In 2016, 2.8 million deaths and 99.2 million disability-adjusted life years (DALYs) were attributed to alcohol use (1). Approximately one-third of all alcohol-attributable DALYs and nearly half of alcohol-attributable deaths are due to injuries that result from alcohol involvement (2, 3). In the lower- and middle-income countries (LMICs) of the Latin American Caribbean (LAC) region, alcohol-related injuries compose a significant portion of the region's global burden of disease and injury, with an estimated one death every 100 s attributed to alcohol misuse (3). Socioeconomic status (SES) is an important risk factor for alcohol-related injury and to the experience of negative alcohol-related consequences (4). While there is substantial previous literature documenting SES risk factors for alcohol-related injuries in high-income countries (HICs), research on the topic in LMICs of the LAC region is scarce (5, 6), and when it exists, it is mostly related to large mega-cities, which deviate from most areas in the LAC countries.

Pooled international studies looking at distribution of socioeconomic disparities and alcohol-related harm SES characteristics and behaviors of alcohol use indicate that patterns of disparities vary greatly across and within countries (6, 7). In HICs, individuals of higher SES are more likely to consume alcohol but tend to do so with greater moderation (and thus less injury risk) (6, 7). In contrast, those of lower SES are more likely to be abstainers, but if they do drink, tend to do so in more harmful ways (6, 7). In Brazil, specifically, previous data indicate high rates of hazardous alcohol use behaviors (i.e., binge drinking, drink driving) across all levels of SES (8, 9). Worldwide, while men are at a higher risk for hazardous alcohol use and associated injury, findings from Brazil note a narrowing of this gap in higher SES strata, as women of higher SES are increasingly reporting alcohol consumption behaviors more similar to men (8–10).

To date, much of the patient-level data on alcohol-related injuries originate from emergency department studies focused on fatally injured patients and from large metropolitan areas, thus are not representative of all regions across Brazil (3, 11). Brazil, as a proxy to many LAC countries, has a heterogeneous socioeconomic distribution by and across regions; more data describing communities outside state capitals or large metropolitan areas is crucial to understand the unique characteristics of alcohol-related injuries. Moreover, these studies only include individuals who seek medical treatment and may not be representative of individuals with alcohol-related injuries of lesser severity. While the 2013 National Health Survey marks the latest effort to evaluate a representative sample of Brazilians regarding health status and associated behaviors (i.e., alcohol use), alcohol-related injuries were not included as a health outcome (8). Individual-level data on SES risk factors for non-fatal alcohol-related injury is important to informing public health strategies aimed at injury control and prevention (12, 13). The objective of this study was to describe the prevalence of alcohol-related non-fatal injuries and analyze its association with demographics and individual-level SES in Maringá, Brazil.

To date, many studies have corroborated a high burden of alcohol-related injury in Brazil and the presence of SES disparities among the injured (3, 5, 11, 25–32). To our knowledge, this study is the first to describe socioeconomic and demographic characteristics of non-fatal alcohol-related injuries, specifically in LMICs, and one of the few looking at non-fatal injuries outside of a large metropolitan area of Brazil. Using household survey data from Maringá/PR, we examined the association of individual-level characteristics with alcohol-related injury. Based on our results, socio-determinant characteristics that were associated with reporting having experienced a non-fatal lifetime alcohol-related injury were age, gender, race, and employment status.

In line with previous research, our study showed gender and age appeared to have the greatest effects on likelihood of reporting having experienced an alcohol-related injury. Males and younger ages (15–29 years) were the most common groups. These findings are consistent with national (Brazilian) and international literature that identified gender and age as significant predictors of alcohol-related injuries, with a greater prevalence of alcohol-related injuries occurring among young men (5, 11, 25–31, 33). Similarly, the most recent Pan American Health Organization report on Alcohol and Health in the Americas highlights that men under the age of 30 represent the largest proportion of patients entering emergency departments with injuries (3, 34). Therefore, it is not surprising that within our study population, the odds of reporting an alcohol-related injury were highest among males and those 15–29 years of age. It is important to note, however, that most literature refers to fatal injuries, usually using hospital-based data. The literature on non-fatal injury is scarce, which highlights the relevance of our study and draws attention to the need to improve public health policy targeted at injury and alcohol use prevention.

The odds of alcohol-related injury among those who identified as Black were observed to be high. In Brazil, very few studies examine racial/ethnic disparities in alcohol-related injury and to date, findings have been inconclusive. Evidence suggest that participants identifying as Black seem to have a higher risk of alcohol-related injury fatality (8, 11, 27, 30, 35, 36). However, recent studies also found that racial/ethnic group did not differ in terms of alcohol positivity in fatally injured patients (26, 37). While there is evidence to support the differential role of race/ethnicity on fatal and non-fatal alcohol-related injuries in LAC countries (38), this relationship has not been researched extensively in Brazil. In the United States, although Blacks have been shown to have lower levels of frequency and amount of alcohol consumption (39, 40), this population has also been associated with a higher risk of injury post–heavy episodic drinking and alcohol dependence (39–43). The United States National Institute of Alcohol Abuse and Alcoholism suggests that US Blacks who drink have a higher frequency of binge drinking and risk of getting involved in injuries (44). Some explanations to this results could be attributed to the effects social/ethnic discrimination leading to alcohol misuse and risk behavior (4, 45, 46), lower socioeconomic status and social disadvantages such as access to highly concentrated alcoholic drinks during binge drinking episodes (e.g., spirits), and greater poverty or inequitable health care treatment (40, 45, 47–49). Blacks, in Brazil, have been consistently suffered from lower quality healthcare and higher mortality, indicating a strong need for an active and enforced public health agenda toward this minority group (38, 49–54).

Individual facets of socioeconomic status, such as income, educational level, and employment, are important determinants of alcohol use and associated harm (4, 55). In HICs, unemployment is usually associated with increased risk for alcohol-related injury (4, 56, 57). However, this association is not definitive and conclusive, as we observed the opposite in our study. We found that participants who were employed were more likely to report an alcohol-related injury than those who were unemployed. Our results are similar to findings in other LMICs with road traffic injuries, such as India, Ghana (32, 58), and Estonia (58). The association between SES and alcohol use, or alcohol-related harm, is complex and dynamic according to contextual characteristics, as it was pointed out in a large review (4). One potential explanation to the results we observed in our study is that exposure to risky behavior for injury after alcohol-use might be linked to greater financial status, such as having a car or drinking in proximity with others such as in bars, parties, or restaurants. Some evidence even supports the notion that alcohol-related injuries are cyclical, happening with higher frequency around the weekends or the end of the month when paychecks are delivered (59, 60). Similarly, evidence suggests that heavy episodic drinking is more common in households with a higher income (4). Injury risk has been shown to increase according to an increase in dosage of alcohol use, more likely to happen in higher income populations.

Similarly, lower educational and income levels have been associated with increased alcohol-injury risk in HICs (4, 5). Whether or not an injury was alcohol-related did not differ across educational or income levels in our study. These findings are in line with a recent study comparing the predictability of demographic factors with alcohol-related injury across countries of varying economic development (5). In the aforementioned study, individual socioeconomic characteristics were important predictors in HICs and lower-middle income countries, but no discernable pattern was observed in upper-middle income countries, including Brazil (5).

Notwithstanding the limitations, our results provide new local evidence regarding socioeconomic and demographic characteristics of non-fatal alcohol-related injury in Brazil. Specifically, we identified that being young, employed, males or who identify as Black were independently associated with an increased risk for non-fatal alcohol-related injury in Maringá. Our results also underlined the complex nature of the associations between individual level facets of SES and demographic factors (age, gender, race) with alcohol-related injury. Future studies with larger sample sizes and inclusion of cultural-contextual variables (i.e., injury type, drinking behavior, environment/mechanism of injury) are needed. Mitigating the burden of alcohol-related injuries in a country as vast and diverse as Brazil requires a comprehensive, multifaceted approach. Individual level data, such as ours, should be considered in combination with area-level and country-level data when developing evidence-based public-health policies. Given the health disparities by race/ethnicity groups in Brazil and worldwide, examining the distribution of alcohol-attributable groups that may be at higher risk for alcohol-related injury is important for public health interventions and to provide equitable access to preventive care for alcohol use and injury risky behavior.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.

NT and LA contributed to the conception and design of the study under the supervision of JV and CS. NG, AO, and PC performed data collection and wrote sections of the manuscript. DE-G, YT, SW, and LA conducted statistical analysis under the supervision of JV. DE-G, YT, and SW wrote the manuscript and revised as needed under the guidance of JV and CS. JV and CS supervised the overall study and provided feedback throughout all stages.