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.

Understanding the social determinants of child mortality in Latin America over the last two decades: a machine learning approach.

The reduction of child mortality rates remains a significant global public health challenge, particularly in regions with high levels of inequality such as Latin America. We used machine learning (ML) algorithms to explore the relationship between social determinants and child under-5 mortality rates (U5MR) in Brazil, Ecuador, and Mexico over two decades. We created a municipal-level cohort from 2000 to 2019 and trained a random forest model (RF) to estimate the relative importance of social determinants in predicting U5MR. We conducted a sensitivity analysis training two more ML models and presenting the mean square error, root mean square error, and median absolute deviation. Our findings indicate that poverty, illiteracy, and the Gini index were the most important variables for predicting U5MR according to the RF. Furthermore, non-linear relationships were found mainly for Gini index and U5MR. Our study suggests that long-term public policies to reduce U5MR in Latin America should focus on reducing poverty, illiteracy, and socioeconomic inequalities. This research provides important insights into the relationships between social determinants and child mortality rates in Latin America. The use of ML algorithms, combined with large longitudinal data, allowed us to evaluate the effects of social determinants on health more carefully than traditional models.

Potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people: A conceptual framework and lines of enquiry for research and policy.

Mental health is inextricably linked to both poverty and future life chances such as education, skills, labour market attachment and social function. Poverty can lead to poorer mental health, which reduces opportunities and increases the risk of lifetime poverty. Cash transfer programmes are one of the most common strategies to reduce poverty and now reach substantial proportions of populations living in low- and middle-income countries. Because of their rapid expansion in response to the COVID-19 pandemic, they have recently gained even more importance. Recently, there have been suggestions that these cash transfers might improve youth mental health, disrupting the cycle of disadvantage at a critical period of life. Here, we present a conceptual framework describing potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people. Furthermore, we explore how theories from behavioural economics and cognitive psychology could be used to more specifically target these mechanisms and optimise the impact of cash transfers on youth mental health and life chances. Based on this, we identify several lines of enquiry and action for future research and policy.

Wealth and inequality gradients for the detection and control of hypertension in older individuals in middle-income economies around 2007-2015.

Socioeconomic inequalities in the detection and treatment of non-communicable diseases represent a challenge for healthcare systems in middle-income countries (MICs) in the context of population ageing. This challenge is particularly pressing regarding hypertension due to its increasing prevalence among older individuals in MICs, especially among those with lower socioeconomic status (SES). Using comparative data for China, Colombia, Ghana, India, Mexico, Russia and South Africa, we systematically assess the association between SES, measured in the form of a wealth index, and hypertension detection and control around the years 2007-15. Furthermore, we determine what observable factors, such as socio-demographic and health characteristics, explain existing SES-related inequalities in hypertension detection and control using a Blinder-Oaxaca decomposition. Results show that the prevalence of undetected hypertension is significantly associated with lower SES. For uncontrolled hypertension, there is evidence of a significant gradient in three of the six countries at the time the data were collected. Differences between rural and urban areas as well as lower and higher educated individuals account for the largest proportion of SES-inequalities in hypertension detection and control at the time. Improved access to primary healthcare in MICs since then may have contributed to a reduction in health inequalities in detection and treatment of hypertension. However, whether this indeed has been the case remains to be investigated.

Inequality in Place: Effects of Exposure to Neighborhood-Level Economic Inequality on Mortality.

This study contributes to the debate on whether income inequality is harmful for health by addressing several analytical weaknesses of previous studies. Using the Panel Study of Income Dynamics in combination with tract-level measures of income inequality in the United States, we estimate the effects of differential exposure to income inequality during three decades of the life course on mortality. Our study is among the first to consider the implications of income inequality within U.S. tracts for mortality using longitudinal and individual-level data. In addition, we improve upon prior work by accounting for the dynamic relationship between local areas and individuals' health, using marginal structural models to account for changes in exposure to local income inequality. In contrast to other studies that found no significant relation between income inequality and mortality, we find that recent exposure to higher local inequality predicts higher relative risk of mortality among individuals at ages 45 or older.

Educational inequalities in obesity: a multilevel analysis of survey data from cities in Latin America.

OBJECTIVE: Using newly harmonised individual-level data on health and socio-economic environments in Latin American cities (from the Salud Urbana en América Latina (SALURBAL) study), we assessed the association between obesity and education levels and explored potential effect modification of this association by city-level socio-economic development. DESIGN: This cross-sectional study used survey data collected between 2002 and 2017. Absolute and relative educational inequalities in obesity (BMI ≥ 30 kg/m2, derived from measured weight and height) were calculated first. Then, a two-level mixed-effects logistic regression was run to test for effect modification of the education-obesity association by city-level socio-economic development. All analyses were stratified by sex. SETTING: One hundred seventy-six Latin American cities within eight countries (Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico and Peru). PARTICIPANTS: 53 186 adults aged >18 years old. RESULTS: Among women, 25 % were living with obesity and obesity was negatively associated with educational level (higher education-lower obesity) and this pattern was consistent across city-level socio-economic development. Among men, 18 % were living with obesity and there was a positive association between education and obesity (higher education-higher obesity) for men living in cities with lower levels of development, whereas for those living in cities with higher levels of development, the pattern was inverted and university education was protective of obesity. CONCLUSIONS: Among women, education was protective of obesity regardless, whereas among men, it was only protective in cities with higher levels of development. These divergent results suggest the need for sex- and city-specific interventions to reduce obesity prevalence and inequalities.

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.

Association Between Social Pensions With Depression, Social, and Health Behaviors Among Poor Older Individuals in Colombia.

OBJECTIVES: Many low- and middle-income countries have introduced social pensions to alleviate extreme poverty and improve the well-being of older individuals. However, evidence remains inconclusive about the potential effects of such programs on mental health, social, and health behaviors. METHODS: Data for individuals aged 60 or older came from the nationally representative Encuesta Nacional de Salud, Bienestar y Envejeciamiento survey in Colombia 2015 (N = 9,456). We used propensity score matching to estimate the association between the country's social pension program (Colombia Mayor) with depression, self-rated health, food insecurity, alcohol consumption, social participation, and labor force participation. RESULTS: Results show that receiving the program does not significantly affect the likelihood of suffering from depression or self-rated health among either men or women. However, receiving the program is associated with significant reductions in the likelihood of experiencing food insecurity and significant increases in the likelihood of participating socially. Among women, receiving the program is associated with significant reduction in the likelihood of participating in the labor force. DISCUSSION: The absence of a measurable effect on depression and self-rated health may be explained, at least partly, by the program's comparatively small cash benefit and the sharing of resources with other family members. Policymakers should assess possibilities to maximize the health and social benefits of social pensions.

Socio-economic inequalities in high blood pressure and additional risk factors for cardiovascular disease among older individuals in Colombia: Results from a nationally representative study.

BACKGROUND: Studies in high-income countries have documented a consistent gradient between socio-economic status (SES) and high blood pressure (HBP), a key risk factor for cardiovascular disease (CVD). However, evidence from Latin American countries (LA) remains comparatively scarce and inconclusive. DATA: Data for 3,984 individuals came from a nationally representative survey of individuals aged 60 years or above in Colombia (Encuesta de Salud, Bienestar y Envejecimiento) (SABE) conducted in 2015. SES was measured by educational achievement and household assets. CVD risk factors included objectively measured HBP and body mass index (BMI), as well as behaviors (smoking, alcohol consumption, fruit and vegetables intake, and physical activity). METHODS: Bivariate methods and multivariate regression models were used to assess associations between SES with HBP as well as additional risk factors for CVD. RESULTS: Individuals with lower SES have significantly higher risk of suffering from HBP. Compared to those with no formal education, individuals with secondary or post-secondary education have a 37% lower risk of HBP (odds ratio [OR] = 0.63, P-value<0.001). Being in the highest asset quartile (most affluent) is associated with a 44% lower risk (OR = 56, P-value = 0.001) of HBP compared to those in the lowest asset quartile (most deprived). Individuals with lower SES are more likely to smoke, not engage in regular physical activity and not regularly consume fruits or vegetables. In contrast, individuals with higher SES are more likely to consume alcohol and, those with more assets, more likely to be obese. CONCLUSIONS: Among older Colombians there exists a marked SES gradient in HBP as well as several additional risk factors for CVD. The results highlight the importance of a public health approach towards HBP and additional CVD risk factors that takes into account the specific conditions of older individuals, especially among disadvantaged groups.

Urban Transformations and Health: Methods for TrUST-a Natural Experiment Evaluating the Impacts of a Mass Transit Cable Car in Bogotá, Colombia.

Background: Cable cars provide urban mobility benefits for vulnerable populations. However, no evaluation has assessed cable cars' impact from a health perspective. TransMiCable in Bogotá, Colombia, provides a unique opportunity to (1) assess the effects of its implementation on the environmental and social determinants of health (microenvironment pollution, transport accessibility, physical environment, employment, social capital, and leisure time), physical activity, and health outcomes (health-related quality of life, respiratory diseases, and homicides); and (2) use citizen science methods to identify, prioritize, and communicate the most salient negative and positive features impacting health and quality of life in TransMiCable's area, as well as facilitate a consensus and advocacy-building change process among community members, policymakers, and academic researchers. Methods: TrUST (In Spanish: Transformaciones Urbanas y Salud: el caso de TransMiCable en Bogotá) is a quasi-experimental study using a mixed-methods approach. The intervention group includes adults from Ciudad Bolívar, the area of influence of TransMiCable. The control group includes adults from San Cristóbal, an area of future expansion for TransMiCable. A conceptual framework was developed through group-model building. Outcomes related to environmental and social determinants of health as well as health outcomes are assessed using questionnaires (health outcomes, physical activity, and perceptions), secondary data (crime and respiratory outcomes) use of portable devices (air pollution exposure and accelerometry), mobility tracking apps (for transport trajectories), and direct observation (parks). The Stanford Healthy Neighborhood Discovery Tool is being used to capture residents' perceptions of their physical and social environments as part of the citizen science component of the investigation. Discussion: TrUST is innovative in its use of a mixed-methods, and interdisciplinary research approach, and in its systematic engagement of citizens and policymakers throughout the design and evaluation process. This study will help to understand better how to maximize health benefits and minimize unintended negative consequences of TransMiCable.

Educational inequalities in disability linked to social security coverage among older individuals in five Latin American countries.

Although Latin American populations are ageing rapidly, many countries have important shortcomings in terms of access to social security coverage. Despite significant improvements regarding access to healthcare, the coverage gap in terms of pensions represents a major challenge for public health and equity in the region. The principal aim of this study was to systematically assess the association between social security coverage and disability among older individuals in five Latin American countries, as well as the extent of existing inequalities and its determinants. To do so we use cross-sectional and comparative data for individuals aged 60 and older in Chile, Colombia, El Salvador, Paraguay and Uruguay from the Longitudinal Social Protection Survey (ELPS). We used multivariate regression to assess the association between disability and healthcare as well as pension coverage. Concentration indices (CI) and an Oaxaca-Blinder decomposition approach were used to assess overall inequalities in disability according to education as well as their components. With the exception of El Salvador, we find significant inequalities in disability disfavoring lower educated individuals. With regards to healthcare, we find no significant association of healthcare coverage with disability in any of the five countries, nor does it explain educational inequalities in disability. However, pension access was associated with lower risks of disability in Chile, Colombia, Paraguay and Uruguay, and explains a substantial share of educational inequality in Chile, Colombia and Paraguay. Whereas significant changes have already been made regarding universal healthcare coverage, the results suggest that expanding access to pensions may not only lead to improvements in health among older individuals in the region, but also substantially reduce socio-economic inequalities in health and successful ageing.

The invisible wounds of five decades of armed conflict: inequalities in mental health and their determinants in Colombia.

ABSTARCT: OBJECTIVES: We analyzed the relation between exposure to the armed conflict and violence with mental health disorders in Colombia and assessed the extent and determinants of socioeconomic inequalities in mental health related to differential exposure to the conflict and violence. METHODS: Regression and decomposition analyses were used in combination with the 2015 nationally representative Mental Health Survey (N = 10,853). Mental health disorders were assessed using the Self-Reporting Questionnaire (SRQ 20), and socioeconomic status by a Multidimensional Poverty Index. RESULTS: 3% of adults have been victim of a violent crime and 13% victim of the armed conflict. Victims of the armed conflict have 1.74 times higher odds (p < .05) of suffering mental health disorders compared to non-victims. Differential exposure to the armed conflict among lower socioeconomic groups explains 86% of total inequality in mental health disorders. CONCLUSIONS: Interventions that increase quality and access of mental health treatments among victims of the conflict will not only lead to improvements in mental health among victims but also significantly reduce inequalities in mental health in Colombia.

Social Pension Income Associated With Small Improvements In Self-Reported Health Of Poor Older Men In Colombia.

The countries of Latin American are aging rapidly. Because most countries in the region lack adequate social protection systems, many Latin American governments have introduced noncontributory pension programs to reduce poverty and food shortages. This study assessed the effects of a large national noncontributory pension program on the health and health care use of older people in Colombia. Using an instrumental variables approach that exploited differential rollout of the program across municipalities, we found evidence that the program led to significant but small improvements in self-reported health and reductions in hospitalizations among men. No significant effects were found among women or among men for other health and health care use outcomes. A small noncontributory pension was associated with improvements in self-reported measures of health for vulnerable older men, but these effects are small in magnitude. Researchers and policy makers should assess ways to maximize the health benefits of cash transfers to poor older people.

Trends and determinants of the Flynn effect in cognitive functioning among older individuals in 10 European countries.

BACKGROUND: Although cognitive performance levels in old age have increased in most countries, recent evidence documents a slowing down or even decline in cohort gains in highly developed countries. The aim of this study was to assess trends and determinants in secular cohort gains in cognitive functioning among older individuals and whether cohort gains are levelling off in most advanced countries. METHODS: Data for individuals aged between 50 and 84 years from the Survey of Health, Ageing and Retirement in Europe in 10 European countries between 2004 and 2013 (n=92 739) were used to assess country and age-specific changes in immediate word recall. Multivariate random intercept models were used to assess associations between secular cohort changes in immediate word recall, initial performance levels and changes in country-level socio-demographic characteristics. RESULTS: Performance in immediate word recall improved in all countries between 2004 and 2013 (from 4.40 to 5.08 words, P<0.05). However, secular cohort gains were significantly smaller in countries with initially higher performance levels (coeff.=-0.554, 95% CI -0.682 to -0.426). Changes in socio-demographic and health conditions, including decreases in cardiovascular disease, physical activity and educational achievement, were associated with larger secular cohort gains. CONCLUSIONS: Results may either reflect that some countries are approaching the limits of cognitive plasticity, are slowing in their progress or that societal structures have not yet been optimised to improve cognitive abilities in midlife and beyond, or a combination of these interpretations.

Economic Downturns, Retirement and Long-Term Cognitive Function Among Older Americans.

Objective: Workers approaching retirement may be particularly vulnerable to economic downturns. This study assesses whether exposure to economic downturns around retirement age leads to poorer cognitive function in later life. Method: Longitudinal data for 13,577 individuals in the Health and Retirement Study were linked to unemployment rates in state of residence. Random- and fixed-effect models were used to examine whether downturns at 55-64 years of age were associated with cognitive functioning levels and decline at ≥65 years, measured by the Wechsler Adult Intelligence Scale-Revised. Results: Longer exposure to downturns at 55-64 years of age was associated with lower levels of cognitive function at ≥65 years. Compared to individuals experiencing only up to 1 year in a downturn at 55-64 years of age, individuals experiencing two downturns at these ages had 0.09 point (95% Confidence Interval [CI, -0.17, -0.02]) lower cognitive functioning scores at ≥65 years (3 years: b = -0.17, 95%CI [-0.29, -0.06]; 4 years: b = -0.14, 95%CI [-0.25, -0.02]; ≥5 years: b = -0.22, 95%CI [-0.38, -0.06]). Downturns at 55-64 years of age were not associated with rates of cognitive decline. Discussion: Exposure to downturns around retirement is associated with a long-lasting decline in cognitive function in later life. Policies mitigating the impact of downturns on older workers may help to maintain cognitive function in later life.

Poor health as a potential risk factor for job loss due to automation: the case of Norway.

OBJECTIVE: This study aimed to quantify the extent to which health characteristics of workers are related to the potential risk of experiencing job displacement due to automation. METHODS: Linking the 2015 Norwegian Statistics on Income and Living Conditions survey (n=6393) with predicted probabilities of automation by occupation, we used Kruskal-Wallis tests and multivariate generalised linear models to assess the association between long-standing illnesses and risk of job automation. RESULTS: Individuals with long-standing illnesses face substantially greater risks of losing their job due to automation. Whereas the average risk of job automation is 57% for men and 49% for women with long-standing illnesses, the risk is only 50% for men and 44% for women with limitations (p<0.001). Controlling for age, having a long-standing illness significantly increases the relative risk of facing job automation among men (risk ratio (RR) 1.13, 95% CI 1.09 to 1.19), as well as women (RR 1.11, 95% CI 1.05 to 1.17). While, among men, the association between long-standing illness and risk of job automation remains significant when controlling for education and income, it becomes insignificant among women. CONCLUSIONS: Individuals with poor health are likely to carry the highest burden of technological change in terms of worsening employment prospects because of working in occupations disproportionally more likely to be automated. Although the extent of technology-related job displacement will depend on several factors, given the far-reaching negative consequences of job loss on health and well-being, this process represents a significant challenge for public health and social equity.

The hidden costs of informal work: lack of social protection and subjective well-being in Colombia.

OBJECTIVES: To examine the association between informal work and subjective well-being in Colombia. METHODS: Repeated cross-sectional study based on data from three nationally representative surveys of 1997, 2005 and 2011 (n = 4485). Life satisfaction was measured with a Likert scale ranging from 1 to 10 points. Informal work was defined as paid work without pension/unemployment contributions. Individual-level pooled Generalized Estimating Equation (GEE) models were used to assess the association between informal work and life satisfaction. Propensity Score Matching (PSM) was applied to address potential selection into informal work. RESULTS: Informal work increased from 52 % in 1997 to 68 % in 2011. Informal workers averaged significantly lower life satisfaction than formal (GEE: b = -0.14, 95 % CI -0.26, -0.01, p < 0.05). These results were confirmed in PSM models that controlled for selection by measured confounders (PSM: b = -0.15, 95 % CI -0.23, -0.03, p < 0.05). CONCLUSIONS: Informal workers who are not covered by social security systems had lower subjective well-being than workers in the formal economy. Results suggest that recent increases in informal work may also translate into reduced subjective well-being.

Economic downturns during the life-course and late-life health: an analysis of 11 European countries.

BACKGROUND: Research has shown that individual socio-economic circumstances throughout life affect health in older ages. However, little attention has been paid to the broad economic context affecting individual's life-chances. This paper examines whether economic downturns experienced during young and mid-adulthood have long-run effects on physical health. METHODS: We exploit data on economic fluctuations in the period 1945-2010 in 11 European countries, linked to longitudinal data from three waves of the Survey of Health, Ageing and Retirement in Europe. We estimate a country fixed effect model assessing whether downturns experienced at 5-year intervals between ages 25 and 54 are associated with levels and onset of new limitations with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) in older age (55-80). RESULTS: Experiencing an economic downturn at ages 45-59 is associated with increased risk of having at least one disability limitation in later-life (odds ratio [OR] for ADL = 1.66, 95% CI [Confidence Interval] 1.24, 2.22; OR for IADL = 1.46, 95% CI 1.10, 1.94). Economic downturns at ages 40-44 and 45-49 also increase the risk of a new functional limitation in later-life (OR for IADL ages 40-44 = 1.20, 95% CI 1.03, 1.40; OR for IADL ages 45-49 = 1.44, CI 1.10-1.88). Economic downturns experienced around these ages are also associated with significantly greater risks of smoking and excessive alcohol consumption as well as lower incomes in older age. CONCLUSIONS: Exposure to an economic downturn at ages 40-49 is associated with poorer health in older ages, possibly by increasing risk of unhealthy behaviours and low incomes persisting into older age.