Effect of the Brazilian cash transfer programme on suicide rates: a longitudinal analysis of the Brazilian municipalities

Health, economic and social impacts of the Brazilian cash transfer program on the lives of its beneficiaries: a scoping review

BACKGROUND

The Bolsa Família cash transfer Program (BFP) aims to break the poverty cycle by providing a minimum income to poor families conditioned on their investment in human capital (such as, education and health) and currently is the largest Program in the world in terms of the number of beneficiaries. Because there is a scarcity of reviews grouping studies on the impacts of the BFP, the objective of this scoping review was to identify and describe studies which evaluate the impact of the BFP on poverty, health, education, and other related outcomes.

METHODS

We searched for quantitative, qualitative, and mixed-method articles that assessed the impact of the BFP on any aspect of the beneficiaries' lives between 2003 and March 2021. We included quantitative articles that used experimental, quasi-experimental or pre and post comparison designs. We excluded articles that analyzed impacts on political outcomes. There was no age restriction for the participants. The search was done in seven electronic databases.

RESULTS

One thousand five hundred forty-six papers were identified and 94 fulfilled the inclusion criteria. Poverty and health outcomes were the most common outcomes studied. We found consistent evidence of the positive impact of the BFP on poverty reduction, as well as employment outcomes. We also found positive impacts in relation to mortality rates for children and adults, school dropout and school attendance among children and adolescents, and violence related outcomes such as homicide, suicide, crime, and hospitalization. However, we also found some evidence that BFP increased intimate partner violence and gender stereotypes among women and no evidence of impact on teenage pregnancy.

CONCLUSIONS

Overall, the studies included found that BFP showed positive impacts on most poverty, health and education outcomes. More studies are needed to confirm some results, especially about violence and stereotype against women as there were few evaluations on these outcomes.

Preventing suicide: a public health approach to a global problem

Suicide is prevalent in all countries and is largely preventable. The causes of suicide are multiple and varied. Social determinants of suicide are crucial, but to date these have received insufficient policy attention. This paper, which is the first in a Series on taking a public health approach to suicide prevention, argues for a major change in the way we think about suicide and its prevention. This Series paper presents a public health model that emphasises the broad social determinants of suicide and describes a framework through which these might be addressed. We argue for a policy reset that would take national suicide prevention strategies to the next level. Such policies would become whole-of-government endeavours that tackle major social determinants of suicide at their source. We also argue that high-quality data and methodologically rigorous evaluation are integral to this public health approach.

Financial Stress Amongst People Who Self-Harm in Sri Lanka

OBJECTIVE

Socioeconomic status deprivation is known to be associated with self-harm in Western countries but there is less information about this association in Low and Middle Income Countries (LMIC). One way of investigating this is to assess the prevalence of indicators of financial stress in people who self-harm. We have assessed the prevalence and correlates of day-to-day financial hardships amongst individual presenting with non-fatal self-harm to hospitals in Sri Lanka.

METHODS

Data on non-fatal self-harm presentations were collected from an ongoing surveillance project in 52 hospitals in Sri Lanka. A questionnaire captured data on two forms of financial stress: unmet need (i.e., costs and bills that cannot be paid) and required support (i.e., steps taken to cover costs, such as selling belongings). Additional data on demographic, economic and clinical characteristics were also collected.

RESULTS

The sample included 2516 individuals. Both forms of financial stress were very common, with pawning/selling items (47%) and asking family or friends for money (46%) in order to pay bills or cover costs being commonly reported. Greater financial stress was associated with being aged 26-55 years, limited education, and low socioeconomic position. Financial stress was greater in women than men after adjusting for other factors.

CONCLUSION

The results indicate that financial stress is commonly reported amongst individuals presenting to hospital with non-fatal self-harm in Sri Lanka, especially women. The research highlights a need to attend to financial stress both within self-harm prevention and aftercare.

Suicide mortality in Paraíba (Brazil) between 2010 and 2021 and the impact of the Covid-19 pandemic: an ecological study

This study aims to analyze the rates of suicide mortality in the State of Paraíba (Brazil) between 2010 and 2021, describing the impact of the COVID-19 pandemic on the suicide rates in 2020 and 2021. We here proposed a mixed longitudinal - ecological study that employed secondary data provided by the Mortality Information System regarding deaths from self-harm in 2010 - 2021 in the state of Paraíba. It also included cases of death from intentional self-inflicted injuries, coded X60-X84 according to the 10th International Classification of Diseases (ICD-10). A linear regression was used to evaluate the relationship between the mortality rates and the years analyzed and also to calculate the predicted values for 2020 and 2021 based on findings from previous years. Although the suicide rates observed in 2020 and 2021 were higher than expected (6.387 and 6.789, respectively), they were still within the confidence interval. The present study found a constant increase in the suicide mortality during the period studied, even if without a significant difference between the expected trends according to previous years and those observed during the COVID-19 pandemic.

The rising trends of self-harm in Brazil: an ecological analysis of notifications, hospitalisations, and mortality between 2011 and 2022

Background

Self-harm is considered an important public health issue and is comprised by a wide range of definitions and behaviours. It is estimated that suicide affects more than 700,000 individuals every year, although, globally, there is a lack of evidence on other self-harm behaviour, such as attempted suicide. The objective of this study is to report and examine temporal trends of notifications, hospitalisations related to self-harm and suicide rates in Brazil between 2011 and 2022, as well as investigating differences in sociodemographic characteristics, methods, and region.

Methods

This ecological study used secondary, Brazilian Health Information System data between 2011 and 2022. Self-harm notifications were collected from the Notifiable Diseases Information System (SINAN); self-harm hospitalisations from the Hospital Information System (SIH), and suicide data from the Mortality Information System (SIM). We calculated self-harm notifications, hospitalisations, and suicide rates by sex, age, race, region, and overall. We assessed time-related trends using Joinpoint regression analyses.

Findings

From 2011 to 2022, 720,480 self-harm notifications, 104,458 self-harm hospitalisations, and 147,698 suicides were recorded in Brazil. In this period, self-harm notifications (AAPC: 21.13 (CI: 17.50, 25.33)) and suicide (AAPC: 3.70 (CI: 3.05, 4.38)) have increased in the country. Male adults (25-59 years old) and the elderly (>60 years old) continue to be the groups most affected by suicide, with respective rates of 9.59 and 8.60/100,000 in 2022. However, the largest percentage increases have been seen in young people (AAPC: 6.14 (CI: 4.57, 7.88)). The Indigenous population had the highest self-harm notification (103.72, 10,000) and suicide (16.58/100,000) rates, but the lowest hospitalisation rates (1.14/100,000) in 2022), compared to the overall population (70.06, 7.27, and 4.69/100,000, respectively, in 2022).

Interpretation

The observed trend of increased self-harm notifications and suicide rates suggests the need for a greater allocation of resources to strategies to prevent self-harm and suicide. The Indigenous population seems to be the group with less access to healthcare.

Funding

Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number R01MH128911-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Links between Household-Level Income-Generating Agricultural Intervention and the Psychological Well-Being of Adolescent Girls in Human Immunodeficiency Virus-Affected Households in Southwestern Kenya: A Qualitative Inquiry

BACKGROUND

Adolescent girls may experience poor psychological well-being, such as social isolation, shame, anxiety, hopelessness, and despair linked to food insecurity.

OBJECTIVES

This study aimed to investigate the experiences with and perceived effects of a household-level income-generating agricultural intervention on the psychological well-being of adolescent girls in human immunodeficiency virus (HIV)-affected households in southwestern Kenya.

METHODS

We conducted 62 in-depth interviews with HIV-affected adolescent girls and caregiver dyads in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in Shamba Maisha (NCT01548599), a multisectoral agricultural and finance intervention trial aimed to improve food security and HIV health indicators. Participants were purposively sampled to ensure diversity in terms of age and location. Data were audiotaped, transcribed, translated, and uploaded into Dedoose (Sociocultural Research Consultants, LLC) software for management. Data were analyzed thematically based on reports from Dedoose.

RESULTS

We found evidence that a household-level structural intervention aimed at increasing food and financial security among persons living with HIV can contribute to better psychological well-being among adolescent girls residing in these households. The intervention also affected: 1) reduction of social isolation, 2) reduction of shame and stigma, 3) increased attendance and concentration in school, 4) improved caregiver mental health, and 5) reduced parental aggression and improved household communication. These associations were reported more commonly among those in the intervention arm than the control arm.

CONCLUSIONS

This study extends existing research by demonstrating how multisectoral structural interventions delivered at a household level can improve the psychological well-being of adolescents. We recommend that future research test livelihood interventions designed specifically for adolescent girls that integrate food-security interventions with other elements to address the social and psychological consequences of food insecurity holistically. This trial was registered at clinicaltrials.gov as NCT03741634.

Sociodemographic characteristics of women who died by suicide in India from 2014 to 2020: findings from surveillance data

BACKGROUND

Women in India have twice the suicide death rate (SDR) compared with the global average for women. The aim of this study is to present a systematic understanding of sociodemographic risk factors, reasons for suicide deaths, and methods of suicide among women in India at the state level over time.

METHODS

Administrative data on suicide deaths among women by education level, marital status, and occupation, and reason for and method of suicide were extracted from the National Crimes Record Bureau reports for years 2014 to 2020. We extrapolated SDR at the population level for Indian women by education, marital status, and occupation to understand the sociodemography of these suicide deaths for India and its states. We reported the reasons for and methods of suicide deaths among Indian women at the state level over this period.

FINDINGS

SDR was higher among women with education of class 6 or more (10·2; 95% CI 10·1-10·4) than those with no education (3·8; 3·7-3·9) or education until class 5 (5·4; 5·2-5·5) in India in 2020, with similar patterns in most states. SDR declined between 2014 and 2020 for women with education until class 5. Women currently married accounted for 28 085 (63·1%) of 44 498 suicide deaths in India, 8336 (56·2%) of 14 840 in less developed states, and 19 661 (66·9%) of 29 407 in more developed states in 2020. For India, women currently married had a significantly higher SDR (8·1; 8·0-8·2) than those never married in 2014. However, women who never married had a significantly higher SDR (8·4; 8·2-8·5) in 2020 than those who were currently married. Many individual states in 2020 had similar SDR for women who never married and those who are currently married. Housewife as an occupation accounted for 50% or more of suicide deaths from 2014 to 2020 in India and its states. Family problems was the most common reason for suicide from 2014 to 2020, accounting for 16 140 (36·3%) of 44 498 suicide deaths in India, 5268 (35·5%) of 14 840 in less developed states, and 10 803 (36·7%) of 29 407 in more developed states in 2020. Hanging was the leading mean of suicide from 2014 to 2020. Insecticide or poison consumption was the second leading cause of suicide, accounting for 2228 (15·0%) of all 14 840 suicide deaths in less developed states and 5753 (19·6%) of 29 407 in more developed states, with a near 70·0% increase in the use of this method from 2014 to 2020.

INTERPRETATION

The higher SDR among women who have received an education, similar SDR between women currently married and never married, and variations in the reasons for and means of suicide at the state level highlight the need to incorporate sociological insights into how the external social environment can matter for women to better understand the complexity of suicide and determine how to effectively intervene.

FUNDING

Bill & Melinda Gates Foundation.

Bolsa Família Program and deaths from oral cancer in Brazil: an ecological study

Objective

To assess the effect of coverage of the Bolsa Família Program (BFP) on oral cancer mortality rates in Brazil between 2005 and 2017, adjusting for health care coverage and socioeconomic characteristics of the Brazilian federative units.

Methods

This is an ecological study using annual data (2005-2017) from all the Brazilian federative units. The dependent variable for this study was the oral cancer mortality rate, standardized by gender and age using the direct standardization technique. BFP coverage was the main independent variable, calculated as the ratio of the number of BFP beneficiaries to those families that should potentially be entitled to this conditional cash transfer. Socioeconomic background and health care coverage were covariables. Choropleth maps were drawn, and space-time cube analysis was used to assess changes in the spatiotemporal distribution of BFP and oral cancer mortality rates. Mixed-effects linear regression analysis estimated the coefficients (β) and 95% confidence intervals (CI) for the association between BFP coverage and oral cancer mortality rates.

Results

BFP coverage trends increased and oral cancer mortality rate trends stabilized in Brazilian federative units, except for Maranhão, Goiás, and Minas Gerais, where the oral cancer mortality rates have increased. In the adjusted model, greater BFP coverage was associated with lower oral cancer mortality rates (β -2.10; 95% CI [-3.291, -0.919]).

Conclusions

Egalitarian strategies such as BFP can reduce the oral cancer mortality rate. We recommend the follow-up of families benefiting from conditional cash transfer program by oral health teams to reduce the oral cancer mortality rate.

Behavioral Interventions Contributing to Reducing Poverty and Inequities

Behavioral science has a long history of engaging in efforts to understand and address socially important issues. Poverty and inequities in health and development are among the most important and complex social issues facing the world today. With its Sustainable Development Goals (SDGs), the United Nations (2015) has focused attention and guidance on addressing key global challenges, including to "end poverty" (SDG 1), "ensure good health and well-being for all" (SDG3), and "reduce inequality within and among countries" (SDG 10). In this paper, we provide a framework and illustrative examples of contributions of behavioral science to these issues. We feature illustrative behavioral interventions at the individual, relationship, community, and societal levels. We highlight the diversity of issues, intervention methods, and settings reflected in applications of behavioral science. By joining methods from behavioral science, public health, and other disciplines-and the experiential knowledge of those most affected by inequities-behavioral methods can make significant contributions to collaborative efforts to assure health and well-being for all.

Income support policies and firearm violence prevention: A scoping review

Firearm violence is a major threat to global public health and safety. Several individual, family, peer, community, and societal risk and protective factors determine or modify the risk of firearm violence. Specifically, there is a strong relationship between poverty, income inequality, and firearm violence; as such, interventions that influence upstream determinants of health by providing income support may hold much promise in affecting multiple domains of risk that are on the causal pathway to firearm violence. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review to examine the current state of evidence on the relationship between income support policies and risk of firearm violence. We searched 8 databases related to health and social sciences from inception through March 30, 2022, and placed no time, language, setting, or other publication restrictions on our search, as long as the study was quantitative or mixed-methods and addressed firearm violence specifically, rather than violence more broadly, as an outcome in relation to income support policies. We found 4 studies; of those, 3 were conducted in the United States and 1 in Brazil. All 4 found associations of policy-relevant magnitude between income support policies and reductions in risk of inter-personal firearm violence. We propose future opportunities to enhance the substantive scope and methodologic rigor of this field of research and inform policy and practice for greater impact.

Barreto M. The impact of social drivers, conditional cash transfers and their mechanisms on the mental health of the young; an integrated retrospective and forecasting approach using the 100 million Brazilian Cohort: A study protocol

Background

Physical, emotional, and social changes, including exposure to poverty, abuse, or violence, increases youth vulnerability to mental illness. These factors interfere with development, limit opportunities, and hamper achievement of a fulfilling life as adults. Addressing these issues can lead to improved outcomes at the population level and better cost-effectiveness for health services. Cash transfer programs have been a promising way to address social drivers for poor mental health. However, it is still unclear which pathways and mechanisms explain the association between socioeconomic support and lower mental illness among youth. Therefore, we will evaluate the effect of social drivers on youth mental health-related hospitalizations and suicide, test mechanisms and pathways of a countrywide socioeconomic intervention, and examine the timing of the intervention during the life course.

Methods

We will combine individual-level data from youth national hospitalization, mental health disorders and attempted suicide, suicide registries and notifications of violence, with large-scale databases, including “The 100 Million Brazilian Cohort”, over an 18-year period (2001–2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Designs, Propensity Score Matching and difference-in-differences, combined with multivariable regressions for cohort analyses. We will run multivariate regressions based on hierarchical analysis approach to evaluate the association between important social drivers (mental health care, demographic and economic aspects) on mental health-related hospitalizations and suicide among youth. Furthermore, we will perform microsimulations to generate projections regarding how mental health-related hospitalizations and suicide trends will be in the future based on the current state, and how BFP implementation scenarios will affect these trends.

Discussion

The results of this project will be of vital importance to guide policies and programs to improve mental health and reduce mental health-related hospitalizations and suicide in youth. It will provide information to improve the effectiveness of these programs worldwide. If cash transfers can decrease mental health problems among youth and reduce suicide.

Establishing political priority for global mental health: a qualitative policy analysis

Mental disorders represent the leading cause of disability worldwide, yet they remain a low global health priority. This paper uses a case study methodology and different data sources (35 interviews and documents) to analyse factors that have shaped the generation of political priority for global mental health over the past three decades (1990-2020) and their changes over time. The Shiffman and Smith framework on determinants of political priority for global health issues is used to organize data into themes: actor power, ideas, political context and issue characteristics. Global mental health has gained political attention, especially over the past decade, yet support remains limited. Findings reveal that actor power is undermined by a fragmented policy community, the absence of one guiding institution or coordination mechanism and little civil society mobilization. Public portrayal of the issue is divided, hampered by the absence of a common understanding by the community and by stigma. Some policy windows have been missed and a strong global governance structure is lacking. Credible indicators and evidence on simple cost-effective solutions, especially in low- and middle-income countries, are scarce. However, opportunities are arising, including an increasing number of leaders and grassroots organizations, multiple arguments for action and integrated solutions resonating with broader audiences, widening political support at the national level, an emerging global governance structure and an expanding evidence base on the scale of the problem and available solutions. The results point to three technical and four political challenges that advocates need to address to increase political support over the next decade.

Excess suicides in Brazil: Inequalities according to age groups and regions during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has already claimed more than six million direct deaths. Low-and middle-income countries, such Brazil, were severely hit, not only due to direct effects on mortality, but also for its indirect effects on other causes of deaths.

AIMS

The objective of this study was to estimate the excess suicides in Brazil and evaluate patterns within and between its regions during the COVID-19 pandemic in 2020.

METHOD

The observed suicides are gathered from the mortality information system of the Brazilian Ministry of Health. The estimates of expected suicides, according to sex, age group, bimonthly period and region, were reached through quasi-Poisson generalized additive models, with adjustment for overdispersion. The analyses were performed in R software, version 3.6.1 and RStudio, version 1.2.1335.

RESULTS

From March 2020 to December 2020, 10,409 suicides were observed in Brazil, resulting in an overall decrease of 13%, in comparison to the expected rate for the period. There were excess suicides of 26% in men from the Northern region in the 60 years and more age group, as well as in women from the Northern region in the 30 to 59 years age group in two consecutive bimonthly periods. Excess suicides of 40% was also observed in women in the 60 years and more age group from the Northeastern region.

CONCLUSIONS

Despite the overall decrease in suicides in Brazil over the period assessed, substantial excess suicides were observed in different age groups and sexes from the Northern and Northeastern regions of the country, which are regions that are historically more prone to health and socioeconomic inequalities.

Effects of the economic recession on suicide mortality in Brazil: interrupted time series analysis

OBJECTIVES

to analyze trends in suicide rates in Brazil in the period before and after the start of the economic recession.

METHODS

interrupted time series research using national suicide data recorded in the period between 2012 and 2017 with socioeconomic subgroups analyses. Quasi-Poisson regression model was employed to analyze trends in seasonally adjusted data.

RESULTS

there was an abrupt increase in the risk of suicide after economic recession in the population with less education (12.5%; RR = 1.125; 95%CI: 1.027; 1.232) and in the South Region (17.7%; 1.044; 1.328). After an abrupt reduction, there was a progressive increase in risk for the black and brown population and for those with higher education. In most other population strata, there was a progressive increase in the risk of suicide.

CONCLUSIONS

the Brazilian economic recession caused different effects on suicide rates, considering social strata, which requires health strategies and policies that are sensitive to the most vulnerable populations.

The mental health of children and young people living in big cities in a revolving postpandemic world

PURPOSE OF REVIEW

The world's population is increasingly urban, with most children and young people growing up and living in cities. Evidence suggests that urbanicity is linked to an increased risk for the development of mental health disorders. Rather than an accumulation of risk factors, urbanization is a complex process that profoundly structures living conditions. In this sense, it is timely to discuss what are the social and structural determinants of mental health of children and young people in such settings.

RECENT FINDINGS

Three domains of determinants of mental health were selected for discussion: economics and living conditions, crime and violence, and urban layouts. For each, we debated realities faced by urban children and young people, providing an overview of recent evidence on implications for mental disorders and well being. We also discuss the potential impacts of the covid-19 pandemic on each domain, as well as recommendations for future action.

SUMMARY

Structural factors are of major relevance for the mental health of children and young people living in cities. The agenda of mental health promotion and prevention must include whole-of-society interventions aimed at improving living conditions, including economic and social capital, violence prevention and urbanistic planning.

Relationship between the Bolsa Família national cash transfer programme and suicide incidence in Brazil: A quasi-experimental study

BACKGROUND

Socioeconomic factors have been consistently associated with suicide, and economic recessions are linked to rising suicide rates. However, evidence on the impact of socioeconomic interventions to reduce suicide rates is limited. This study investigates the association of the world's largest conditional cash transfer programme with suicide rates in a cohort of half of the Brazilian population.

METHODS AND FINDINGS

We used data from the 100 Million Brazilian Cohort, covering a 12-year period (2004 to 2015). It comprises socioeconomic and demographic information on 114,008,317 individuals, linked to the "Bolsa Família" programme (BFP) payroll database, and nationwide death registration data. BFP was implemented by the Brazilian government in 2004. We estimated the association of BFP using inverse probability of treatment weighting, estimating the weights for BFP beneficiaries (weight = 1) and nonbeneficiaries by the inverse probability of receiving treatment (weight = E(ps)/(1-E(ps))). We used an average treatment effect on the treated (ATT) estimator and fitted Poisson models to estimate the incidence rate ratios (IRRs) for suicide associated with BFP experience. At the cohort baseline, BFP beneficiaries were younger (median age 27.4 versus 35.4), had higher unemployment rates (56% versus 32%), a lower level of education, resided in rural areas, and experienced worse household conditions. There were 36,742 suicide cases among the 76,532,158 individuals aged 10 years, or older, followed for 489,500,000 person-years at risk. Suicide rates among beneficiaries and nonbeneficiaries were 5.4 (95% CI = 5.32, 5.47, p < 0.001) and 10.7 (95% CI = 10.51, 10.87, p < 0.001) per 100,000 individuals, respectively. BFP beneficiaries had a lower suicide rate than nonbeneficiaries (IRR = 0.44, 95% CI = 0.42, 0.45, p < 0.001). This association was stronger among women (IRR = 0.36, 95% CI = 0.33, 0.38, p < 0.001), and individuals aged between 25 and 59 (IRR = 0.41, 95% CI = 0.40, 0.43, p < 0.001). Study limitations include a lack of control for previous mental disorders and access to means of suicide, and the possible under-registration of suicide cases due to stigma.

CONCLUSIONS

We observed that BFP was associated with lower suicide rates, with similar results in all sensitivity analyses. These findings should help to inform policymakers and health authorities to better design suicide prevention strategies. Targeting social determinants using cash transfer programmes could be important in limiting suicide, which is predicted to rise with the economic recession, consequent to the Coronavirus Disease 2019 (COVID-19) pandemic.

Efeitos da recessão econômica na mortalidade por suicídio no Brasil: análise com séries temporais interrompidas

RESUMO Objetivos: analisar as tendências nas taxas de suicídio no Brasil, no período antes e depois do início da recessão econômica. Métodos: estudo de séries temporais interrompidas utilizando dados nacionais de suicídio registrados no período entre 2012 e 2017 com análises por subgrupos socioeconômicos. Modelo de regressão quasi-Poisson foi empregado para analisar as tendências dos dados ajustados sazonalmente. Resultados: observou-se aumento abrupto no risco de suicídio após recessão econômica na população com menor escolaridade (12,5%; RR = 1,125; IC95%:1,027; 1,232) e na Região Sul (17,7%; 1,044; 1,328). Após redução abrupta, ocorreu aumento progressivo no risco para a população de pretos e pardos e na de maior escolaridade. Na maioria dos demais estratos populacionais, verificou-se aumento progressivo no risco de suicídio. Conclusões: a recessão econômica brasileira produziu efeitos diferentes nas taxas de suicídio, considerando os estratos sociais, o que demanda estratégias de saúde e políticas sensíveis às populações mais vulneráveis.

Conditional cash transfers and adolescent mental health in Brazil: Evidence from the 2004 Pelotas Birth Cohort

BACKGROUND

Young people living in poverty are at higher risk of mental disorders, but whether interventions aimed to reduce poverty have lasting effects on mental health has not been well established. We examined whether exposure to Brazil's conditional cash transfers programme (CCT), Bolsa Família (BFP), during childhood reduces the risk of mental health problems in early adolescence.

METHODS

We used data from 2063 participants in the 2004 Pelotas Birth Cohort study. Propensity score matching (PSM) estimated the association between BFP participation at age 6 and externalising problems (Strengths and Difficulties Questionnaire - SDQ and violent behaviour) and socio-emotional competencies (Development and Well-Being Assessment questionnaire, and the Nowick-Strickland Internal-External Scale) at age 11.

RESULTS

PSM results suggest that programme participation at age of six was not significantly associated with externalising problems (P = 0.433), prosocial behaviour (P = 0.654), violent behaviour (P = 0.342), social aptitudes (P = 0.281), positive attributes (P = 0.439), or locus of control (P = 0.148) at the age of 11 years.

CONCLUSIONS

Participation in BFP during childhood was not associated with improved or worsened mental health in early adolescence. While we cannot fully discard that findings may be due to adverse selection, results suggest that CCTs alone may not be sufficient to improve mental health outcomes and would be prudent to assess whether mental health interventions as an addition to CCTs may be helpful.

Suicide cases in developed and emerging countries: an analysis using wavelets

ABSTRACT Objective The aim of this study was to use a wavelet technique to determine whether the number of suicides is similar between developed and emerging countries. Methods Annual data were obtained from World Health Organization (WHO) reports from 1986 to 2015. Discrete nondecimated wavelet transform was used for the analysis, and the Daubechies wavelet function was applied with five-level decomposition. Regarding clustering, energy (variance) was used to analyze the clusters and visualize the clustering process. We constructed a dendrogram using the Mahalanobis distance. The number of groups was set using a specific function in the R program. Results The cluster analysis verified the formation of four groups as follows: Japan, the United States and Brazil were distinct and isolated groups, and other countries (Austria, Belgium, Chile, Israel, Mexico, Italy and the Netherlands) constituted a single group. Conclusion The methods utilized in this paper enabled a detailed verification of countries with similar behaviors despite very distinct socioeconomic, geographic and climate characteristics.

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

Integrating youth mental health into cash transfer programmes in response to the COVID-19 crisis in low-income and middle-income countries

Social protection measures can play an important part in securing livelihoods and in mitigating short-term and long-term economic, social, and mental health impacts of the COVID-19 pandemic. In particular, cash transfer programmes are currently being adapted or expanded in various low-income and middle-income countries to support individuals and families during the pandemic. We argue that the current crisis offers an opportunity for these programmes to focus on susceptible young people (aged 15-24 years), including those with mental health conditions. Young people living in poverty and with mental health problems are at particular risk of experiencing adverse health, wellbeing, and employment outcomes with long-term consequences. They are also at risk of developing mental health conditions during this pandemic. To support this population, cash transfer programmes should not only address urgent needs around food security and survival but expand their focus to address longer-term mental health impacts of pandemics and economic crises. Such an approach could help support young people's future life chances and break the vicious cycle between mental illness and poverty that spirals many young people into both socioeconomic and mental health disadvantage.

Influence of the global crisis of 2008 and the brazilian political oscillations of 2014 on suicide rates: An analysis of the period from 2002 to 2017

Global suicide rates have increased in recent decades becoming a serious social and public health problem. In Brazil, rates have been increasing annually. We aimed to analyze the correlation between suicide mortality rates and global economic and political crisis periods of 2008 and 2014 in Brazil. The analysis of suicide mortality in Brazil was done using a time-series segmented linear regression model that estimated the trend of rates over time. To obtain the model, changes in the trend of both abrupt and gradual suicide rates were investigated. The results indicate statistically significant changes showing an upward trend of suicide rates during the world economic crisis (2008-2013) and during the economic and political crisis in Brazil (2014-2017) compared to previous periods, especially at the extremes of schooling (3 < years and > 8 years). Among white and parda, there were significant trend rates increases in both periods and in different regions. In the Northeast and South regions, we observed a significant increase in the trend rate for males after the Brazilian economic and political crisis (2014 to 2017). We can conclude that the national suicide rates were influenced by the economic and political instability that our country has been going through since 2008, affecting each region differently. Further studies are needed to explore the reasons for interregional differences and the relation of suicide with unemployment rates and possible economic predictors.

Examining the dynamics between young people's mental health, poverty and life chances in six low- and middle-income countries: protocol for the CHANCES-6 study

PURPOSE

Poverty and poor mental health are closely related and may need to be addressed together to improve the life chances of young people. There is currently little evidence about the impact of poverty-reduction interventions, such as cash transfer programmes, on improved youth mental health and life chances. The aim of the study (CHANCES-6) is to understand the impact and mechanisms of such programmes.

METHODS

CHANCES-6 will employ a combination of quantitative, qualitative and economic analyses. Secondary analyses of longitudinal datasets will be conducted in six low- and middle-income countries (Brazil, Colombia, Liberia, Malawi, Mexico and South Africa) to examine the impact of cash transfer programmes on mental health, and the mechanisms leading to improved life chances for young people living in poverty. Qualitative interviews and focus groups (conducted among a subset of three countries) will explore the views and experiences of young people, families and professionals with regard to poverty, mental health, life chances, and cash transfer programmes. Decision-analytic modelling will examine the potential economic case and return-on-investment from programmes. We will involve stakeholders and young people to increase the relevance of findings to national policies and practice.

RESULTS

Knowledge will be generated on the potential role of cash transfer programmes in breaking the cycle between poor mental health and poverty for young people, to improve their life chances.

CONCLUSION

CHANCES-6 seeks to inform decisions regarding the future design and the merits of investing in poverty-reduction interventions alongside investments into the mental health of young people.

Association between homicide rates and suicide rates: a countrywide longitudinal analysis of 5507 Brazilian municipalities

OBJECTIVE

To estimate the association between homicide and suicide rates in Brazilian municipalities over a period of 7 years.

DESIGN

We conducted a longitudinal ecological study using annual mortality data from 5507 Brazilian municipalities between 2008 and 2014. Multivariable negative binomial regression models were used to examine the relationship between homicide and suicide rates. Robustness of results was explored using sensitivity analyses to examine the influence of data quality, population size, age and sex on the relationship between homicide and suicide rates.

SETTING

A nationwide study of municipality-level data.

PARTICIPANTS

Mortality data and corresponding population estimates for municipal populations aged 10 years and older.

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-standardised suicide rates per 100 000.

RESULTS

Municipal suicide rates were positively associated with municipal homicide rates; after adjusting for socioeconomic and demographic factors, a doubling of the homicide rate was associated with 22% increase in suicide rate (rate ratio=1.22, 95% CI: 1.13 to 1.33). A dose-response effect was observed with 4% increase in suicide rates at the third quintile, 9% at the fourth quintile and 12% at the highest quintile of homicide rates compared with the lowest quintile. The observed effect estimates were robust to sensitivity analyses.

CONCLUSIONS

Municipalities with higher homicide rates have higher suicide rates and the relationship between homicide and suicide rates in Brazil exists independently of many sociodemographic and socioeconomic factors. Our results are in line with the hypothesis that changes in homicide rates lead to changes in suicide rates, although a causal association cannot be established from this study. Suicide and homicide rates have increased in Brazil despite increased community mental health support and incarceration, respectively; therefore, new avenues for intervention are needed. The identification of a positive relationship between homicide and suicide rates suggests that population-based interventions to reduce homicide rates may also reduce suicide rates in Brazil.

The Impact of Infectious Disease-Related Public Health Emergencies on Suicide, Suicidal Behavior, and Suicidal Thoughts

Abstract. Background: Infectious disease-related public health emergencies (epidemics) may increase suicide risk, and high-quality evidence is needed to guide an international response. Aims: We investigated the potential impacts of epidemics on suicide-related outcomes. Method: We searched MEDLINE, EMBASE, PsycInfo, CINAHL, Scopus, Web of Science, PsyArXiv, medRxiv, and bioRxiv from inception to May 13–16, 2020. Inclusion criteria: primary studies, reviews, and meta-analyses; reporting the impact of epidemics; with a primary outcome of suicide, suicidal behavior, suicidal ideation, and/or self-harm. Exclusion criteria: not concerned with suicide-related outcomes; not suitable for data extraction. PROSPERO registration: #CRD42020187013. Results: Eight primary papers were included, examining the effects of five epidemics on suicide-related outcomes. There was evidence of increased suicide rates among older adults during SARS and in the year following the epidemic (possibly motivated by social disconnectedness, fears of virus infection, and concern about burdening others) and associations between SARS/Ebola exposure and increased suicide attempts. A preprint study reported associations between COVID-19 distress and past-month suicidal ideation. Limitations: Few studies have investigated the topic; these are of relatively low methodological quality. Conclusion: Findings support an association between previous epidemics and increased risk of suicide-related outcomes. Research is needed to investigate the impact of COVID-19 on suicide outcomes.

The Centre for Data and Knowledge Integration for Health (CIDACS): Linking Health and Social Data in Brazil

The Centre for Data and Knowledge Integration for Health (CIDACS) was created in 2016 in Salvador, Bahia-Brazil with the objective of integrating data and knowledge aiming to answer scientific questions related to the health of the Brazilian population. This article details our experiences in the establishment and operations of CIDACS, as well as efforts made to obtain high-quality linked data while adhering to security, ethical use and privacy issues. Every effort has been made to conduct operations while implementing appropriate structures, procedures, processes and controls over the original and integrated databases in order to provide adequate datasets to answer relevant research questions. Looking forward, CIDACS is expected to be an important resource for researchers and policymakers interested in enhancing the evidence base pertaining to different aspects of health, in particular when investigating, from a nation-wide perspective, the role of social determinants of health and the effects of social and environmental policies on different health outcomes.

Government of Malawi's unconditional cash transfer improves youth mental health

We explore the impacts of Malawi's national unconditional cash transfer program targeting ultra-poor households on youth mental health. Experimental findings show that the program significantly improved mental health outcomes. Among girls in particular, the program reduces indications of depression by about 15 percentage points. We investigate the contribution of different possible pathways to the overall program impact, including education, health, consumption, caregiver's stress levels and life satisfaction, perceived social support, and participation in hard and unpleasant work. The pathways explain from 46 to 65 percent of the program impact, advancing our understanding of how economic interventions can affect mental health of youth in resource-poor settings. The findings underline that unconditional cash grants, which are used on an increasingly large scale as part of national social protection systems in Sub-Saharan Africa, have the potential to improve youth mental wellbeing and thus may help break the vicious cycle of poverty and poor mental health.