Processos de exclusão social e iniquidades em saúde: um estudo de caso a partir do Programa Bolsa Família, Brasil / Social exclusion and health inequity: a case study based on a cash distribution program (Bolsa Família) in Brazil

OBJETIVO: Compreender as repercussões do Programa Bolsa Família (PBF) e analisar seus efeitos nos processos de inclusão e exclusão social vividos pelas famílias pobres no Brasil, em especial sua potencialidade para enfrentar iniquidades em saúde. MÉTODOS: A investigação de abordagem qualitativa empregou a metodologia de estudo de caso com utilização das técnicas de observação participante, pesquisa documental e entrevistas semiestruturadas com famílias beneficiárias e ex-beneficiárias do PBF, além de gestores municipais. O estudo foi conduzido em um município de pequeno porte do estado do Rio de Janeiro, com elevado índice de exclusão social e cobertura de 100% da Estratégia Saúde da Família (ESF).A abordagem dosprocessos deinclusão e exclusão socialem suas dimensões econômica, social, política e cultural foi utilizada para orientar a coleta e análise dos dados. RESULTADOS: O programa favoreceu a inclusão social das famílias pobres, especialmente nas dimensões econômica e social, apesar de não promover as mudanças reivindicadas pelos beneficiários na esfera do trabalho. Os efeitos na dimensão política foram limitados pelo funcionamento inadequado das instâncias de participação social. Os entrevistados destacaram os efeitos positivos da ESF relacionados ao usufruto do direito à saúde, em particular a ampliação do acesso e utilização de serviços de saúde de atenção primária. No entanto, esses efeitos mostraram-se desvinculados do PBF. CONCLUSÕES: O trabalho aponta efeitos, limites e desafios do PBF para modificar os determinantes sociais produtores de iniquidades da saúde, a fim de que se alterem, de modo mais permanente, as dinâmicas de exclusão/inclusão social de famílias vivendo em situação de pobreza.

OBJECTIVE: To understand the impact of Bolsa Família (PBF), a federal cash transfer program, and to analyze its effects on social inclusion and exclusion processes experienced by low-income families in Brazil, with a focus on the program's potential to help overcome health inequity. METHODS: This qualitative investigation used a case study methodology including observant participation, review of documents, and semi-structured interviews with current and former PBF beneficiaries, as well as with the program's local managers. The study was conducted in a small city in the state of Rio de Janeiro with a high social exclusion index and 100% coverage by the Family Health Strategy (Estratégia Saúde da Família, ESF) program. The economic, political, social, and cultural dimensions of social exclusion and inclusion processes were used to guide data collection and analysis. RESULTS: The program facilitated social inclusion of low-income families, especially in the economic and social dimensions. Nevertheless, it did not produce the changes desired by the beneficiaries in the work dimension. The effects on the political dimension were limited by the insufficient social engagement of the PBF. The interviewees underscored the positive effects of the ESF, which allowed them to exercise their right to health by granting them wider access to primary health care services. However, these effects appeared to be unrelated to the PBF. CONCLUSIONS: The results reveal effects, limitations, and challenges of the PBF towards modifying the social determinants of health inequity, in order to promote more effective changes in the social exclusion/inclusion dynamics affecting low-income families.

[Social exclusion and health inequity: a case study based on a cash distribution program (Bolsa Família) in Brazil]. / Processos de exclusão social e iniquidades em saúde: um estudo de caso a partir do Programa Bolsa Família, Brasil.

OBJECTIVE: To understand the impact of Bolsa Família (PBF), a federal cash transfer program, and to analyze its effects on social inclusion and exclusion processes experienced by low-income families in Brazil, with a focus on the program's potential to help overcome health inequity. METHODS: This qualitative investigation used a case study methodology including observant participation, review of documents, and semi-structured interviews with current and former PBF beneficiaries, as well as with the program's local managers. The study was conducted in a small city in the state of Rio de Janeiro with a high social exclusion index and 100% coverage by the Family Health Strategy (Estratégia Saúde da Família, ESF) program. The economic, political, social, and cultural dimensions of social exclusion and inclusion processes were used to guide data collection and analysis. RESULTS: The program facilitated social inclusion of low-income families, especially in the economic and social dimensions. Nevertheless, it did not produce the changes desired by the beneficiaries in the work dimension. The effects on the political dimension were limited by the insufficient social engagement of the PBF. The interviewees underscored the positive effects of the ESF, which allowed them to exercise their right to health by granting them wider access to primary health care services. However, these effects appeared to be unrelated to the PBF. CONCLUSIONS: The results reveal effects, limitations, and challenges of the PBF towards modifying the social determinants of health inequity, in order to promote more effective changes in the social exclusion/inclusion dynamics affecting low-income families.

Welfare reform, time limits, and infant health.

This paper offers evidence that welfare time limits contributed to a deterioration of infant health. We use the fact that the dates at which TANF recipients were first subject to timing out varied by state. We show that by 2000 there was a marked difference in TANF duration spells depending on whether the state employed the 60-month Federally imposed time limit, or a shorter limit, differences that were not present under AFDC. There were significant increases in infant mortality when time limits became binding in a state. These increases occurred primarily among mothers who could have plausibly timed-out of TANF: poorly educated and unmarried women with at least one previous live-birth. There is some evidence that the population of mothers affected by time limits were less likely to seek prenatal care in the first trimester, suggesting a possible role for reduced medical care in explaining the deterioration in infant health.

SCHIP. Does this model for covering kids have legs?

The popular federal-state insurance program for kids is caught between legislators who want to expand its scope and others who want to rein it in.

Can private companies contribute to public programs' outreach efforts? Evidence from California.

We studied an innovative outreach effort in California, which trains and certifies community organizations to help complete Medicaid and State Children's Health Insurance Program (SCHIP) applications. In this paper we provide a detailed description of participating organizations, the populations they serve, and their success at turning submitted applications into enrollments. We found that insurance brokers and income tax preparers-for-profit groups that are not typically associated with outreach-make important contributions to Medicaid and SCHIP in California. Brokers, in particular, help serve a hard-to-reach population: those on the higher end of the income eligibility thresholds.

SCHIP expansion and parental coverage: an evaluation of Wisconsin's BadgerCare.

The Wisconsin BadgerCare program, which became operational in July 1999, expanded public health insurance eligibility to both parents and children in families with incomes below 185% of the U.S. poverty line (200% for those already enrolled). This eligibility expansion was part of a federal initiative known as the State Children's Health Insurance Program (SCHIP). Wisconsin was one of only four states that initially expanded coverage to parents of eligible children. In this paper, we attempt to answer the following question: To what extent does a public program with the characteristics of Wisconsin's BadgerCare program reduce the proportion of the low-income adult population without health care coverage? Using a coordinated set of administrative databases, we track three cohorts of mother-only families: those who were receiving cash assistance under the Wisconsin AFDC and TANF programs in September 1995, 1997, and 1999, and who subsequently left welfare. We follow these 19,201 "welfare leaver" families on a quarterly basis for up to 25 quarters, from 2 years before they left welfare through the end of 2001, making it possible to use the labor market information and welfare history of the women in analyzing outcomes. We apply multiple methods to address the policy evaluation question, including probit, random effects, and two difference-in-difference strategies, and compare the results across methods. All of our estimates indicate that BadgerCare substantially increased public health care coverage for mother-only families leaving welfare. Our best estimate is that BadgerCare increased the public health care coverage of all adult leavers by about 17-25% points.

Hijos de pacientes psicóticos en el proyecto SASPE: investigar para cuidar un futuro comprometido / Children of psychotic patients in the SASPE projects: research for a future of commitment

Objetivos: Contribuir al conocimientod e la fertilidad y la fecundidad de una muestra urbana de pacientes diagnosticados bajo los rótulos de «trastorno esquizofrénico» y «otras psicosis» (estudio SASPE), así como de la psicopatología de su descendencia. Diseño:Estudio retrospectivo fundamentado en el procesamiento informático de los datos del Proyecto SASPE, en el vaciado de historias clínicas de cinco Equipos deSalud Mental Comunitaria estrechamente vinculada con la Atención Primaria a la Salud (APS) y en entrevistas con pacientes, hijos de pacientes y profesionales de losEquipos de Atención Primaria (EAP) y de Pediatría de AP. Emplazamiento del Proyecto: Unitat de Salut Mental (USM) de Sant Martí-La Mina, cinco Áreas Básicas de Salud (ABS) de Barcelona y Sant Adria (provincia de Barcelona),además de la Unidad Funcional de Atención a la Primera Infancia de Sant Martí(Institut Catalá de la Salut).Sujetos: 838 pacientes esquizofrénicos y con «otras psicosis» detectados por la USM. 917 descendientedse los mismos. Personal asistencial de la USM,5 ABS y de la Unidad Funcional de Atención a la Primera Infancia ( UFAP1).N iños con señalesd e alerta detectadase n los diversosC entrosd e la USM,y niños con señalesd e alerta o factoresd e riesgo detectadose n los EAP y en los Equiposd e Pediatríad e APS. Metodologíae instrumentos:D iagnósticosD SM-1V.E ntrevistase structuradasE RIElRAOS. E scalaso sistemasd e cribado en la infancia: cribadosA RBB-ADBB,C BCL y USMEP. Based e datos informatizadosd e la USM-SASPE

Objectives: To contribute to the knowledge of the fertility and fecundity of an urban sample of patients diagnosed with schizophrenic disorder or «other psychoses» (SASPE study), as well as of the offspring's psychopathology. Design: A retrospective study based in the computer treatment of the data of Project SASPE, in the casting of clinical histories of five Units of Community Mental Health closely linked with the Primary Health CaTe (PHC) and in interviews with patients, patient's offspring and professionals of the PHC and of Pediatrics of PHC. Location of the Project: Mental Health Unir (USM) of Sant Martí -The Mine, five Basic Health Areas of Barcelona and Sant Adria (Barcelona), besides the Functional Unir of Attention to the Early Childhood of Sant Martí (Catalan lnstitute of Health). Participants: 838 schizophrenic patients and with «delirant psychoses» detected by the USM. 917 descendants of the same ones. Staff of the USM, 5 Basic Health Areas and of the Functional Unir of Attention to the Early Childhood (UFAPI). Children with alert signs detected in the diverse Centers of the USM, and children with signs of alert or factors of risk detected in the PHC Teams and Pediatrics PHC teams. Methodology and instruments: Diagnoses DSM-IV. Structured'interview ERIE-lRAOS. Screening for childhood mental health ARBB-ADBB, CBCL and LISMEP. Informatized Data Base USM-SASPE

Conflicto marital y consumo de drogas en los hijos / Marital conflict and children´s drug use

Objetivo.- Se analiza la relación entre el funcionamiento familiar, los conflictos de la pareja y el consumo de drogas por parte de los hijos. Método.- A través de un diseño transversal se ha encuestado a una muestra de 130 jóvenes (72 chicas y 57 chicos; con edades comprendidas entre los 13 y 17 años) y sus respectivas madres. Para la valoración de las variables de interés se ha utilizado una batería de cuestionarios que comprende los siguientes: Consumo de Sustancias (CS), la Escala de Percepción de los Hijos del Conflicto Interparental (CPIC), el Inventario para Hijos del Comportamiento Parental (CRPBI), la Escala de Evaluación de Adaptabilidad y Cohesión Familiar (FACES), el Índice de Satisfacción Matrimonial (ISM) y la Escala de Estabilidad Matrimonial (EEM). Los hijos respondían a los cuatro primeros (CS, CPIC, CRPBI y FACES), mientras sus familiares lo hacían a los tres últimos (FACES, ISM, EEM). Para el análisis de las relaciones entre variables se utilizaron modelos de regresión logística tomando como variable dependiente ser o no ser el hijo consumidor de sustancias. Resultados.- Cuatro dimensiones de conflicto marital (frecuencia: OR=1,30; intensidad: OR=1,56; inestabilidad: OR=1,32; y contenido: OR=1,33), siete de las ocho dimensiones del CRPBI y la percepción de cohesión familiar por parte de los hijos (OR=0,51) resultaron estadísticamente significativos (p<0,05). No obstante, el control del conjunto de variables mediante un modelo de regresión múltiple ofreció significación estadística para sólo dos de ellas: la percepción de cohesión familiar por parte del hijo/a (OR=0,59; p=0,03) y la percepción de control por parte de la madre (OR=0,69; p=0,04). Conclusiones.- Los resultados muestran que la presencia de conflicto entre los padres se asocia a una mayor presencia de consumo de sustancias entre los hijos, si bien son necesarias más investigaciones para confirmar estos hallazgos. El estudio sí permite constatar el efecto protector de la cohesión familiar y el control materno percibido por los hijos sobre la probabilidad de consumir drogas por éstos

Objective.-We examined the relationship between family functioning, marital conflict and drug use by children. Method.- A cross-over design was used in interviewing a sample of 130 young people (72 girls and 57 boys, ranging from 13 to 17 years of age) and their respective mothers. The battery of questionnaires, used to evaluate the variables of interest, comprised: Substance Use (SU), the Children’s Perception of Interparental Conflict Scale (CPIC), the Children’s Report on Parent Behaviour Inventory (CRPBI), the Family Adaptability and Cohesion Evaluation Scale (FACES), Marital Satisfaction Index (MSI), and the Marital Stability Scale (MSS). The children answered the first four (SU, CPIC, CRPBI and FACES), and their mothers the last three (FACES, MSI and MSS). Logistic regression models were used to analyse the relationship between different variables, taking the child being a substance user or non-user as the dependent variable. Results.- Four dimensions of marital conflict (frequency: OR=1.30; intensity: OR=1.56; uncertainty: OR=1.32; and content: OR=1.33), seven of the eight CRPBI dimensions and the family cohesion perceived by children (OR=0,51) were statistically significant (p <0,05). Nevertheless, multiple regression on the group of variables showed statistical significance for only two of them, the children’s perception of family cohesion (OR=0.59; p=0.03) and the mothers’ perception of control (OR=0.69; p=004). Conclusions.- The results show that the presence of conflict between parents is associated with a greater presence of drug use in children; although further research is necessary to confirm these relationships. However, the study does point to family cohesion, and children’s perception of control by the mother as having a protective effect on the probability of drug use by the former

Role of SCHIP in serving children with special health care needs.

The purpose of this article is to provide new information about two policy issues: (1) Is the State Children's Health Insurance Program (SCHIP) an important source of health insurance for children with special health care needs (CSHCN)? and (2) Does SCHIP provide CSHCN with better access to care, compared with other insurance coverage? Using the 2001 National Survey of CSHCN, we found that a limited fraction of CSHCN were eligible for SCHIP while a relatively small proportion of SCHIP-eligible CSHCN were uninsured. Access to care for CSHCN under SCHIP was better than those SCHIP-eligible but uninsured, and similar to those income-eligible for SCHIP but privately insured.

Addressing racial disparities in social welfare programs: using social equity analysis to examine the problem.

The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) allows states considerable discretion in developing and implementing their Temporary Assistance for Needy Families (TANF) programs. Little research so far has compared the implementation of TANF programs across racial groups. Without such analysis, it is difficult to interpret program outcomes. Using client survey data from a large Manpower Demonstration Research Corporation (MDRC) study, the Project on Devolution and Urban Change, this article compares African-American, Hispanic and White Clients' experiences with diversion, case management, sanctioning, exiting welfare, and dispute resolution. Using residual differences analysis, this article identifies significant differences in treatment among racial and ethnic groups.

Implementation of the Child Care and Development Block Grant: a research synthesis.

The Child Care and Development Block Grant (CCDBG) is the largest source of state and federal child care assistance. Between 1996-2004, the number of reports on state implementation of the CCDBG soared. Using the matrix method, this article synthesizes 39 reports from public and private entities on how states differed in the use of CCDBG funds. We found considerable variation among states with regard to populations served, financing of child care through CCDBG and TANF (Temporary Assistance to Needy Families), administration of the CCDBG, and use of its quality set-asides. This issue is of prime importance to nurses who work with low-income families with children, especially because quality, accessibility and affordability of child care affects a child's emotional, social, cognitive, and physical development. The CCDBG reauthorization and annual appropriations are currently on the congressional agenda and warrant nurse's input for ongoing sustainability and support. Recommendations for policy and future research are included.

Community health changes under welfare reform.

This comparative case study examined changes in community health under New Jersey welfare reform policy implementation (1994-2001). The boundaries of these case descriptions were directed by Milii's ecological framework for policy studies. The separate cases consist of descriptions of changes in social climate and health indicators within Camden, Essex, and Hudson counties in New Jersey. Data analysis revealed a greater public health challenge in these counties than the state as a whole. A large increase in the numbers of low income and uninsured in the population may begin in 2004, 2 years following the 5-year lifetime limit of the receipt of welfare benefits. A growing uninsured population would place additional burdens on the abilities of safety net providers to meet health care needs of vulnerable populations. If left unchanged, these wider effects of the New Jersey welfare reform policy would have negative implications for improving quality of care.

Providing care coordination and treatment services for substance-abusing women in the Work First/New Jersey (TANF) Program.

This paper explores results of a program for substance-abusing welfare recipients in New Jersey. New Jersey hired an outside contractor, placed them in the welfare offices and proactively identified recipients with problems, assessed and placed them in appropriate treatment and then managed their care. The program eased the burden on welfare caseworkers who had had little motivation to help these recipients obtain treatment. While the initiative started slowly, because of concerns of the caseworkers and the recipients, recruitment, assessment and placement rates have continued to grow. In addition, those getting into treatment now appear to be receiving more treatment services as opposed to only detox (which was what they primarily received in the past) with no additional costs to the program. Finally, some preliminary outcomes data indicates improvements in the population in terms of both less drug use and increased employment.

Effects of Medicaid managed care programs on health services access and use.

OBJECTIVE: To estimate the effects of Medicaid managed care (MMC) programs on Medicaid enrollees' access to and use of health care services at the national level. DATA SOURCES/STUDY SETTING: 1991-1995 National Health Interview Surveys (NHIS) and a 1998 Urban Institute survey on state Medicaid managed care programs. STUDY DESIGN: Using multivariate regression models, we estimated the effect of living in a county with an MMC program on several access and use measures for nonelderly women who receive Medicaid through AFDC and child Medicaid recipients. We focus on mandatory programs and estimate separate effects for primary care case management (PCCM) programs, health maintenance organization (HMO) programs, and mixed PCCM/HMO programs, relative to fee-for-service (FFS) Medicaid. We control for individual and county characteristics, and state and year effects. DATA COLLECTION/EXTRACTION METHOD: This study uses pooled individual-level data from up to five years of the NHIS (1991-1995), linked to information on Medicaid managed care characteristics at the county level from the 1998 MMC survey. PRINCIPAL FINDINGS: We find virtually no effects of mandatory PCCM programs. For women, mandatory HMO programs reduce some types of non-emergency room (ER) use, and increase reported unmet need for medical care. The PCCM/HMO programs increase access, but had no effects on use. For children, mandatory HMO programs reduce ER visits, and increase the use of specialists. The PCCM/HMO programs reduce ER visits, while increasing other types of use and access. CONCLUSIONS: Mandatory PCCM/HMO programs improved access and utilization relative to traditional FFS Medicaid, primarily for children. Mandatory HMO programs caused some access problems for women.

The impact of local welfare offices on children's enrollment in Medicaid and SCHIP.

Nearly 20% of children entering Kansas' State Children's Health Insurance Program (SCHIP) and more than 25% of children entering the state's Medicaid program leave public health insurance altogether before completing a full year of coverage, when the first redetermination of eligibility should occur. Analyses of administrative data indicate that high rates of premature disenrollment are strongly associated with case management practices at local social services offices. However, local offices enroll the vast majority of children into public health insurance. To avoid a potential trade-off between local offices' impact on enrollment and retention, the study suggests that states such as Kansas consider improvements in automation to support caseworkers' difficult jobs.