Intersectional insights into racism and health: not just a question of identity.

Intersectionality is a useful tool to address health inequalities, by helping us understand and respond to the individual and group effects of converging systems of power. Intersectionality rejects the notion of inequalities being the result of single, distinct factors, and instead focuses on the relationships between overlapping processes that create inequities. In this Series paper, we use an intersectional approach to highlight the intersections of racism, xenophobia, and discrimination with other systems of oppression, how this affects health, and what can be done about it. We present five case studies from different global locations that outline different dimensions of discrimination based on caste, ethnicity and migration status, Indigeneity, religion, and skin colour. Although experiences are diverse, the case studies show commonalities in how discrimination operates to affect health and wellbeing: how historical factors and coloniality shape contemporary experiences of race and racism; how racism leads to separation and hierarchies across shifting lines of identity and privilege; how racism and discrimination are institutionalised at a systems level and are embedded in laws, regulations, practices, and health systems; how discrimination, minoritisation, and exclusion are racialised processes, influenced by visible factors and tacit knowledge; and how racism is a form of structural violence. These insights allow us to begin to articulate starting points for justice-based action that addresses root causes, engages beyond the health sector, and encourages transnational solidarity.

Association between self-control and health risk behaviors: a cross-sectional study with 9th grade adolescents in São Paulo.

BACKGROUND: Self-control (SC) has been consistently found associated with diverse health risk behaviors (HRBs), but little research refers to low- and middle-income countries. Furthermore, there is evidence that some HRBs tend to aggregate, however studies with the specific purpose of addressing the relation between SC and multiple health risk behaviors (MHRBs) are rare. The objective of this study is to analyze these associations and provide evidence to help filling these gaps. METHODS: A sample of 2106 9th grade students from the city of São Paulo responded a self-administered questionnaire in 2017. We tested the association of SC measured as an ordinal variable with four levels (higher, high, medium and low) with six HRBs (binge drinking, marijuana use, smoking, high consumption of ultra-processed food, sedentary behavior and bullying perpetration), in both separated and aggregated forms (MHRBs), controlling for potential confounders. Binary logistic regression was used to test the association between exposure (SC) and single outcomes. In order to analyze the association of SC with MHRBs, multinomial logistic regression was employed. RESULTS: SC was associated with five of six HRBs investigated and with MHRBs. The effect size of the association of SC and MHRBs increased in a steep pattern with accumulation of more HRBs. CONCLUSION: Low self-control is associated with most HRBs investigated and the magnitude of the association increases when more than two or three HRBs are accumulated. There seems to be a group of adolescents in a position of pronounced vulnerability for MHRBs. This should be considered when designing public policy and prevention programs. In contexts of limited or scarce resources and public funds, interventions focusing the most vulnerable groups, instead of universal interventions, should be considered.

Violence, discrimination, and sexual health practices among adolescent men who have sex with men, transgender women and travestis in three cities in Brazil.

The HIV epidemic has a disproportionate impact on adolescent and young men who have sex with men (AMSM) and transgender women and travestis (ATGW), with an increased HIV prevalence over the last 10 years. Violence affects the lives of these populations, undermining their ability to self-care and making them more vulnerable to HIV infection. In this study, we aimed to examine the association between different types of victimization by violence and discrimination and sexual health practices of these adolescent populations in steady and casual relationships. We conducted a cross-sectional study using baseline data from the cohort of PrEP1519 project. We used the mean score of sexual health practices as our outcome and the cumulative score of discrimination (within family, community, education, religious, online and public spaces) and violence (physical, sexual and intimate partner) as our exposure variable. We performed linear regression analyses to estimate the association between exposure and outcome. We found that 90% of AMSM and 95% of ATGW experienced at least one form of violence in the three months prior to this study and about 45% of ATGW suffered sexual violence during the same period. Experiencing discrimination within healthcare settings (from facilities or providers) was negatively associated with sexual health practices. Discrimination and violence negatively affect sexual health practices. HIV prevention and care of AMSM and ATGW people should involve listening to their experiences and addressing discrimination and violence in this population.

[Data quality analysis of deaths committed by the police in the city of São Paulo, Brazil, 2014-2015]. / Análise da qualidade dos dados das mortes cometidas por policiais no Município de São Paulo, Brasil, 2014-2015.

Deadly police force is a public health problem. Although the Mortality Information System (SIM) is the most reliable record of deaths from violence, the same is not true for cases of deadly police force, which displays a high degree of underreporting when compared to data from the São Paulo Department of Law Enforcement (SSP-SP). The current study aimed to estimate underreporting in the two official data sources (SIM and SSP-SP), identifying the ICD-10 categories used in cases of incorrectly classified deadly police force and mortality rates in the years 2014 and 2015 in the city of São Paulo, Brazil. Using linkage of data from the SIM and SSP-SP databases, we describe the use of underlying causes of death in cases of deadly police force, estimating underreporting in the SIM and the SSP-SP with the capture-recapture methodology and mortality rates in the city. Based on the database linkage, most of the deaths from deadly police force were classified incorrectly (53%) as other underlying causes of death in the SIM. Both the SIM and SSP-SP underreported the deaths committed by police officers, with different magnitudes (53.2% in the SIM and 7.9% in the SSP-SP). Reclassification of the deaths via linkage added a gain in the SIM, which now had the same mean mortality rate as the SSP-SP (3.44/100,000), thereby decreasing the underreporting in comparison to the initial scenario. Correct recording of death is the first step to the ensuring the right to justice and truth. Recording with quality means to guarantee the right to information, which is not an end per se, but the start in the task of prevention. Data-sharing and inter-sector work are urgently needed.

A violência policial letal é um problema de saúde pública. Embora o Sistema de Informações sobre Mortalidade (SIM) seja o registro mais confiável sobre mortes por agressão, o mesmo não acontece nos casos de violência policial letal, que apresenta um alto grau de subnotificação quando comparado aos dados da Secretaria de Segurança Pública de São Paulo (SSP-SP). O presente estudo tem como objetivo estimar a subnotificação nas duas fontes oficiais de informação (SIM e SSP-SP), identificando as categorias da CID-10 utilizadas nos casos de violência policial letal incorretamente classificadas e calcular as taxas de mortalidade nos anos de 2014 e 2015 no Município de São Paulo, Brasil. Por meio da vinculação dos dados do SIM e da SSP-SP, descrevemos o uso das causas básicas de morte nos casos de violência policial letal, estimamos a subnotificação no SIM e na SSP-SP com a metodologia captura-recaptura e as taxas de mortalidade no município. A partir da vinculação das duas bases de dados, nota-se que a maior parte dos óbitos por violência policial letal foi classificada incorretamente (53%) em outras causas básicas de morte no SIM. Observa-se que tanto o SIM como a SSP-SP subnotificam as mortes cometidas por policiais em magnitudes distintas (53,2% no SIM e 7,9% na SSP-SP). A reclassificação dos óbitos a partir da vinculação adicionou ganho por parte do SIM, que passou a ter a mesma taxa média de mortalidade do que a SSP-SP (3,44/100 mil), diminuindo a subnotificação em comparação com o cenário inicial. O registro correto da morte é o primeiro passo para o direito à justiça e à verdade. Registrar com qualidade é garantir o direito à informação, sendo este não um fim, mas apenas o começo na tarefa da prevenção. O compartilhamento de dados e o trabalho intersetorial se faz urgente.

La violencia policial letal es un problema de salud pública. A pesar de que el Sistema de Información de la Mortalidad (SIM) sea el registro más fiable sobre muertes por agresión, este no se produce en los casos de violencia policial letal, que presenta un alto grado de subnotificación, cuando se compara con los datos de la Secretaria de Seguridad Pública de São Paulo (SSP-SP). Este estudio tiene como objetivo estimar la subnotificación en las dos fuentes oficiales de información (SIM y SSP-SP), identificando las categorías de la CID-10 utilizadas en los casos de violencia policial letal incorrectamente clasificados, así como calcular las tasas de mortalidad durante los años de 2014 y 2015 en el municipio de São Paulo, Brasil. Mediante la vinculación de los datos del SIM y de la SSP-SP, describimos el uso de las causas básicas de muerte en los casos de violencia policial letal, estimamos la subnotificación en el SIM y en la SSP-SP, con la metodología capture-recapture y las tasas de mortalidad en el municipio. A partir de la vinculación de las dos bases de datos, se nota que la mayor parte de los óbitos de violencia policial letal se clasificaron incorrectamente (53%) en otras causas básicas de muerte en el SIM. Se observa que tanto el SIM, como la SSP-SP, subnotifican las muertes cometidas por policías, en magnitudes distintas (53,2% en el SIM y 7,9% en la SSP-SP). La reclasificación de los óbitos a partir de la vinculación benefició al SIM, que pasó a tener la misma tasa media de mortalidad que la SSP-SP (3,44/100 mil), disminuyendo la subnotificación, en comparación con el escenario inicial. El registro correcto de la muerte es el primer paso para el derecho a la justicia y a la verdad. Registrar con calidad es garantizar el derecho a la información, siendo este no un fin, sino solo el comienzo de la tarea de prevención. El intercambio de datos y el trabajo intersectorial es algo urgente.

Social segregation and lethal police violence in the city of São Paulo, Brazil (2014-2015).

We aimed to investigate how lethal police violence (LPV) in the City of São Paulo (CSP), Brazil, is associated with socioeconomic development when we consider the victims' place of residence and the locations of the fatal injuries. The spatial distribution of lethal police violence rate (LPVR) and its association with the human development index (HDI) was investigated using the Moran's I (Global and Bivariate Local). Between 2014 and 2015 we found 403 police victims in the Health database and 794 victims in the Security Department. We found a non-random spatial distribution of the LPV considering the victim's place of residence (I=+0.12; p<0.001) and the locations where the fatal injuries were inflicted (I=+0.07; p<0.001). We found a negative association between LPVR and the HDI of the place of residence (I=-0.10; p<0.001) and a positive association between LPVR and the HDI of the locations of the fatal injuries (I=+0.02; p<0.001). The results point to different dynamics of LPV in CSP. High mortality clusters are found in areas with lower HDI, when considering the victim's address, and in areas with higher HDI, when considering the address of the violent events. LPV impacts young blacks, poorly educated residents of outskirts informing us about patterns of social segregation.

Victims, bullies and bully-victims: prevalence and association with negative health outcomes from a cross-sectional study in São Paulo, Brazil.

OBJECTIVES: To estimate the prevalence of self-reported bullying as victims, bullies or bully-victims among 9th grade adolescents in the city of São Paulo, Brazil; to investigate association between bullying with negative health outcomes. METHODS: Cross-sectional data were obtained in 2017 from a sample of Brazilian adolescents (n = 2680) using a structured, self-administered questionnaire. Bivariate and multivariate Poisson regression were employed to assess in which extent the experience of bullying in position of victim, bully or bully-victim affects adolescents' health. RESULTS: Prevalence of bullying victimization was 18.3%, while victimization/perpetration and perpetration corresponded to 10.42% and 4.9%, respectively. Adolescents who experienced bullying victimization were more likely to present high levels of internalizing symptoms, to report self-harm, to present negative self-rated health and to use tobacco, when compared with those not involved. Bullies were more likely to use alcohol and to binge drinking. bully-victims presented a higher prevalence of all health outcomes, except for tobacco use. CONCLUSIONS: Our findings highlight the effect of bullying in adolescents' health, regardless of the position. Planned intersectoral efforts between parents, health and education systems to prevent bullying could therefore reduce negative health outcomes during adolescence.

Violence, discrimination, and sexual health practices among adolescent men who have sex with men, transgender women and travestis in three cities in Brazil / Violência, discriminação e práticas de saúde sexual entre homens adolescentes que fazem sexo com homens, mulheres transgêneros e travestis em três cidades do Brasil / Violencia, discriminación y prácticas de salud sexual entre hombres adolescentes que tienen sexo con hombres, mujeres transgénero y travestis en tres ciudades de Brasil

The HIV epidemic has a disproportionate impact on adolescent and young men who have sex with men (AMSM) and transgender women and travestis (ATGW), with an increased HIV prevalence over the last 10 years. Violence affects the lives of these populations, undermining their ability to self-care and making them more vulnerable to HIV infection. In this study, we aimed to examine the association between different types of victimization by violence and discrimination and sexual health practices of these adolescent populations in steady and casual relationships. We conducted a cross-sectional study using baseline data from the cohort of PrEP1519 project. We used the mean score of sexual health practices as our outcome and the cumulative score of discrimination (within family, community, education, religious, online and public spaces) and violence (physical, sexual and intimate partner) as our exposure variable. We performed linear regression analyses to estimate the association between exposure and outcome. We found that 90% of AMSM and 95% of ATGW experienced at least one form of violence in the three months prior to this study and about 45% of ATGW suffered sexual violence during the same period. Experiencing discrimination within healthcare settings (from facilities or providers) was negatively associated with sexual health practices. Discrimination and violence negatively affect sexual health practices. HIV prevention and care of AMSM and ATGW people should involve listening to their experiences and addressing discrimination and violence in this population.

A epidemia de HIV afeta desproporcionalmente homens adolescentes que fazem sexo com homens (AHSH) e mulheres transgênero e travestis. Nos últimos 10 anos, a prevalência do HIV aumento. A violência afeta a vida dessas populações adolescentes, comprometendo sua capacidade de autocuidado e tornando-as mais vulneráveis à infecção pelo HIV. Este estudo buscou examinar a associação entre diferentes tipos de vitimização por violência e discriminação e práticas de saúde sexual entre essas populações adolescentes em relacionamentos estáveis e casuais. Realizamos um estudo transversal usando dados basais do estudo de coorte PrEP1519. Usamos o escore médio de práticas de saúde sexual como desfecho e o escore cumulativo de discriminação (familiar, comunitária, educacional, religiosa, online e em espaços públicos) e violência (parceiro físico, sexual e íntimo) como variável de exposição. Realizamos análises de regressão linear para estimar a associação entre exposição e desfecho. No todo, 90% dos AHSH e 95% dos mulheres transgênero e travestis sofreram pelo menos uma forma de violência nos três meses anterior à pesquisa e cerca de 45% dos mulheres transgênero e travestis sofreram violência sexual no mesmo período. Vivenciar discriminação dentro de ambientes de cuidados de saúde (instituições ou provedores) foi negativamente associado às práticas de saúde sexual. A discriminação e a violência afetam negativamente práticas de saúde sexual. A prevenção contra o HIV e o cuidado a AHSH e mulheres transgênero e travestis devem escutar suas experiências e enfrentar a discriminação e da violência nessa população.

La epidemia del VIH afecta desproporcionadamente a los hombres adolescentes que tienen sexo con hombres (AHSH) y las mujeres transgénero y travestis. En los últimos 10 años, la prevalencia del VIH aumento. La violencia afecta la vida de estas poblaciones adolescentes, comprometiendo su capacidad de autocuidado y haciéndolas más vulnerables a la infección por VIH. Este estudio buscó examinar la asociación entre los diferentes tipos de victimización por violencia y discriminación y las prácticas de salud sexual entre estas poblaciones adolescentes en relaciones estables y casuales. Realizamos un estudio transversal utilizando datos basales del estudio de cohorte PrEP1519. Utilizamos el puntaje promedio de las prácticas de salud sexual como resultado y el puntaje acumulativo de discriminación (familiar, comunitario, educativo, religioso, en línea y en espacios públicos) y la violencia (pareja física, sexual e íntima) como variable de exposición. Realizamos análisis de regresión lineal para estimar la asociación entre la exposición y el resultado. En total, el 90 % de los AHSH y el 95 % de los mujeres transgénero y travestis experimentaron al menos una forma de violencia en los tres meses anteriores a la encuesta, y alrededor del 45 % de los mujeres transgénero y travestis experimentaron violencia sexual en el mismo período. Experimentar discriminación dentro de los ambientes de atención médica (instituciones o proveedores) se asoció negativamente con las prácticas de salud sexual. La discriminación y la violencia afectan negativamente las prácticas de salud sexual. La prevención contra el VIH y el cuidado a AHSH y mujeres transgénero y travestis deben escuchar sus experiencias y hacer frente a la discriminación y la violencia en esa población.

Análise da qualidade dos dados das mortes cometidas por policiais no Município de São Paulo, Brasil, 2014-2015 / Data quality analysis of deaths committed by the police in the city of São Paulo, Brazil, 2014-2015 / Análisis de la calidad de datos de las muertes cometidas por policías en el municipio de São Paulo, 2014-2015

A violência policial letal é um problema de saúde pública. Embora o Sistema de Informações sobre Mortalidade (SIM) seja o registro mais confiável sobre mortes por agressão, o mesmo não acontece nos casos de violência policial letal, que apresenta um alto grau de subnotificação quando comparado aos dados da Secretaria de Segurança Pública de São Paulo (SSP-SP). O presente estudo tem como objetivo estimar a subnotificação nas duas fontes oficiais de informação (SIM e SSP-SP), identificando as categorias da CID-10 utilizadas nos casos de violência policial letal incorretamente classificadas e calcular as taxas de mortalidade nos anos de 2014 e 2015 no Município de São Paulo, Brasil. Por meio da vinculação dos dados do SIM e da SSP-SP, descrevemos o uso das causas básicas de morte nos casos de violência policial letal, estimamos a subnotificação no SIM e na SSP-SP com a metodologia captura-recaptura e as taxas de mortalidade no município. A partir da vinculação das duas bases de dados, nota-se que a maior parte dos óbitos por violência policial letal foi classificada incorretamente (53%) em outras causas básicas de morte no SIM. Observa-se que tanto o SIM como a SSP-SP subnotificam as mortes cometidas por policiais em magnitudes distintas (53,2% no SIM e 7,9% na SSP-SP). A reclassificação dos óbitos a partir da vinculação adicionou ganho por parte do SIM, que passou a ter a mesma taxa média de mortalidade do que a SSP-SP (3,44/100 mil), diminuindo a subnotificação em comparação com o cenário inicial. O registro correto da morte é o primeiro passo para o direito à justiça e à verdade. Registrar com qualidade é garantir o direito à informação, sendo este não um fim, mas apenas o começo na tarefa da prevenção. O compartilhamento de dados e o trabalho intersetorial se faz urgente.

Deadly police force is a public health problem. Although the Mortality Information System (SIM) is the most reliable record of deaths from violence, the same is not true for cases of deadly police force, which displays a high degree of underreporting when compared to data from the São Paulo Department of Law Enforcement (SSP-SP). The current study aimed to estimate underreporting in the two official data sources (SIM and SSP-SP), identifying the ICD-10 categories used in cases of incorrectly classified deadly police force and mortality rates in the years 2014 and 2015 in the city of São Paulo, Brazil. Using linkage of data from the SIM and SSP-SP databases, we describe the use of underlying causes of death in cases of deadly police force, estimating underreporting in the SIM and the SSP-SP with the capture-recapture methodology and mortality rates in the city. Based on the database linkage, most of the deaths from deadly police force were classified incorrectly (53%) as other underlying causes of death in the SIM. Both the SIM and SSP-SP underreported the deaths committed by police officers, with different magnitudes (53.2% in the SIM and 7.9% in the SSP-SP). Reclassification of the deaths via linkage added a gain in the SIM, which now had the same mean mortality rate as the SSP-SP (3.44/100,000), thereby decreasing the underreporting in comparison to the initial scenario. Correct recording of death is the first step to the ensuring the right to justice and truth. Recording with quality means to guarantee the right to information, which is not an end per se, but the start in the task of prevention. Data-sharing and inter-sector work are urgently needed.

La violencia policial letal es un problema de salud pública. A pesar de que el Sistema de Información de la Mortalidad (SIM) sea el registro más fiable sobre muertes por agresión, este no se produce en los casos de violencia policial letal, que presenta un alto grado de subnotificación, cuando se compara con los datos de la Secretaria de Seguridad Pública de São Paulo (SSP-SP). Este estudio tiene como objetivo estimar la subnotificación en las dos fuentes oficiales de información (SIM y SSP-SP), identificando las categorías de la CID-10 utilizadas en los casos de violencia policial letal incorrectamente clasificados, así como calcular las tasas de mortalidad durante los años de 2014 y 2015 en el municipio de São Paulo, Brasil. Mediante la vinculación de los datos del SIM y de la SSP-SP, describimos el uso de las causas básicas de muerte en los casos de violencia policial letal, estimamos la subnotificación en el SIM y en la SSP-SP, con la metodología capture-recapture y las tasas de mortalidad en el municipio. A partir de la vinculación de las dos bases de datos, se nota que la mayor parte de los óbitos de violencia policial letal se clasificaron incorrectamente (53%) en otras causas básicas de muerte en el SIM. Se observa que tanto el SIM, como la SSP-SP, subnotifican las muertes cometidas por policías, en magnitudes distintas (53,2% en el SIM y 7,9% en la SSP-SP). La reclasificación de los óbitos a partir de la vinculación benefició al SIM, que pasó a tener la misma tasa media de mortalidad que la SSP-SP (3,44/100 mil), disminuyendo la subnotificación, en comparación con el escenario inicial. El registro correcto de la muerte es el primer paso para el derecho a la justicia y a la verdad. Registrar con calidad es garantizar el derecho a la información, siendo este no un fin, sino solo el comienzo de la tarea de prevención. El intercambio de datos y el trabajo intersectorial es algo urgente.

Social segregation and lethal police violence in the city of São Paulo, Brazil (2014-2015) / Segregação social e a violência policial letal na cidade de São Paulo, Brasil (2014-2015)

Abstract We aimed to investigate how lethal police violence (LPV) in the City of São Paulo (CSP), Brazil, is associated with socioeconomic development when we consider the victims' place of residence and the locations of the fatal injuries. The spatial distribution of lethal police violence rate (LPVR) and its association with the human development index (HDI) was investigated using the Moran's I (Global and Bivariate Local). Between 2014 and 2015 we found 403 police victims in the Health database and 794 victims in the Security Department. We found a non-random spatial distribution of the LPV considering the victim's place of residence (I=+0.12; p<0.001) and the locations where the fatal injuries were inflicted (I=+0.07; p<0.001). We found a negative association between LPVR and the HDI of the place of residence (I=-0.10; p<0.001) and a positive association between LPVR and the HDI of the locations of the fatal injuries (I=+0.02; p<0.001). The results point to different dynamics of LPV in CSP. High mortality clusters are found in areas with lower HDI, when considering the victim's address, and in areas with higher HDI, when considering the address of the violent events. LPV impacts young blacks, poorly educated residents of outskirts informing us about patterns of social segregation.

Resumo Investigamos em que medida a violência policial letal (VPL) na cidade de São Paulo, Brasil, guarda relação com desenvolvimento socioeconômico, considerando os locais de residência das vítimas e os endereços dos eventos fatais. A distribuição espacial da taxa de violência policial letal (TVPL) e sua associação com o índice de desenvolvimento humano (IDH) foi investigada por meio do Moran's I (Global e o Local Bivariado). Entre 2014 e 2015 encontramos 403 vítimas da polícia no banco de dados da Saúde e 794 no da Segurança Pública. Constatamos uma distribuição não aleatória da TVPL considerando os locais de residência das vítimas (I=+0,12; p<0,001) e os locais de encontro fatal com a polícia (I=+0,07; p<0,001). Encontramos uma associação negativa (I=-0,10; p<0,001) entre as TVPL e o IDH nos locais de residência e uma associação positiva entre as TVPL e o IDH nos endereços dos eventos fatais (I=+0,02; p<0,001). Os resultados apontam para dinâmicas distintas da VPL na CSP. Clusters de alta mortalidade foram encontrados em áreas com menor IDH, quando consideramos o endereço das vítimas, e em áreas com maior IDH, quando consideramos o endereço dos eventos fatais. A VPL impacta jovens negros, com baixa escolaridade, vivendo nas periferias, nos informando dos padrões de segregação social.