Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data

Current and Projected Mortality and Hospitalization Rates Associated With Conditional Cash Transfer, Social Pension, and Primary Health Care Programs in Brazil, 2000-2030

Importance

The health outcomes of increased poverty and inequalities in low- and middle-income countries (LMICs) have been substantially amplified as a consequence of converging multiple crises. Brazil has some of the world's largest conditional cash transfer (Programa Bolsa Família [PBF]), social pension (Beneficio de Prestacão Continuada [BPC]), and primary health care (Estratégia de Saúde da Família [ESF]) programs that could act as mitigating interventions during the current polycrisis era of increasing poverty, slow or contracting economic growth, and conflicts.

Objective

To evaluate the combined association of the Brazilian conditional cash transfer, social pension, and primary health care programs with the reduction of morbidity and mortality over the last 2 decades and forecast their potential mitigation of the current global polycrisis and beyond.

Design, Setting, and Participants

This cohort study used a longitudinal ecological design with multivariable negative binomial regression models (adjusted for relevant socioeconomic, demographic, and health care variables) integrating the retrospective analysis from 2000 to 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. Participants included a cohort of 2548 Brazilian municipalities from 2004 to 2019, projected from 2020 to 2030. Data analysis was performed from September 2022 to February 2023.

Exposure

PBF coverage of the target population (those who were poorest) was categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). ESF coverage was categorized as null (0), low (0.1%-29.9%), intermediate (30.0%-69.9%), and consolidated (70.0%-100%). BPC coverage was categorized by terciles.

Main outcomes and measures

Age-standardized, all-cause mortality and hospitalization rates calculated for the entire population and by age group (<5 years, 5-29 years, 30-69 years, and ≥70 years).

Results

Among the 2548 Brazilian municipalities studied from 2004 to 2019, the mean (SD) age-standardized mortality rate decreased by 16.64% (from 6.73 [1.14] to 5.61 [0.94] deaths per 1000 population). Consolidated coverages of social welfare programs studied were all associated with reductions in overall mortality rates (PBF: rate ratio [RR], 0.95 [95% CI, 0.94-0.96]; ESF: RR, 0.93 [95% CI, 0.93-0.94]; BPC: RR, 0.91 [95% CI, 0.91-0.92]), having all together prevented an estimated 1 462 626 (95% CI, 1 332 128-1 596 924) deaths over the period 2004 to 2019. The results were higher on mortality for the group younger than age 5 years (PBF: RR, 0.87 [95% CI, 0.85-0.90]; ESF: RR, 0.89 [95% CI, 0.87-0.93]; BPC: RR, 0.84 [95% CI, 0.82-0.86]), on mortality for the group aged 70 years and older, and on hospitalizations. Considering a shorter scenario of economic crisis, a mitigation strategy that will increase the coverage of PBF, BPC, and ESF to proportionally cover the newly poor and at-risk individuals was projected to avert 1 305 359 (95% CI, 1 163 659-1 449 256) deaths and 6 593 224 (95% CI, 5 534 591-7 651 327) hospitalizations up to 2030, compared with fiscal austerity scenarios that would reduce the coverage of these interventions.

Conclusions and relevance

This cohort study's results suggest that combined expansion of conditional cash transfers, social pensions, and primary health care should be considered a viable strategy to mitigate the adverse health outcomes of the current global polycrisis in LMICs, whereas the implementation of fiscal austerity measures could result in large numbers of preventable deaths.

Income Segregation, Conditional Cash Transfers, and Breast Cancer Mortality Among Women in Brazil

Importance

Women living in income-segregated areas are less likely to receive adequate breast cancer care and access community resources, which may heighten breast cancer mortality risk.

Objective

To investigate the association between income segregation and breast cancer mortality and whether this association is attenuated by receipt of the Bolsa Família program (BFP), the world's largest conditional cash-transfer program.

Design, Setting, and Participants

This cohort study was conducted using data from the 100 Million Brazilian Cohort, which were linked with nationwide mortality registries (2004-2015). Data were analyzed from December 2021 to June 2023. Study participants were women aged 18 to 100 years.

Exposure

Women's income segregation (high, medium, or low) at the municipality level was obtained using income data from the 2010 Brazilian census and assessed using dissimilarity index values in tertiles (low [0.01-0.25], medium [0.26-0.32], and high [0.33-0.73]).

Main Outcomes and Measures

The main outcome was breast cancer mortality. Mortality rate ratios (MRRs) for the association of segregation with breast cancer deaths were estimated using Poisson regression adjusted for age, race, education, municipality area size, population density, area of residence (rural or urban), and year of enrollment. Multiplicative interactions of segregation and BFP receipt (yes or no) in the association with mortality (2004-2015) were assessed.

Results

Data on 21 680 930 women (mean [SD] age, 36.1 [15.3] years) were analyzed. Breast cancer mortality was greater among women living in municipalities with high (adjusted MRR [aMRR], 1.18; 95% CI, 1.13-1.24) and medium (aMRR, 1.08; 95% CI, 1.03-1.12) compared with low segregation. Women who did not receive BFP had higher breast cancer mortality than BFP recipients (aMRR, 1.17; 95% CI, 1.12-1.22). By BFP strata, women who did not receive BFP and lived in municipalities with high income segregation had a 24% greater risk of death from breast cancer compared with those living in municipalities with low income segregation (aMRR, 1.24: 95% CI, 1.14-1.34); women who received BFP and were living in areas with high income segregation had a 13% higher risk of death from breast cancer compared with those living in municipalities with low income segregation (aMRR, 1.13; 95% CI, 1.07-1.19; P for interaction = .008). Stratified by the amount of time receiving the benefit, segregation (high vs low) was associated with an increase in mortality risk for women receiving BFP for less time but not for those receiving it for more time (<4 years: aMRR, 1.16; 95% CI, 1.07-1.27; 4-11 years: aMRR, 1.09; 95% CI, 1.00-1.17; P for interaction <.001).

Conclusions and Relevance

These findings suggest that place-based inequities in breast cancer mortality associated with income segregation may be mitigated with BFP receipt, possibly via improved income and access to preventive cancer care services among women, which may be associated with early detection and treatment and ultimately reduced mortality.

The combined effect of social pensions and cash transfers on child mortality: evaluating the last two decades in Brazil and projecting their mitigating effect during the global economic crisis

Background

The world is currently experiencing multiple economic crises due to the COVID-19 pandemic, war in Ukraine, and inflation surge, which disproportionately affect children, especially in low- and middle-income countries (LMICs). We evaluated if the expansion of Social Assistance, represented by Social Pensions (SP) and Conditional Cash Transfers (CCT), could reduce infant and child mortality, and mitigate excess deaths among children in Brazil, one of the LMICs most affected by these economic crises.

Methods

We conducted a retrospective impact evaluation in a cohort of Brazilian municipalities from 2004 to 2019 using multivariable fixed-effects negative binomial models, adjusted for relevant demographic, social, and economic factors, to estimate the effects of the SP and CCT on infant and child mortality. To verify the robustness of the results, we conducted several sensitivity and triangulation analyses, including difference-in-difference with propensity-score matching. These results were incorporated into dynamic microsimulation models to generate projections to 2030 of various economic crises and Social Assistance scenarios.

Findings

Consolidated coverage of SP was associated with significant reductions in infant and child mortality rates, with a rate ratio (RR) of 0.843 (95% CI: 0.826-0.861) and 0.840 (95% CI: 0.824-0.856), respectively. Similarly, CCT consolidated coverages showed RRs of 0.868 (95% CI: 0.842-0.849) and 0.874 (95% CI: 0.850-0.899) for infant and child mortality, respectively. The higher the degree of poverty in the municipalities, the stronger the impact of CCT on reducing child mortality. Given the current economic crisis, a mitigation strategy that will increase the coverage of SP and CCT could avert 148,736 (95% CI: 127,148-170,706) child deaths up to 2030, compared with fiscal austerity measures.

Interpretation

SP and CCT programs could strongly reduce child mortality in LMICs, and their expansion should be considered as an effective strategy to mitigate the impact of the current multiple global economic crises.

Funding

Bill & Melinda Gates Foundation, Grant_Number:INV-027961. Medical Research Council(MRC-UKRI),Grant_Number:MC_PC_MR/T023678/1.

Implementation of strategies and programs for breastfeeding, complementary feeding, and malnutrition of young children in Brazil: advances and challenges

Malnutrition in all its forms has risen on global agendas due to the recognition of its magnitude and consequences for a wide range of human, social, and economic outcomes. Implementing strategies and programs with the needed scale and quality is a major challenge. The Brazilian National Survey on Child Nutrition (ENANI-2019) pointed out several advances but numerous challenges. In this paper, we reflect on the implementation progress of breastfeeding, complementary feeding and young children malnutrition strategies and programs in Brazil and how existing challenges can be overcome through the lens of implementation science. First, we present a brief history of such programs. Second, we selected two breastfeeding initiatives to illustrate and reflect on common implementation challenges. In these case studies, we used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to analyze the implementation and scaling up barriers and facilitators. We found common barriers related to unclear goals about the reach of programs, challenges in assessing effectiveness and fidelity/quality during the real-world implementation, discontinuation or lack of funding, and lack of monitoring and evaluation impacting the sustainability of programs. We also discuss the use of implementation science to achieve adequate nutrition by 2030 and present critical elements for successful scale implementation of nutrition programs based on global evidence. Despite the investment to implement different actions aimed at facing infant feeding and malnutrition, high-quality implementation research must become a priority to catalyze progress in Brazil.

Evaluation and Forecasting Analysis of the Association of Conditional Cash Transfer With Child Mortality in Latin America, 2000-2030

Importance

Latin America has implemented the world's largest and most consolidated conditional cash transfer (CCT) programs during the last 2 decades. As a consequence of the COVID-19 pandemic, poverty rates have markedly increased, and a large number of newly low-income individuals, especially children, have been left unprotected.

Objective

To evaluate the association of CCT programs with child health in Latin American countries during the last 2 decades and forecast child mortality trends up to 2030 according to CCT alternative implementation options.

Design, Setting, and Participants

This cohort study used a multicountry, longitudinal, ecological design with multivariable negative binomial regression models, which were adjusted for all relevant demographic, socioeconomic, and health care variables, integrating the retrospective impact evaluations from January 1, 2000, to December 31, 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. The study cohort included 4882 municipalities from Brazil, Ecuador, and Mexico with adequate quality of civil registration and vital statistics according to a validated multidimensional criterion. Data analysis was performed from September 2022 to February 2023.

Exposure

Conditional cash transfer coverage of the target (lowest-income) population categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%).

Main Outcomes and Measures

The main outcomes were mortality rates for those younger than 5 years and hospitalization rates (per 1000 live births), overall and by poverty-related causes (diarrheal, malnutrition, tuberculosis, malaria, lower respiratory tract infections, and HIV/AIDS), and the mortality rates for those younger than 5 years by age groups, namely, neonatal (0-28 days), postneonatal (28 days to 1 year), infant (<1 year), and toddler (1-4 years).

Results

The retrospective analysis included 4882 municipalities. During the study period of January 1, 2000, to December 31, 2019, mortality in Brazil, Ecuador, and Mexico decreased by 7.8% in children and 6.5% in infants, and an increase in coverage of CCT programs of 76.8% was observed in these Latin American countries. Conditional cash transfer programs were associated with significant reductions of mortality rates in those younger than 5 years (rate ratio [RR], 0.76; 95% CI, 0.75-0.76), having prevented 738 919 (95% CI, 695 641-782 104) child deaths during this period. The association of highest coverage of CCT programs was stronger with poverty-related diseases, such as malnutrition (RR, 0.33; 95% CI, 0.31-0.35), diarrhea (RR, 0.41; 95% CI, 0.40-0.43), lower respiratory tract infections (RR, 0.66, 95% CI, 0.65-0.68), malaria (RR, 0.76; 95% CI, 0.63-0.93), tuberculosis (RR, 0.62; 95% CI, 0.48-0.79), and HIV/AIDS (RR, 0.32; 95% CI, 0.28-0.37). Several sensitivity and triangulation analyses confirmed the robustness of the results. Considering a scenario of moderate economic crisis, a mitigation strategy that will increase the coverage of CCTs to protect those newly in poverty could reduce the mortality rate for those younger than 5 years by up to 17% (RR, 0.83; 95% CI, 0.80-0.85) and prevent 153 601 (95% CI, 127 441-180 600) child deaths by 2030 in Brazil, Ecuador, and Mexico.

Conclusions and Relevance

The results of this cohort study suggest that the expansion of CCT programs could strongly reduce childhood hospitalization and mortality in Latin America and should be considered an effective strategy to mitigate the health impact of the current global economic crisis in low- and middle-income countries.

The effects of cash transfers on adult and child mortality in low- and middle-income countries

Poverty is an important social determinant of health that is associated with increased risk of death^1-5. Cash transfer programmes provide non-contributory monetary transfers to individuals or households, with or without behavioural conditions such as children's school attendance^6,7. Over recent decades, cash transfer programmes have emerged as central components of poverty reduction strategies of many governments in low- and middle-income countries^6,7. The effects of these programmes on adult and child mortality rates remains an important gap in the literature, however, with existing evidence limited to a few specific conditional cash transfer programmes, primarily in Latin America^8-14. Here we evaluated the effects of large-scale, government-led cash transfer programmes on all-cause adult and child mortality using individual-level longitudinal mortality datasets from many low- and middle-income countries. We found that cash transfer programmes were associated with significant reductions in mortality among children under five years of age and women. Secondary heterogeneity analyses suggested similar effects for conditional and unconditional programmes, and larger effects for programmes that covered a larger share of the population and provided larger transfer amounts, and in countries with lower health expenditures, lower baseline life expectancy, and higher perceived regulatory quality. Our findings support the use of anti-poverty programmes such as cash transfers, which many countries have introduced or expanded during the COVID-19 pandemic, to improve population health.

The dose-response association between LEAP 1000 and birthweight - no clear mechanisms: a structural equation modeling approach

BACKGROUND

Birthweight is an important indicator of maternal and fetal health globally. The multifactorial origins of birthweight suggest holistic programs that target biological and social risk factors have great potential to improve birthweight. In this study, we examine the dose-response association of exposure to an unconditional cash transfer program before delivery with birthweight and explore the potential mediators of the association.

METHODS

Data for this study come from the Livelihood Empowerment Against Poverty (LEAP) 1000 impact evaluation conducted between 2015 and 2017 among a panel sample of 2,331 pregnant and lactating women living in rural households of Northern Ghana. The LEAP 1000 program provided bi-monthly cash transfers and premium fee waivers to enroll in the National Health Insurance Scheme (NHIS). We used adjusted and unadjusted linear and logistic regression models to estimate the associations of months of LEAP 1000 exposure before delivery with birthweight and low birthweight, respectively. We used covariate-adjusted structural equation models (SEM) to examine mediation of the LEAP 1000 dose-response association with birthweight by household food insecurity and maternal-level (agency, NHIS enrollment, and antenatal care) factors.

RESULTS

Our study included a sample of 1,439 infants with complete information on birthweight and date of birth. Nine percent of infants (N = 129) were exposed to LEAP 1000 before delivery. A 1-month increase in exposure to LEAP 1000 before delivery was associated with a 9-gram increase in birthweight and 7% reduced odds of low birthweight, on average, in adjusted models. We found no mediation effect by household food insecurity, NHIS enrollment, women's agency, or antenatal care visits.

CONCLUSIONS

LEAP 1000 cash transfer exposure before delivery was positively associated with birthweight, though we did not find any mediation by household- or maternal-level factors. The results of our mediation analyses may serve to inform program operations and improve targeting and programming to optimize health and well-being among this population.

TRIAL REGISTRATION

The evaluation is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations (RIDIESTUDY- ID-55942496d53af) and in the Pan African Clinical Trial Registry (PACTR202110669615387).

The impact of a randomized cash transfer intervention on mortality of adult household members in rural South Africa, 2011-2022

BACKGROUND

Increasing socioeconomic resources through cash transfer payments could help promote healthy longevity. However, research in this area is limited due to endogeneity in cash transfer exposures and limited geographic representation.

METHODS

We leveraged the HPTN 068 randomized cash transfer trial, conducted from 2011 to 2015 in a rural setting in South Africa. We assessed long-term mortality follow-up (until March 2022) on older adult members (n = 3568) of households enrolled in the trial from the complete Agincourt Health and socio-Demographic Surveillance System census of the underlying source population. The trial intervention was a monthly cash payment of 300 Rand conditional on school enrollment of index young women. The payments were split between the young woman (1/3) and their caregiver (2/3). Young women and their households were randomized 1:1 to intervention vs. control. We used Cox PH models to compare mortality rates in older adults living in intervention vs. control households.

FINDINGS

The cash transfer intervention did not significantly impact mortality in the full sample [HR (95% CI): 0.94 (0.80, 1.10)]. However, we observed strong protective effects of the cash transfer intervention among those with above-median household assets [HR (95% CI): 0.66 (0.50, 0.86)] and higher educational attainment [HR (95% CI): 0.37 (0.15, 0.93)].

INTERPRETATION

Our findings indicate that short-term cash transfers can lead to reduced mortality in certain subgroups of older adults with higher baseline socioeconomic status. Future work should focus on understanding the optimal timing, structure, and targets to maximize the benefits of cash transfer programs in promoting healthy aging and longevity.

Women and health professionals' perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study

OBJECTIVES

Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns.

DESIGN

Prospective qualitative research.

SETTING

We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial.

PARTICIPANTS

26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs.

INTERVENTIONS

We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth.

RESULTS

Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT.

CONCLUSIONS

In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby's birth.

TRIAL REGISTRATION NUMBER

NCT02402855.

Spatial-temporal distribution of incidence, mortality, and case-fatality ratios of coronavirus disease 2019 and its social determinants in Brazilian municipalities

The COVID-19 pandemic caused impact on public health worldwide. Brazil gained prominence during the pandemic due to the magnitude of disease. This study aimed to evaluate the spatial-temporal dynamics of incidence, mortality, and case fatality of COVID-19 and its associations with social determinants in Brazilian municipalities and epidemiological week. We modeled incidence, mortality, and case fatality rates using spatial-temporal Bayesian model. "Bolsa Família Programme" (BOLSAFAM) and "proportional mortality ratio" (PMR) were inversely associated with the standardized incidence ratio (SIR), while "health insurance coverage" (HEALTHINSUR) and "Gini index" were directly associated with the SIR. BOLSAFAM and PMR were inversely associated with the standardized mortality ratio (SMR) and standardized case fatality ratio (SCFR). The highest proportion of excess risk for SIR and the SMR started in the North, expanding to the Midwest, Southeast, and South regions. The highest proportion of excess risk for the SCFR outcome was observed in some municipalities in the North region and in the other Brazilian regions. The COVID-19 incidence and mortality in municipalities that most benefited from the cash transfer programme and with better social development decreased. The municipalities with a higher proportion of non-whites had a higher risk of becoming ill and dying from the disease.

Association of Conditional Cash Transfers With Maternal Mortality Using the 100 Million Brazilian Cohort

IMPORTANCE

Conditional cash transfers (CCTs) have been consistently associated with improvements to the determinants of maternal health, but there have been insufficient investigations regarding their effects on maternal mortality.

OBJECTIVE

To evaluate the association between being a Bolsa Família program (BFP) beneficiary and maternal mortality and to examine how this association differs by duration of BFP receipt, maternal race, living in rural or urban areas, the Municipal Human Development Index (MHDI), and municipal primary health care coverage.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis was nested within the 100 Million Brazilian Cohort. Girls and women aged 10 to 49 years (hereinafter referred to as women) who had at least 1 live birth were included, using data from Brazilian national health databases linked to the 100 Million Brazilian Cohort (January 1, 2004, to December 31, 2015). Propensity score kernel weighting was applied to control for sociodemographic and economic confounders in the association between BFP receipt and maternal mortality, overall and stratified by different subgroups (race, urban or rural area, and MHDI), and duration of BFP receipt. Data were analyzed from July 12, 2019, to December 31, 2022.

MAIN OUTCOME(S) AND MEASURES

Maternal death.

RESULTS

A total of 6 677 273 women aged 10 to 49 years were included in the analysis, 4056 of whom had died from pregnancy-related causes. The risk of maternal death was 18% lower in women who received BFP (weighted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]). A longer duration receiving BFP was associated with an increased reduction in maternal mortality (OR for 1-4 years, 0.85 [95% CI, 0.75-0.97]; OR for 5-8 years, 0.70 [95% CI, 0.60-0.82]; OR for ≥9 years, 0.69 [95% CI, 0.53-0.88]). Receiving BFP was also associated with substantial increases in the number of prenatal appointments and interbirth intervals. The reduction was more pronounced in the most vulnerable groups.

CONCLUSIONS AND RELEVANCE

This cross-sectional analysis nested within the 100 Million Brazilian Cohort found an association between BFP receipt and maternal mortality. This association was of greater magnitude in women with longer exposure to BFP and in the most vulnerable groups. These findings reinforce evidence that programs such as BFP, which have already proven effective in poverty reduction, have great potential to improve maternal survival.

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.

Global disease burden and trends of leukemia attributable to occupational risk from 1990 to 2019: An observational trend study

Background

Leukemia caused by occupational risk is a problem that needs more attention and remains to be solved urgently, especially for acute lymphoid leukemia (ALL), acute myeloid leukemia (AML), and chronic lymphoid leukemia (CLL). However, there is a paucity of literature on this issue. We aimed to assess the global burden and trends of leukemia attributable to occupational risk from 1990 to 2019.

Methods

This observational trend study was based on the Global Burden of Disease (GBD) 2019 database, the global deaths, and disability-adjusted life years (DALYs), which were calculated to quantify the changing trend of leukemia attributable to occupational risk, were analyzed by age, year, geographical location, and socio-demographic index (SDI), and the corresponding estimated annual percentage change (EAPC) values were calculated.

Results

Global age-standardized DALYs and death rates of leukemia attributable to occupational risk presented significantly decline trends with EAPC [-0.38% (95% CI: -0.58 to -0.18%) for DALYs and -0.30% (95% CI: -0.45 to -0.146%) for death]. However, it was significantly increased in people aged 65-69 years [0.42% (95% CI: 0.30-0.55%) for DALYs and 0.38% (95% CI: 0.26-0.51%) for death]. At the same time, the age-standardized DALYs and death rates of ALL, AML, and CLL were presented a significantly increased trend with EAPCs [0.78% (95% CI: 0.65-0.91%), 0.87% (95% CI: 0.81-0.93%), and 0.66% (95% CI: 0.51-0.81%) for DALYs, respectively, and 0.75% (95% CI: 0.68-0.82%), 0.96% (95% CI: 0.91-1.01%), and 0.55% (95% CI: 0.43-0.68%) for death], respectively. The ALL, AML, and CLL were shown an upward trend in almost all age groups.

Conclusion

We observed a substantial reduction in leukemia due to occupational risks between 1990 and 2019. However, the people aged 65-69 years and burdens of ALL, AML, and CLL had a significantly increased trend in almost all age groups. Thus, there remains an urgent need to accelerate efforts to reduce leukemia attributable to occupational risk-related death burden in this population and specific causes.

Effect of a conditional cash transfer programme on AIDS incidence, hospitalisations, and mortality in Brazil: a longitudinal ecological study

BACKGROUND

One of the biggest challenges of the response to the AIDS epidemic is to reach the poorest people. In 2004, Brazil implemented one of the world's largest conditional cash transfer programmes, the Bolsa Família Programme (BFP). We aimed to evaluate the effect of BFP coverage on AIDS incidence, hospitalisations, and mortality in Brazil.

METHODS

In this longitudinal ecological study, we developed a conceptual framework linking key mechanisms of BFP effects on AIDS indicators and used ecological panel data from 5507 Brazilian municipalities over the period of 2004-18. We used government sources to calculate municipal-level AIDS incidence, hospitalisation, and mortality rates, and used multivariable regressions analyses of panel data with fixed-effects negative binomial models to estimate the effect of BFP coverage, which was classified as low (0-29%), intermediate (30-69%), and high (≥70%), on AIDS indicators, while adjusting for all relevant demographic, socioeconomic, and health-care covariates at the municipal level.

FINDINGS

Between 2004 and 2018, in the municipalities under study, 601 977 new cases of AIDS were notified, of which 376 772 (62·6%) were in males older than 14 years, 212 465 (35·3%) were in females older than 14 years, and 12 740 (2·1%) were in children aged 14 years or younger. 533 624 HIV/AIDS-related hospitalisations, and 176 868 AIDS-related deaths had been notified. High BFP coverage was associated with reductions in incidence rate ratios of 5·1% (95% CI 0·9-9·1) for AIDS incidence, 14·3% (7·7-20·5) for HIV/AIDS hospitalisations, and 12·0% (5·2-18·4) for AIDS mortality. The effect of the BFP on AIDS indicators was more pronounced in municipalities with higher AIDS endemicity levels, with reductions in incidence rate ratios of 12·7% (95% CI 5·4-19·4) for AIDS incidence, 21·1% (10·7-30·2) for HIV/AIDS hospitalisations, and 14·7% (3·2-24·9) for AIDS-related mortality, and reductions in AIDS incidence of 14·6% (5·9-22·5) in females older than 14 years, 9·7% (1·4-17·3) in males older than 14 years, and 24·5% (0·5-42·7) in children aged 14 years or younger.

INTERPRETATION

The effect of BFP coverage on AIDS indicators in Brazil could be explained by the reduction of households' poverty and by BFP health-related conditionalities. The protection of the most vulnerable populations through conditional cash transfers could contribute to the reduction of AIDS burden in low-income and middle-income countries.

FUNDING

US National Institute of Allergy and Infectious Diseases, National Institutes of Health.

TRANSLATION

For the Portugese translation of the abstract see Supplementary Materials section.

Sociodemographic inequalities in the trends of different types of leisure-time physical activity among Brazilian adults between 2006 and 2019

Background

The current study aimed to describe the trends in gender, ethnicity, and education inequalities of types of leisure-time physical activity (LTPA) practiced by Brazilian adults from 2006 to 2019.

Methods

We used data from 2006 to 2019 of the Brazilian Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey, which is an annual survey with a representative sample of adults (≥ 18y) living in state capital cities. The types of LTPA considered were walking, running, strength/gymnastics, sports, other LTPA, and no LTPA participation. Gender (women or men), ethnicity (white, black, brown, or yellow/indigenous), and years of formal education were also self-reported. We used relative frequencies and their respective 95% confidence intervals to analyze trends. The absolute and relative differences between the proportions were used to assess the inequalities.

Results

We observed increases in inequalities related to gender and education (running and strength/gymnastics), while gender inequalities for sports, other types, and no LTPA participation decreased. There were persistent inequalities related to gender (walking) and education (sports, other types, and no LTPA participation). Considering ethnicity, we noted increases in inequality for strength/gymnastics, where white adults were more active than black and brown adults. In addition, white adults reported more access to LTPA than brown adults over the years analyzed.

Conclusion

Women, black and brown people, and subjects with less schooling were the most unfavored groups. While some inequalities persisted over the years, others increased, such as ethnicity and education inequalities for strength/gymnastics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01728-y.

Prevalence of vitamin A deficiency in women of childbearing age in Brazil: a systematic review and meta-analysis

Vitamin A is an essential micronutrient, especially during pregnancy. We aimed to assess the prevalence of vitamin A deficiency in Brazilian women of childbearing age. We conducted a systematic review with meta-analysis of studies that assessed vitamin A deficiency in women of childbearing age following the registered protocol (CRD42020171856). Independent peer researchers selected the studies retrieved from MEDLINE, Embase, Scopus and other sources. Data from the eligible studies were extracted in pairs and assessed for methodological quality. The prevalence of vitamin A deficiency (< 0·70 µmol/l or <0·20 µg/dl) and 95 % CI was combined by meta-analysis, and heterogeneity was estimated by I². Out of 3610 screened records, thirty-two studies were included, which assessed 12 577 women from 1965 to 2017, mostly in maternity hospitals. Main limitations of the studies were in sample frame (30/32) and sampling method (29/32). Deficiency occurred in 13 % (95 % CI 9·4, 17·2 %; I² = 97 %) of all women and was higher in pregnant women (16·1 %; 95 % CI 5·6, 30·6 %; I² = 98 %) than non-pregnant women (12·3 %; 95 % CI 8·4, 16·8 %; I² = 96 %). The prevalence increased according to the decade, from 9·5 % (95 % CI 1·9–21·6 %; I² = 98 %) up to 1990, 10·8 % (95 % CI 7·9, 14·2 %; I² = 86 %) in the 2000s and 17·8 % (95 % CI 8·7, 29·0 %; I² = 98 %) in the 2010s. Over 10 % of Brazilian women in childbearing age were deficient in vitamin A. Higher prevalence was observed in pregnant women, and deficiency seemed to be increasing over the decades. Low representativeness of the studies, mainly based on convenience sampling that included pregnant, postpartum, lactating and non-pregnant women, as well as high heterogeneity, limits the findings.