2011.

Indigenous Health in Brazil is organized into Special Indigenous Health Districts (DSEI) which report to the Health Ministry’s Special Indigenous Health Secretariat (Sesai).¹⁶16. Garnelo L. Política de saúde indígena no Brasil: notas sobre as tendências atuais do processo de implantaçãodo subsistema de atenção à saúde. In: Garnelo L, Pontes AL, organizadores. Saúde indígena: uma introdução ao tema [Internet]. Brasília: MEC-SECADI; 2012 [citado 2019 jun 2]. p. 18-59.^,1717. Orellana JDY, Gonçalves MJF, Basta PC. Características sociodemográficas e indicadores operacionais de controle da tuberculose entre indígenas e não indígenas de Rondônia, Amazônia Ocidental, Brasil. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2019 jun 26];15(4):846-56. Disponível em: Disponível em: http://www.scielo.br/pdf/rbepid/v15n4/04.pdf . doi: 10.1590/S1415-790X2012000400004
http://www.scielo.br/pdf/rbepid/v15n4/04... The structure of the DSEIs is comprised of: Health Outposts in villages; Base Centers (health and/or administrative centers); and Indigenous Health Support Shelters (Casai) (support for indigenous people during appointments/procedures at other health care levels).¹⁶16. Garnelo L. Política de saúde indígena no Brasil: notas sobre as tendências atuais do processo de implantaçãodo subsistema de atenção à saúde. In: Garnelo L, Pontes AL, organizadores. Saúde indígena: uma introdução ao tema [Internet]. Brasília: MEC-SECADI; 2012 [citado 2019 jun 2]. p. 18-59.^,1717. Orellana JDY, Gonçalves MJF, Basta PC. Características sociodemográficas e indicadores operacionais de controle da tuberculose entre indígenas e não indígenas de Rondônia, Amazônia Ocidental, Brasil. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2019 jun 26];15(4):846-56. Disponível em: Disponível em: http://www.scielo.br/pdf/rbepid/v15n4/04.pdf . doi: 10.1590/S1415-790X2012000400004
http://www.scielo.br/pdf/rbepid/v15n4/04...

In Rondônia state, the Porto Velho DSEI, which also covers part of Amazonas state, concentrates its actions in five municipalities and is responsible for the health care of 11000 indigenous people. The Vilhena DSEI, which also covers part of Mato Grosso state, concentrates its actions in four municipalities and is responsible for the health care of 7000 indigenous people.¹⁸18. Ministério da Saúde (BR). Distritos sanitários especiais indígenas (DSEIs) [Internet]. Brasília: Ministério da Saúde; 2017 [citado 2018 dez 10]. Disponível em: Disponível em: http://portalms.saude.gov.br/saude-indigena/saneamento-e-edificacoes/dseis
http://portalms.saude.gov.br/saude-indig...

We chose Rondônia because of the sizeable occurrence of TB cases in the region between 1997 and 2006,⁵5. Malacarne J, Rios DPG, Silva CMFP, Braga JU, Camacho LAB, Basta PC. Prevalence and factors associated with latent tuberculosis infection in an indigenous population in the Brazilian Amazon. Rev Soc Bras Med Trop [Internet]. 2016 Aug [cited 2019 Jun 26];49(4):456-64. Available from: Available from: http://www.scielo.br/pdf/rsbmt/v49n4/1678-9849-rsbmt-49-04-00456.pdf . doi: 10.1590/0037-8682-0220-2016
http://www.scielo.br/pdf/rsbmt/v49n4/167... ^,99. Basta PC, Oelemann MAC, Oelemann WMR, Fonseca LS, Coimbra CEA. Detection of mycobacterium tuberculosis in sputum from Suruí Indian subjects, Brazilian Amazon. Mem Inst Oswaldo Cruz [Internet]. 2006 Sep [cited 2019 Jun 26];101(6):581-4. Available from: Available from: http://www.scielo.br/pdf/mioc/v101n6/v101n6a01.pdf . doi: 10.1590/S0074-02762006000600001
http://www.scielo.br/pdf/mioc/v101n6/v10... ^,1717. Orellana JDY, Gonçalves MJF, Basta PC. Características sociodemográficas e indicadores operacionais de controle da tuberculose entre indígenas e não indígenas de Rondônia, Amazônia Ocidental, Brasil. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2019 jun 26];15(4):846-56. Disponível em: Disponível em: http://www.scielo.br/pdf/rbepid/v15n4/04.pdf . doi: 10.1590/S1415-790X2012000400004
http://www.scielo.br/pdf/rbepid/v15n4/04... ^,1919. Melo TEMP, Resendes APC, Souza-Santos R, Basta PC. Distribuição espacial da tuberculose em indígenas e não-indígenas de Rondônia, Amazônia Ocidental, Brasil. Cad Saúde Pública [Internet]. 2012 fev [citado 2019 jun 26];28(2):267-80. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v28n2/06.pdf . doi: 10.1590/S0102-311X2012000200006
http://www.scielo.br/pdf/csp/v28n2/06.pd... as well as the perspective of the local DSEIs expressing the capacity of the Indigenous Health subsystem to detect TB cases among the population that lives in indigenous lands both within and outside of Rondônia state.

We used a semi-structured questionnaire adapted from Coimbra Jr. et al.²⁰20. Coimbra JúniorCE, Santos RV, Welch JR, Cardoso JR, Souza MC, Garnelo L, et al. The first national survey of indigenous people’s health and nutrition in Brazil: rationale, methodology, and overview of results. BMC Public Health [Internet]. 2013 Jan [cited 2019 Jun 26];13:52. Available from: Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-52 . doi: 10.1186/1471-2458-13-52
https://bmcpublichealth.biomedcentral.co... and Scatena-Villa & Ruffino-Netto.²¹21. Scatena LM, Scatena-Villa TC, Ruffino-Netto A, Kritski AL, Figueiredo TMRM, Vendramini SHF, Assis MMA, Motta MCS. Dificuldades de acesso a serviços de saúde para diagnóstico de tuberculose em municípios do Brasil. Rev Saúde Pública [Internet]. 2009 jun [citado 2019 jun 26];43(3):389-97. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v43n3/248.pdf . doi: 10.1590/S0034-89102009005000022
http://www.scielo.br/pdf/rsp/v43n3/248.p... In the case of indigenous people who did not speak Portuguese, we were assisted by indigenous health agents (AIS) who translated for us.

The following variables were considered for analysis: DSEI/Casai responsible for health care/support; sex; and age.

We also investigated the following access dimensions:

The Casai access dimensions were compared using Pearson’s chi-squared test (χ²). We calculated average distances (in km) between indigenous villages and Casais, based on geographic coordinates. We analyzed the time correlation (in days) between onset of symptoms and starting treatment using Spearman’s rank correlation coefficient. We used SPSS v.9.0.

The interviews took place once the study project had been approved by the Research Ethics Committee and by the National Research Ethics Commission (CEP/CONEP): Opinion No. 176/07 and Opinion No. 327/2008.

Results

We interviewed 52 indigenous people, 16 in Porto Velho, 10 in Guajará-Mirim, 3 in Ji-Paraná and 23 in Cacoal. Two of the indigenous people lived in Amazonas state, three in Mato Grosso state and the remainder in Rondônia state. On average three new TB cases per month were detected in the places we studied. The majority of cases occurred those aged over 10 years old, being 47 out of 52 indigenous people (mean age, 40.4; median, 34,5; variation from 1-90 years), and 28 were male. We identified 46 cases of pulmonary TB.

With regard to the geographic dimension, lack of transport and money were the main complaints in Cacoal and Guajará-Mirim. The distance between the indigenous village and the Casai was the main complaint of the indigenous in Porto Velho, and absence of health professionals to provide care was the most relevant barrier for those interviewed in Ji-Paraná (Table 1).

Time between first consultation at the Casais and starting treatment was more than 30 days in 25 cases. We did not find association between average distance traveled to the Casais and length of time before starting treatment. Some of the indigenous people traveled distances of between 24km and 62km and took more than 30 days to start treatment. On the other hand, correlation was found (Spearman’s coefficient = 0.654; p-value <0.05) between the distance from the indigenous villages and time taken to start treatment in the case of those who sought care in the state capital, Porto Velho (Table 2).

In the economic dimension, 15 indigenous people reported incurring cost/expense in getting to the Casais.

In the functional dimension, 21 went to the Casais on their own initiative. Of the 31 referred by health services, 16 were referred by AIS. Twenty needed to go to the Casais more than five times (Table 1).

Twenty indigenous people reported exclusive use of medication/chemotherapy; thirteen reported exclusive use of medicinal plants/roots as their first treatment; ten used both traditional medicine and biomedicine; four exclusively used prayer and one exclusively used a shamanic/healing ritual.

Sputum culture was used for diagnosis for just 22 of the indigenous people and was more frequent in Porto Velho. Twenty-two had their treatment observed daily (Table 1).

Discussion

As in other contexts,⁷7. Belo EN, Orellana JDY, Levino A, Basta PC. Tuberculosis in Amazonian municipalities of the Brazil-Colombia-Peru-Venezuela border: epidemiological situation and risk factors associated with treatment default. Pan Am J Public Health [Internet]. 2013 Nov [cited 2019 Jun 26];34(5):321-9. Available from: Available from: https://www.ncbi.nlm.nih.gov/pubmed/24553759
https://www.ncbi.nlm.nih.gov/pubmed/2455... ^,1919. Melo TEMP, Resendes APC, Souza-Santos R, Basta PC. Distribuição espacial da tuberculose em indígenas e não-indígenas de Rondônia, Amazônia Ocidental, Brasil. Cad Saúde Pública [Internet]. 2012 fev [citado 2019 jun 26];28(2):267-80. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v28n2/06.pdf . doi: 10.1590/S0102-311X2012000200006
http://www.scielo.br/pdf/csp/v28n2/06.pd... ^,2222. Basta PC, Marques M, Oliveira RL, Cunha EAT, Resendes APC, Souza-Santos R. Social inequalities and tuberculosis: an analysis by race/color in Mato Grosso do Sul, Brazil. Rev Saúde Pública [Internet]. 2013 Oct [cited 2019 Jun 26];47(5):854-64. Available from: Available from: http://www.scielo.br/pdf/rsp/v47n5/en_0034-8910-rsp-47-05-0854.pdf . doi: 10.1590/S0034-8910.2013047004628
http://www.scielo.br/pdf/rsp/v47n5/en_00... the majority of the indigenous people consulted in this study were men and young adults. Although the majority of cases were from Rondônia, two were from Amazonas and three were from Mato Grosso.

As reported in relation to the Munduruku people in the state of Pará,²³23. Nogueira LM, Teixeira E, Basta PC, Motta MC. Therapeutic itineraries and explanations for tuberculosis: an indigenous perspective. Rev Saúde Pública [Internet]. 2015 Jan [cited 2019 Jun 26];49. Available from: Available from: http://www.scielo.br/pdf/rsp/v49/0034-8910-rsp-S0034-89102015049005904.pdf . doi: 10.1590/S0034-8910.2015049005904
http://www.scielo.br/pdf/rsp/v49/0034-89... approximately half the indigenous people went to the Casais on their own initiative, suggesting that Primary Care has been inefficient in detecting symptomatic respiratory cases in indigenous villages.

A quarter of the respondents mentioned having needed to return to the Casais five times, and waiting for more than 30 days to get conclusive diagnosis, similarly to reports from rural areas in India and from interior regions of Brazil.²⁴24. Reis SP, Harter J, Lima LM, Vieira DA, Palha PF, Gonzales RIC. Aspectos geográficos e organizacionais dos serviços de atenção primária à saúde na detecção de casos de tuberculose em Pelotas, Rio Grande do Sul, 2012. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 26];26(1):141-8. Disponível em: Disponível em: http://www.scielo.br/pdf/ress/v26n1/2237-9622-ress-26-01-00141.pdf . doi: 10.5123/s1679-49742017000100015
http://www.scielo.br/pdf/ress/v26n1/2237...

25. Lemos EF, Alves AM, Oliveira GC, Rodrigues MP, Martins ND, Croda J. Health-service performance of TB treatment for indigenous and non-indigenous populations in Brazil: a cross-sectional study. BMC Health Serv Res [Internet]. 2014 May [cited 2019 Jun 26]14:237. Available from: Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-237 . doi:10.1186/1472-6963-14-237
https://bmchealthservres.biomedcentral.c...

26. Tripathy JP, Srinath S, Naidoo P, Ananthakrishnan R, Bhaskar R. Is physical access an impediment to tuberculosis diagnosis and treatment? A study from a rural district in North India. PHA [Internet]. 2013 Sep [cited 2019 Jun 26];3(3):235-9. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463123/ . doi: 10.5588/pha.13.0044
https://www.ncbi.nlm.nih.gov/pmc/article... ^-2727. Maior ML, Guerra RL, Cailleaux-Cezar M, Golub JE, Conde MB. Tempo entre o início dos sintomas e o tratamento de tuberculose pulmonar em um município com elevada incidência da doença. J Bras Pneumol [Internet]. 2012 mar-abr [citado 2019 jun 26];38(2):202-9. Disponível em: Disponível em: http://www.scielo.br/pdf/jbpneu/v38n2/v38n2a09.pdf . doi: 10.1590/S1806-37132012000200009
http://www.scielo.br/pdf/jbpneu/v38n2/v3...

Traditional indigenous medicine appeared among the treatment options, but without excluding biomedicine. Both use of medicinal plants and prayer and/or shamanism, either on their own or in association with use of Western medicine, were considered in treatment. The therapeutic options used for TB treatment appeared to be interconnected without clearly defined limits. Similar findings have been reported among indigenous people in the Alto Rio Negro region,⁶6. Rios DPG, Malacarne J, Alves LC, Sant’Anna CC, Camacho LA, Basta PC. Tuberculosis in indigenous peoples in the Brazilian Amazon: an epidemiological study in the Upper Rio Negro region. Rev Panam Salud Pública [Internet]. 2013 Jan [cited 2019 Jun 26];33(1):22-9. Available from: Available from: https://www.ncbi.nlm.nih.gov/pubmed/23440154 . doi: 10.1590/s1020-49892013000100004
https://www.ncbi.nlm.nih.gov/pubmed/2344... ^,2828. Garnelo L, Wright R. Doença, cura e serviços de saúde. Representações, práticas e demandas Baníwa. Cad Saúde Pública [Internet]. 2001 mar-abr [citado 2019 jun 26];17(2):273-84. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v17n2/4173.pdf . doi: 10.1590/S0102-311X2001000200003
http://www.scielo.br/pdf/csp/v17n2/4173.... and in the Munduruku²³23. Nogueira LM, Teixeira E, Basta PC, Motta MC. Therapeutic itineraries and explanations for tuberculosis: an indigenous perspective. Rev Saúde Pública [Internet]. 2015 Jan [cited 2019 Jun 26];49. Available from: Available from: http://www.scielo.br/pdf/rsp/v49/0034-8910-rsp-S0034-89102015049005904.pdf . doi: 10.1590/S0034-8910.2015049005904
http://www.scielo.br/pdf/rsp/v49/0034-89... and Xavante ethnic groups.

Contrary to the recommendations contained in national and international guidelines regarding directly observed medication taking,²⁹29. World Health Organization. Global tuberculosis report [Internet]. Geneva: World Health Organization; 2015 [cited 2019 Jun 26]. 192 p. Available from: Available from: https://apps.who.int/iris/handle/10665/191102
https://apps.who.int/iris/handle/10665/1... less than half of the indigenous people had their treatment observed. Incomplete or inexistent treatment observation, as found here, reduces the chances of cure and increases the possibilities of unfavorable outcomes.¹⁷17. Orellana JDY, Gonçalves MJF, Basta PC. Características sociodemográficas e indicadores operacionais de controle da tuberculose entre indígenas e não indígenas de Rondônia, Amazônia Ocidental, Brasil. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2019 jun 26];15(4):846-56. Disponível em: Disponível em: http://www.scielo.br/pdf/rbepid/v15n4/04.pdf . doi: 10.1590/S1415-790X2012000400004
http://www.scielo.br/pdf/rbepid/v15n4/04... ^,2222. Basta PC, Marques M, Oliveira RL, Cunha EAT, Resendes APC, Souza-Santos R. Social inequalities and tuberculosis: an analysis by race/color in Mato Grosso do Sul, Brazil. Rev Saúde Pública [Internet]. 2013 Oct [cited 2019 Jun 26];47(5):854-64. Available from: Available from: http://www.scielo.br/pdf/rsp/v47n5/en_0034-8910-rsp-47-05-0854.pdf . doi: 10.1590/S0034-8910.2013047004628
http://www.scielo.br/pdf/rsp/v47n5/en_00...

A considerable part of the cases began treatment more than 30 days after diagnosis. In Porto Velho, we found direct and positive association between distance traveled and time taken to start treatment, possibly as a result of referrals to services in the capital which are not available in other cities, revealing low Primary Care ability to effectively deal with cases in the municipalities, besides the fact of Porto Velho being located in a strategic position between the states of Acre, Amazonas and Mato Grosso.

Multidisciplinary health teams in indigenous villages should identify symptomatic respiratory cases, diagnose and treat TB, as well as monitor contacts. However, in view of the precarious diagnosis infrastructure, lack of trained staff and geographic isolation, these actions end up taking place in the urban areas of municipalities.⁶6. Rios DPG, Malacarne J, Alves LC, Sant’Anna CC, Camacho LA, Basta PC. Tuberculosis in indigenous peoples in the Brazilian Amazon: an epidemiological study in the Upper Rio Negro region. Rev Panam Salud Pública [Internet]. 2013 Jan [cited 2019 Jun 26];33(1):22-9. Available from: Available from: https://www.ncbi.nlm.nih.gov/pubmed/23440154 . doi: 10.1590/s1020-49892013000100004
https://www.ncbi.nlm.nih.gov/pubmed/2344...

In India, delay in starting treatment was found to be associated with the distance between patients’ homes and health services.²⁶26. Tripathy JP, Srinath S, Naidoo P, Ananthakrishnan R, Bhaskar R. Is physical access an impediment to tuberculosis diagnosis and treatment? A study from a rural district in North India. PHA [Internet]. 2013 Sep [cited 2019 Jun 26];3(3):235-9. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463123/ . doi: 10.5588/pha.13.0044
https://www.ncbi.nlm.nih.gov/pmc/article... Souza et al.³⁰30. Souza MSPL, Pereira RAG, Pereira SM, Costa MCN, Barreto ML, Natividade M, et al, Fatores associados ao acesso geográfico aos serviços de saúde por pessoas com tuberculose em três capitais do Nordeste brasileiro. Cad Saúde Pública [Internet]. 2015 [citado 2019 jun 26];31(1):111-20. Disponível em: Disponível em: https://www.arca.fiocruz.br/handle/icict/20562
https://www.arca.fiocruz.br/handle/icict... considered that a distance of more than 800 meters between a patient’s home and a health service already makes access difficult. If this parameter were applied in Rondônia, access by all the indigenous people interviewed to the Casai would be difficult.

With regard to the limitations of this study, part of the questionnaire was adapted from an instrument validated only for patients receiving care in non-indigenous health services. In some cases interviews were conducted with the aid of interpreters whereby it is possible that there may have been incorrect interpretations. With the aim of minimizing these problems, the interviewers were trained in data collection standardization, including testing the questionnaire prior to the interviews. We emphasize that the interviews were conducted under the supervision of the authors of this study. The small sample size may also limit robust inferences about barriers to service access. This limitation needs to be considered because these barriers can contribute to TB continuing to be transmitted in the communities and, consequently, contribute to the high burden of the disease reported in the region.⁹9. Basta PC, Oelemann MAC, Oelemann WMR, Fonseca LS, Coimbra CEA. Detection of mycobacterium tuberculosis in sputum from Suruí Indian subjects, Brazilian Amazon. Mem Inst Oswaldo Cruz [Internet]. 2006 Sep [cited 2019 Jun 26];101(6):581-4. Available from: Available from: http://www.scielo.br/pdf/mioc/v101n6/v101n6a01.pdf . doi: 10.1590/S0074-02762006000600001
http://www.scielo.br/pdf/mioc/v101n6/v10... ^,1717. Orellana JDY, Gonçalves MJF, Basta PC. Características sociodemográficas e indicadores operacionais de controle da tuberculose entre indígenas e não indígenas de Rondônia, Amazônia Ocidental, Brasil. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2019 jun 26];15(4):846-56. Disponível em: Disponível em: http://www.scielo.br/pdf/rbepid/v15n4/04.pdf . doi: 10.1590/S1415-790X2012000400004
http://www.scielo.br/pdf/rbepid/v15n4/04... ^,1919. Melo TEMP, Resendes APC, Souza-Santos R, Basta PC. Distribuição espacial da tuberculose em indígenas e não-indígenas de Rondônia, Amazônia Ocidental, Brasil. Cad Saúde Pública [Internet]. 2012 fev [citado 2019 jun 26];28(2):267-80. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v28n2/06.pdf . doi: 10.1590/S0102-311X2012000200006
http://www.scielo.br/pdf/csp/v28n2/06.pd...

Notwithstanding, our study did reveal the difficulties faced by 52 indigenous people in obtaining correct diagnosis and treatment.

Despite the scarcity of studies with this approach in Brazil, it is reasonable to assume that similar situations may occur in other places and with other indigenous groups. There is no data available for public consultation about health facilities available in indigenous territories, but our field experience indicates that in the municipalities of Rondônia, laboratory infrastructure is not adequate for correct diagnosis of suspected TB cases among indigenous people. This fact alone reduces the spectrum of the actions undertaken by the Primary Healthcare teams in the territory.

We recommend that the health authorities equip health services, provide training for health teams in correct management of suspected TB cases among indigenous people, and develop strategies culturally adapted to local reality, in order to guarantee effective and equitable access to TB diagnosis and treatment.

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