Alcohol consumption among women living in rural contexts

Objective: to identify the reasons associated with alcohol consumption in women living in rural contexts. Method: a descriptive study with a qualitative approach, whose data were obtained from semi-structured interviews, conducted between March and August 2018, with a total of 23 women in alcohol consumption who live in rural areas in Central Western Rio Grande do Sul. We used a discursive textual analysis, marked by the Bioecological Theory of human development. Results: The reasons associated with alcohol consumption are: leisure time, transportation, territorial and cultural characteristics, but they differ between women living in rural areas and those living in settlements. Final considerations: The context in which rural women live influences alcohol consumption. Therefore, it is necessary to include guidelines in public policies that address the problematic of rural women.


INTRODUCTION
Alcohol consumption by women is a serious problem due to the greater vulnerability of their tissues, these women are more likely to develop liver cirrhosis, early cardiomyopathies, hypertension and stroke. In addition, compared to abstinent women, they are also more likely to develop breast cancer and disorders such as dysmenorrhea, hypermenorrhea, premenstrual discomfort and variations in the menstrual cycle (1) .
From the social point of view, women using alcohol is the target of a more intense social stigma, since their social role is strongly based on the responsibility for the family care, especially children and home (2) . Thus, when women become dependent on alcohol, the family also becomes fragile. In the case of women living in rural contexts, censorship and criticism by their community is even stronger, due to the cultural norms of that specific context.
Studies show that in rural regions, where a more conservative culture prevails, relationships are strongly influenced by a patriarchal organization that considers women inferior to men (3)(4) . In these contexts, women's work still predominantly includes taking care of the house, children, food, hygiene and, in addition, helping their partner in the field. Thus, men dominate work and manage family and financial production (2)(3)(4) . In Brazil, when it comes to women living in rural contexts, the associations between alcohol consumption and violence are strengthened, since, in general, they live far from big cities and, therefore, from health, social, political and community resources. Such factors make it difficult to access the structures that can provide greater protection to these women (2) .
Studies that associate living conditions with alcohol consumption, particularly the unique social conditions of these women, are scarce at national and international levels. Most knowledge produced on this specific theme comes from studies that addresses alcoholism in urban men and women, which does not include the particularities of women in alcohol consumption who live in rural contexts (4)(5)(6) .
Likewise, this gap identified in the literature is reproduced in the area of public policies. With regard to the National Mental Health Policy (7) , there is no established guideline for the care of rural population. Even in the most recent National Policy on Comprehensive Health for Rural and Forest Populations of 2013, there is no reference as to the territorial, social and cultural particularities that demarcate the lifestyle of these populations and, consequently, their health needs, the ways of getting sick and caring, alcohol consumption, to guide the planning and ordering of care networks, as well as the offer of psychosocial actions and services (8) .
Similarly, the Ministry of Health's policy for Comprehensive Care for Alcohol Users and other drugs, implemented in 2003, addresses the problem of alcoholism in general, however, it does not include alcoholism in women. On the other hand, the National Policy for Comprehensive Care to Women's Health, 2004, inserted in its guidelines the care to rural women's health (9) , however, NPCCWH has existed for over a decade and the health actions for this specific population are limited (2) . In summary, Public Health Policies do not include specialized care for women who consume alcohol and who live in rural contexts (10) , that is, they do not consider that these women have specificities and face adversities that need to be addressed.
These gaps identified in the literature and in public policies justify the need to deepen the study on the use of alcohol in women living in rural contexts, more specifically about the associated reasons, since they have a strong impact on family life. The guiding question of the study was: What are the reasons associated with alcohol consumption in women living in rural contexts?

OBJECTIVE
To identify the reasons associated with alcohol consumption in women living in rural contexts.

Ethical aspects
The study followed the precepts related to research with human beings, established by Resolution No. 466, of December 12, 2012, of the National Health Council (11). The anonymity of the participating women was guaranteed through the use of the alphanumeric system, using the letter W (Woman), followed by Arabic numbers, 1, 2, up to 23. The study proposal was submitted to the Research Ethics Committees of the Federal University do Rio Grande -FURG on February 28, 2018, with number on the Certificate of Presentation for Ethical Appreciation (CPEA).

Theoretical-methodological framework
We used Bronfenbrenner's Bioecological theory of human development (12) , for the interpretation, which made it possible to understand the cultural and social issues and other interactions that permeate the life of women in alcohol consumption. This theory is justified by the possibility of understanding phenomena based on personal characteristics, process, context and time. The theory applied to this study allows us to understand alcohol consumption among rural women from different perspectives. People who live in this context has their lives strongly marked by the characteristics of this place, which also has social aspects, which attribute to the interactions between women in alcohol consumption and who live in the rural context with the family, work in agriculture, health services and the context where they live and how these interactions directly influence the women's living process. Therefore, the context in which the person lives is involved in interactions that progress over time and determine what happens there (12) .
The theory allowed knowing how the participants live a certain experience (use of alcohol), placed in different contexts. These contexts have physical and social aspects, which individualize them and influence the person and the Family.

Type of study
This is a descriptive study (13) with a qualitative approach (14) guided by the SRQR -Standards for Reporting Qualitative Research) tool .

Study scenario
This study was carried out in rural areas of a city in Central Western Rio Grande do Sul, which was chosen because it is small and most of Alcohol consumption among women living in rural contexts Ebling SBD, Silva MRS.
people live in rural areas. In these areas there are also Agrarian Reform settlements of the Landless Rural Workers Movement (MST). It is noteworthy that the researcher has a bond with a women, as she acted in the supervision of practical classes of undergraduate nursing students, which facilitated the conduct of interviews.

Data source
For the eligibility of the study participants, we used the following inclusion criteria: being a woman, being over 18 years old and living in rural areas of the study city for at least one year, that is, people who really experience the rural context. In addition to these, we considered the history of alcohol consumption, identified by the Community Health Workers (CHW) of the reference Health Unit (HU) in the region. As well as the fact that it does not belong to the area covered by the reference ESF was the exclusion criteria considered. Data collection occurred between March and August 2018, at the participants' homes. The first contact with rural women occurred during Home Visits carried out by the CHW.

Data collection and organization
Interviews were conducted with a total of twenty-three (23) women in alcohol consumption, all of them were appointed by the CHW and none of the women refused to participate. At the time of the face-to-face interview, the CHW did not participate, the dialogue occurred only between one of the researchers and the participants, in a private space of their home chosen by themselves, and had an average duration of 50 minutes. We used a script organized in five steps: (1) Characterization of the participants; (2) Women's interaction with alcohol; (3) Interaction of the alcoholic woman with the family; (4) Social interactions with an emphasis on the relationship between women and work; and, (5) Interactions with health services. This study shows the results of the analysis of the data related to steps one and two. The material was properly recorded and transcribed.

Data analysis
The data analysis was based on the Discursive Textual Analysis, adopting the steps recommended by its authors Moraes and Galiazzi (15) , that is, to the collected data, the process that begins with the disassembly of the texts was applied, a stage in which the texts were separated into units of meaning. Then, similar meanings started to be articulated, that is, the establishment of relationships. Subsequently, new elements in the speeches were captured and, finally, the interpretative texts are brought together in a process called categorization (13) .

Characterization of study participants
Among the 23 women who participated in the study, 11 live in rural areas and 12 live in rural settlements, all of them report consuming alcohol on a daily basis. The age range varied between 21 and 66 years old, with a total of ten women aged between 21 and 30 years old; six of them are aged between 31 and 39 years old; five are aged between 41 and 56 years old; and, two are aged between 57 and 66 years old. They are women from different regions of the State of Rio Grande do Sul, but at the time of data collection, they were living in rural areas in the city of Capao do Cipo -RS. They have an average of three children, with the exception of a woman who had no children. Most of them (18) are Catholic.
As for education: a total of eleven women had incomplete elementary school and three women had incomplete high school. Likewise, three of them had completed high school, one had higher education, one had technical education and four of them did not attend school. Regarding the number of children: seven of them had three children, eight had one child, three had two children, three had four children, one had eight children and one had no children.
The participants' income varied between one and two minimum wages (R$ 937.00 -minimum wage) and 12 of them additionally receive the Bolsa Familia (Family Allowance) benefit from the Federal Government. With regard to occupation, 13 women work in their own tillage, three are salaried on farms, two in dairy farms, one lives with money from the rent of their land, a widow woman lives on the pension left by her husband, one takes a technician course and two declare themselves housewives. All of them depend exclusively on the Unified Health System (SUS).

Reasons associated with alcohol consumption among women living in rural contexts
The data analysis pointed out different reasons associated with alcohol consumption -according to the perception of rural women who participated in this study -which are related to the context in which they live. Women living in Agrarian Reform Settlements, from the (MST), refer to a feeling of not belonging to the place where they live, they feel sad and distressed. This territory is recognized by them as an isolated place with no prospects, and the associated reasons refer to difficult social conditions such as: a) difficulties in accessing transport; b) lack of leisure; c) isolation and loneliness due to territorial characteristics; d) many bars in the settlements.
As for women living in rural areas, they have a feeling of belonging to the rural context and the reasons associated with alcohol consumption can be categorized as social practices, including leisure time and entertainment with family/friends. However, the cultural practice of drinking together with the family stands out. Therefore, the motivations for the use of alcohol among rural women are linked to the nuclei of coexistence, as well as local and family practices.

The settlement context and alcohol consumption among women
Among women living in settlements, there seems to be no sense of belonging to the place where they live. They are women who consider themselves as sad, isolated and with no prospects for the future.  In the context of the settlement, social factors such as lack of leisure activities, difficulty in transportation and access, contribute to alcohol consumption. All women living in settlements (12) reported that there are few possibilities for leisure and entertainment, as well as the presence of a lot of bars, named by the participants by the expression "bolichos" and "bodegas". Regarding resources for displacement in the settlements, the answers of the participants emphasize the absence of transportation, which makes access to leisure, entertainment and health services difficult. There is school transportation here, but it is a favor that they do to give a ride sometimes. If they want to give a ride, they do, but they have no obligation to do so. And we are unable to afford a ride. For women living in settlements, the characteristics of the context in which they live put them in isolation, "far from everything and everyone". This is a problem that generates distress and, consequently, a factor that contributes to alcohol consumption among these women.

The rural context and alcohol consumption among women
Other reasons associated with alcohol consumption, pointed out by rural women who participated in this study, are related to the practice of drinking together with family and friends. Women living in rural contexts refer to social and cultural characteristics of this environment that can contribute to alcohol consumption. These characteristics are related to the family and the rural context leisure. Regarding the transportation, several women living in rural contexts (10) have their own vehicles. The statements show that having a means of transportation available facilitates access to social and leisure practices, which, consequently, are also associated with alcohol consumption.

Alcohol consumption among women living in rural contexts
Ebling SBD, Silva MRS.

DISCUSSION
The participants of this study who live in agrarian reform settlements, of the Landless Movement (MST), manifest a feeling of not belonging to the place where they live, they feel sad and distressed. The settlement territory, for these women, is not a place to live. Confirmed in the literature (16)(17) , this fact can be explained by ideological issues of the movement (between not having the land and having it), since the women's lives in the settlements are characterized by feelings of fear, discouragement and impotence, due to the fact that most of the time they do not have the rural culture and are allocated in this space to work in agriculture.
These women report few possibilities for leisure and entertainment. The fact that there are many bars, transport difficulties and the territorial characteristics of the settlements are shown in the statements, demonstrating that these are reasons associated with alcohol consumption. Corroborating these results, another study conducted in Sri Lanka shows that isolation is one of the most predisposing factors to the use alcohol among the rural population (18) . The settlement areas where this study was carried out are geographically isolated, a fact that can make women more vulnerable to alcohol consumption. Likewise, in a study carried out with women in India, it was demonstrated that the pattern of alcohol use was higher in women who lived in areas of geographic isolation, social and economic backwardness (6) . A study conducted in Africa, with women living in different rural and urban areas, showed that the social environment and isolation are reflected in alcohol consumption (19) .
The condition of women living in settlements is characterized by difficulties in accessing leisure, transportation and loneliness. These are related to great distances, lack of transportation in the settlements and absence of cultural practices, which demonstrates that the use of alcoholic beverages seems to be the only way of entertainment in the perception of these women. In a study carried out in settlements in Bahia, it was shown that drinking is "almost the only way to have fun in the settlement region" (17) . Thus, people who live in this context has their lives strongly marked by the "characteristics of this place, which has social and physical aspects" (15) . From the social point of view, it can be attributed to the interactions between the woman living in settlement with the context where she lives, that is, as work, family and social activities. As for the physical aspects, it is possible to check the difficulties of access due to the territorial characteristics of the settlements, which also present themselves as a limitation to these women. A study carried out in a French outpatient with women who consume alcohol showed that few women seek health services, which demonstrates the need for greater knowledge of the specific characteristics of rural women in order to develop programs that increase access to specialized treatment services among these women (20) .
As for women living in rural areas, the reasons associated with alcohol consumption refer to leisure, having fun with family/ friends and cultural practices, as the statements mention that the use of alcohol has a strong connection with festivities among families. Women who are born and live in the rural context bring with them cultural values typical of rural living, such as working in the garden, traditions such as gaucho dances and the use of alcohol. It is interesting to note that culture is a social element, impossible to be develop individually. Then, it can be considered that the context assumes a fundamental role, since it is there that the interactions happen (15) , but not necessarily determine them.
It is important to highlight that, according to the perception of the participants in this study, alcohol consumption has its characteristics associated particularly with the context in which they live. On the other hand, a study carried out with rural women from the Telangana region of Andhra Pradesh, which assessed the prevalence of alcohol use among them, found that this practice is 5% lower (21) . For this reason, it is necessary to consider that there is an important relationship with the characteristics of these women associated with the context in which they live, showing that alcohol dependence is determined by the interaction among various associated reasons and not only determined by the context in which they live.
As for transportation for the population of this study, it is worth noting that for women living in settlements, transportation is a limiting factor for access to leisure practices and it contributes to alcohol consumption, on the other hand, for women who live in rural areas, transportation facilitates access to certain services, as well as leisure activities, which are also associated with alcohol consumption.
Considering both contexts (settlements and rural areas), intersectoral policies and educational actions, health promotion and alcoholism prevention are essential for women living in these areas. In addition, intersectoral policies (transport secretariat and health secretariat) need to work collectively, however the political issue is understood as an important device in order to alleviate problems and qualify the health care of these women.

Limitations of the study
This study did not have the standard dose criteria to characterize alcohol consumption in the studied population. In addition, the results presented in this manuscript are a smaller project from the thesis research material, which implies the impossibility of total results.

Contributions to the area of nursing, health or public policy
This study contributed to show how the context where women live can interfere with alcohol use. In the nursing in Rural Primary Care area, the study shows how it is necessary to identify early signs of alcohol abuse among rural women and to map educational strategies with women and their families, in order to consider the cultural habits of the rural family.

FINAL CONSIDERATIONS
Knowing the reasons associated with alcohol consumption among women who live in agrarian reform settlements showed how this context can be associated with the problematic consumption. In addition, the difficulties in transportation and living/ leisure spaces expose these women to alcohol consumption, since alcoholic beverages become a way of entertainment in the 7 of Alcohol consumption among women living in rural contexts Ebling SBD, Silva MRS.
perception of women living in settlements. As for rural women, it is possible that the reported alcohol consumption is motivated by the form of leisure, festivities and especially the cultural practices of family members.
In terms of public policies, there is much to be done, since there is no specific guideline for alcoholism in rural women. It is essential to have an accurate look at the populations living in the field, to know the specifics and how they function as a community.