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

BACKGROUND: Socioeconomic factors have been consistently associated with suicide, and economic recessions are linked to rising suicide rates. However, evidence on the impact of socioeconomic interventions to reduce suicide rates is limited. This study investigates the association of the world's largest conditional cash transfer programme with suicide rates in a cohort of half of the Brazilian population. METHODS AND FINDINGS: We used data from the 100 Million Brazilian Cohort, covering a 12-year period (2004 to 2015). It comprises socioeconomic and demographic information on 114,008,317 individuals, linked to the "Bolsa Família" programme (BFP) payroll database, and nationwide death registration data. BFP was implemented by the Brazilian government in 2004. We estimated the association of BFP using inverse probability of treatment weighting, estimating the weights for BFP beneficiaries (weight = 1) and nonbeneficiaries by the inverse probability of receiving treatment (weight = E(ps)/(1-E(ps))). We used an average treatment effect on the treated (ATT) estimator and fitted Poisson models to estimate the incidence rate ratios (IRRs) for suicide associated with BFP experience. At the cohort baseline, BFP beneficiaries were younger (median age 27.4 versus 35.4), had higher unemployment rates (56% versus 32%), a lower level of education, resided in rural areas, and experienced worse household conditions. There were 36,742 suicide cases among the 76,532,158 individuals aged 10 years, or older, followed for 489,500,000 person-years at risk. Suicide rates among beneficiaries and nonbeneficiaries were 5.4 (95% CI = 5.32, 5.47, p < 0.001) and 10.7 (95% CI = 10.51, 10.87, p < 0.001) per 100,000 individuals, respectively. BFP beneficiaries had a lower suicide rate than nonbeneficiaries (IRR = 0.44, 95% CI = 0.42, 0.45, p < 0.001). This association was stronger among women (IRR = 0.36, 95% CI = 0.33, 0.38, p < 0.001), and individuals aged between 25 and 59 (IRR = 0.41, 95% CI = 0.40, 0.43, p < 0.001). Study limitations include a lack of control for previous mental disorders and access to means of suicide, and the possible under-registration of suicide cases due to stigma. CONCLUSIONS: We observed that BFP was associated with lower suicide rates, with similar results in all sensitivity analyses. These findings should help to inform policymakers and health authorities to better design suicide prevention strategies. Targeting social determinants using cash transfer programmes could be important in limiting suicide, which is predicted to rise with the economic recession, consequent to the Coronavirus Disease 2019 (COVID-19) pandemic.

The presidential election of the human body: applying contextual learning to promote connections between the student and the curricular content.

Using real-world situations to engage students in learning specific content is advocated by educational research as an effective strategy. However, motivating students to establish personal and emotional connections with the curricular content is challenging. We presented a didactic strategy named "the presidential election of the human body," created to use the presidential election context to engage students in studying cell function and structure using role-playing and appropriation of scientific concepts. Four groups of students (n = 124) of the science and mathematics teacher training program chose a cell of the human body to impersonate, they studied the biology of their cell, and they ran in a presidential election campaign. They created slogans, videos, and materials for their campaign, and on the day of the election the group of students voted for the best slogan. The didactic strategy was capable of stimulating the appropriation of the characteristics of the cells they represented. The majority (75%) of the elected candidates represented cells that are linked to the nervous system. Musicality and humor were the most frequent styles that appeared in the slogans. Students strongly agreed that they enjoyed the activity and considered it valuable for contextualizing the learning of anatomy and physiology. Thus, the activity is a didactic resource to stimulate the students to embrace the content they are learning in the contextualized momentum of a presidential election.

Trends in method-specific suicide in Brazil from 2000 to 2017.

PURPOSE: Understanding long-term patterns of suicide methods can inform public health policy and prevention strategies. In Brazil, firearm-related policies may be one salient target for suicide prevention. This study describes trends in method-specific suicide at the national and state-levels in Brazil, with a particular focus on firearm-related suicides. METHODS: Brazilian mortality data for suicide and undetermined intent among people aged 10 years and older between 2000 and 2017 were obtained from the National Mortality Information System. We examined national and state-level trends in age-standardised suicide rates for hanging, self-poisoning, firearms, jumping from a high place, other, and unspecified methods. We also compared total rates of mortality from suicide and undetermined intent over the period. Applying Joinpoint regression, we tested changes in trends of firearm-specific suicide rates. RESULTS: The total suicide rate increased between 2000 and 2017. Rates of hanging, self-poisoning by drugs or alcohol and jumping from a high place showed the largest increases, while firearm-specific suicide rates decreased over the study period. Trends in methods of suicide varied by sex and state. CONCLUSION: It is of public health concern that suicide rates in Brazil have risen this millennium. Restricting access to firearms might be an effective approach for reducing firearm-specific suicides, especially in states where firearm availability remains particularly high. Treatment and management of substance misuse may also be an important target for suicide prevention policies. More work is needed to understand the causes of rising suicide rates in Brazil and to improve the mental health of the population.

Monitoring the progress of health-related sustainable development goals (SDGs) in Brazilian states using the Global Burden of Disease indicators.

BACKGROUND: Measuring the Global Burden of Disease (GBD) has been the key to verifying the evolution of health indicators worldwide. We analyse subnational GBD data for Brazil in order to monitor the performance of the Brazilian states in the last 28 years on their progress towards meeting the health-related SDGs. METHODS: As part of the GBD study, we assessed the 41 health-related indicators from the SDGs in Brazil at the subnational level for all the 26 Brazilian states and the Federal District from 1990 to 2017. The GBD group has rescaled all worldwide indicators from 0 to 100, assuming that for each one of them, the worst value among all countries and overtime is 0, and the best is 100. They also estimate the overall health-related SDG index as a function of all previously estimated health indicators and the SDI index (Socio-Demographic Index) as a function of per capita income, average schooling in the population aged 15 years or over, and total fertility rate under the age of 25 (TFU25). RESULTS: From 1990 to 2017, most subnational health-related SDGs, the SDG and SDI indexes improved considerable in most Brazilian states. The observed differences in SDG indicators within Brazilian states, including HIV incidence and health worker density, increased over time. In 2017, health-related indicators that achieved good results globally included the prevalence of child wasting, NTD, household air pollution, conflict mortality, skilled birth attendance, use of modern contraceptive methods, vaccine coverage, and health worker density, but poor results were observed for child overweight and homicide rates. The high rates of overweight, alcohol consumption, and smoking prevalence found in the historically richest regions (i.e., the South and Southeast), contrast with the high rates of tuberculosis, maternal, neonatal, and under-5 mortality and WASH-related mortality found in the poorer regions (i.e., the North and Northeast). CONCLUSIONS: The majority of Brazil's health-related SDG indicators have substantially improved over the past 28 years. However, inequalities in health among the Brazilian states and regions remain noticeable negatively affecting the Brazilian population, which can contribute to Brazil not achieving the SDG 2030 targets.

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

PURPOSE: There is a growing awareness of the economic and contextual factors that may play a role in the aetiology of suicide. The Programa Bolsa Família (PBF) the Brazilian conditional cash transfer programme, established in 2004, aims to attenuate the effects of poverty of Brazilians. Our study aims to evaluate the effect of Bolsa Família Programme (BFP) coverage on suicide rates in Brazilian municipalities. METHODS: We conducted an ecological study using 2004-2012 panel data for 5507 Brazilian municipalities. We calculated age-standardized suicide rates for each municipality and year. BFP coverage was categorized according to three levels (< 30%, ≥ 30% and < 70% and ≥ 70%) and duration (coverage ≤ 70% for all years, ≥ 70% for 1 year, ≥ 70% for 2 years, ≥ 70% for 3 or more years). We used negative binomial regression models with fixed effects, adjusting for socio-economic, demographic and social welfare co-variables. RESULTS: An increase in BFP coverage was associated with a reduction in suicide rates. The strongest effect was observed when in addition to greater municipal coverage (RR 0.942, 95% CI 0.936-0.947), the duration of the high coverage was maintained for 3 years or more (RR 0.952 95% CI 0.950-0.954). CONCLUSIONS: The results provide evidence that the conditional cash transfer programme may reduce suicide in Brazilian municipalities, mitigating the effect of poverty on suicide incidence.

Impact of the New Mental Health Services on Rates of Suicide and Hospitalisations by Attempted Suicide, Psychiatric Problems, and Alcohol Problems in Brazil.

A sizeable proportion of all suicides have mental health issues in the background. The association between access to mental health care in the community and decreased suicide rates is inconsistent in the literature. Brazil undertook a major psychiatric reform strengthening psychiatric community-based care. To evaluate the impact of the new Brazilian community mental health care units (CAPS-Psychosocial-Community-Centres) on municipal rates of suicide, and hospitalisations by attempted suicide, psychiatric and alcohol problems. We performed robust multivariable negative binomial regression models with fixed effect for panel data from all 5507 Brazilian municipalities. Suicide and hospitalization rates were calculated by sex and standardised by age for each municipality and year from 2008 to 2012. The main variable of interest was municipal CAPS coverage. CAPS municipal coverage was associated with lower suicide rates but this was not statistically significant (RR: 0.981; 95% CI 0.952-1.011). However, increased CAPS coverage was associated with lower hospitalizations for attempted suicide (RR: 0.887; 95% CI 0.841-0.935), psychiatric (RR: 0.841; 95% CI 0.821-0.862), and alcohol problems (RR: 0.882; 95% CI 0.860-0.904). Our results suggest that access to community mental health services seems to reduce hospitalisations due to attempted suicide, psychiatric and alcohol problems but not suicidal rates. Therefore, increased investments in community mental health services in low-middle-income countries might decrease costs associated with potentially avoidable hospitalizations.

Genome sequencing and genetic characterization of Culex Flavirirus (CxFV) provides new information about its genotypes.

BACKGROUND: Culex Flavivirus (CxFV) is an insect-specific virus that is widely distributed and primarily infects mosquito species from the genus Culex. Its hosts include Culex tritaeniorhynchus, Culex quinquefasciatus, and Anopheles sinensis mosquitoes. Since its original identification, CxFV has been reported in several countries. Despite the increasing number of reports on CxFV, little is known about its genomic characteristics. It is unclear whether the phylogenetic relationships between the strains are influenced by host species and geographic location. RESULTS: We characterized the Brazilian CxFV strain and performed a comprehensive genetic and phylogenetic characterization of CxFV based on all ORF sequences described so far. Our results revealed that the Brazilian strain is in a monophyletic clade with the Mexican strain. Overall, selective pressure indicates that the ORF is undergoing purifying selection. CONCLUSIONS: The phylogenetic analysis revealed a strong association between climate and CxFV ancestry. Also, based on phylogeny and the genetic distance between the main branches of the tree, we propose the classification of the available sequences into two different genotypes. We also suggest the existence of two different subtypes within Genotype 1.

Dose-Dependent Association Between Body Mass Index and Mental Health and Changes Over Time.

Importance: Overweight and obesity affect 340 million adolescents worldwide and constitute a risk factor for poor mental health. Understanding the association between body mass index (BMI) and mental health in adolescents may help to address rising mental health issues; however, existing studies lack comprehensive evaluations spanning diverse countries and periods. Objective: To estimate the association between BMI and mental health and examine changes over time from 2002 to 2018. Design, Setting, and Participants: This was a repeated multicountry cross-sectional study conducted between 2002 and 2018 and utilizing data from the Health Behaviour in School-aged Children (HBSC) survey in Europe and North America. The study population consisted of more than 1 million adolescents aged 11 to 15 years, with all surveyed children included in the analysis. Data were analyzed from October 2022 to March 2023. Main Outcomes and Measures: Mental health difficulties were measured by an 8-item scale for psychological concerns, scoring from 0 to 32, where a higher score reflects greater psychosomatic issues. BMI was calculated using weight divided by height squared and adjusted for age and sex. Data were fitted by multilevel generalized additive model. Confounders included sex, living with parents, sibling presence, academic pressure, the experience of being bullied, family affluence, screen time, and physical activity. Results: Our analysis of 1 036 869 adolescents surveyed from 2002 to 2018, with a mean (SD) age of 13.55 (1.64) years and comprising 527 585 girls (50.9%), revealed a consistent U-shaped association between BMI and mental health. After accounting for confounders, adolescents with low body mass and overweight or obesity had increased psychosomatic symptoms compared to those with healthy weight (unstandardized ß, 0.14; 95% CI, 0.08 to 0.19; unstandardized ß, 0.27; 95% CI, 0.24 to 0.30; and unstandardized ß, 0.62; 95% CI, 0.56 to 0.67, respectively), while adolescents with underweight had fewer symptoms (unstandardized ß, -0.18; 95% CI, -0.22 to -0.15). This association was observed across different years, sex, and grade, indicating a broad relevance to adolescent mental health. Compared to 2002, psychosomatic concerns increased significantly in 2006 (unstandardized ß, 0.19; 95% CI, 0.11 to 0.26), 2010 (unstandardized ß, 0.14; 95% CI, 0.07 to 0.22), 2014 (unstandardized ß, 0.48; 95% CI, 0.40 to 0.56), and 2018 (unstandardized ß, 0.82; 95% CI, 0.74 to 0.89). Girls reported significantly higher psychosomatic concerns than boys (unstandardized ß, 2.27; 95% CI, 2.25 to 2.30). Compared to primary school, psychosomatic concerns rose significantly in middle school (unstandardized ß, 1.15; 95% CI, 1.12 to 1.18) and in high school (unstandardized ß, 2.12; 95% CI, 2.09 to 2.15). Conclusions and Relevance: Our study revealed a U-shaped association between adolescent BMI and mental health, which was consistent across sex and grades and became stronger over time. These insights emphasize the need for targeted interventions addressing body image and mental health, and call for further research into underlying mechanisms.

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

Background: Self-harm is considered an important public health issue and is comprised by a wide range of definitions and behaviours. It is estimated that suicide affects more than 700,000 individuals every year, although, globally, there is a lack of evidence on other self-harm behaviour, such as attempted suicide. The objective of this study is to report and examine temporal trends of notifications, hospitalisations related to self-harm and suicide rates in Brazil between 2011 and 2022, as well as investigating differences in sociodemographic characteristics, methods, and region. Methods: This ecological study used secondary, Brazilian Health Information System data between 2011 and 2022. Self-harm notifications were collected from the Notifiable Diseases Information System (SINAN); self-harm hospitalisations from the Hospital Information System (SIH), and suicide data from the Mortality Information System (SIM). We calculated self-harm notifications, hospitalisations, and suicide rates by sex, age, race, region, and overall. We assessed time-related trends using Joinpoint regression analyses. Findings: From 2011 to 2022, 720,480 self-harm notifications, 104,458 self-harm hospitalisations, and 147,698 suicides were recorded in Brazil. In this period, self-harm notifications (AAPC: 21.13 (CI: 17.50, 25.33)) and suicide (AAPC: 3.70 (CI: 3.05, 4.38)) have increased in the country. Male adults (25-59 years old) and the elderly (>60 years old) continue to be the groups most affected by suicide, with respective rates of 9.59 and 8.60/100,000 in 2022. However, the largest percentage increases have been seen in young people (AAPC: 6.14 (CI: 4.57, 7.88)). The Indigenous population had the highest self-harm notification (103.72, 10,000) and suicide (16.58/100,000) rates, but the lowest hospitalisation rates (1.14/100,000) in 2022), compared to the overall population (70.06, 7.27, and 4.69/100,000, respectively, in 2022). Interpretation: The observed trend of increased self-harm notifications and suicide rates suggests the need for a greater allocation of resources to strategies to prevent self-harm and suicide. The Indigenous population seems to be the group with less access to healthcare. Funding: Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number R01MH128911-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Income determines the impact of cash transfers on HIV/AIDS: cohort study of 22.7 million Brazilians.

Living with extremely low-income is an important risk factor for HIV/AIDS and can be mitigated by conditional cash transfers. Using a cohort of 22.7 million low-income individuals during 9 years, we evaluated the effects of the world's largest conditional cash transfer, the Programa Bolsa Família, on HIV/AIDS-related outcomes. Exposure to Programa Bolsa Família was associated with reduced AIDS incidence by 41% (RR:0.59; 95%CI:0.57-0.61), mortality by 39% (RR:0.61; 95%CI:0.57-0.64), and case fatality rates by 25% (RR:0.75; 95%CI:0.66-0.85) in the cohort, and Programa Bolsa Família effects were considerably stronger among individuals of extremely low-income [reduction of 55% for incidence (RR:0.45, 95% CI:0.42-0.47), 54% mortality (RR:0.46, 95% CI:0.42-0.49), and 37% case-fatality (RR:0.63, 95% CI:0.51 -0.76)], decreasing gradually until having no effect in individuals with higher incomes. Similar effects were observed on HIV notification. Programa Bolsa Família impact was also stronger among women and adolescents. Several sensitivity and triangulation analyses demonstrated the robustness of the results. Conditional cash transfers can significantly reduce AIDS morbidity and mortality in extremely vulnerable populations and should be considered an essential intervention to achieve AIDS-related sustainable development goals by 2030.

Mortality among over 6 million internal and international migrants in Brazil: a study using the 100 Million Brazilian Cohort.

Background: To understand if migrants living in poverty in low and middle-income countries (LMICs) have mortality advantages over the non-migrant population, we investigated mortality risk patterns among internal and international migrants in Brazil over their life course. Methods: We linked socio-economic and mortality data from 1st January 2011 to 31st December 2018 in the 100 Million Brazilian Cohort and calculated all-cause and cause-specific age-standardised mortality rates according to individuals' migration status for men and women. Using Cox regression models, we estimated the age- and sex-adjusted mortality hazard ratios (HR) for internal migrants (i.e., Brazilian-born individuals living in a different Brazilian state than their birth) compared to Brazilian-born non-migrants; and for international migrants (i.e., people born in another country) compared to Brazilian-born individuals. Findings: The study followed up 45,051,476 individuals, of whom 6,057,814 were internal migrants, and 277,230 were international migrants. Internal migrants had similar all-cause mortality compared to Brazilian non-migrants (aHR = 0.99, 95% CI = 0.98-0.99), marginally higher mortality for ischaemic heart diseases (aHR = 1.04, 95% CI = 1.03-1.05) and higher for stroke (aHR = 1.11, 95% CI = 1.09-1.13). Compared to Brazilian-born individuals, international migrants had 18% lower all-cause mortality (aHR = 0.82, 95% CI = 0.80-0.84), with up to 50% lower mortality from interpersonal violence among men (aHR = 0.50, 95% CI = 0.40-0.64), but higher mortality from avoidable causes related to maternal health (aHR = 2.17, 95% CI = 1.17-4.05). Interpretation: Although internal migrants had similar all-cause mortality, international migrants had lower all-cause mortality compared to non-migrants. Further investigations using intersectional approaches are warranted to understand the marked variations by migration status, age, and sex for specific causes of death, such as elevated maternal mortality and male lower interpersonal violence-related mortality among international migrants. Funding: The Wellcome Trust.

Suicide among Indigenous peoples in Brazil from 2000 to 2020: a descriptive study.

Background: Previous studies in Australia, Canada, and Brazil, found that suicide among ethnic minority groups is higher than in the general population. Indigenous peoples in Brazil have been reported to have a high suicide rate, with reports of suicide clusters occurring in several communities. The objective of this study was to report trends in countrywide suicide rates among Indigenous peoples in Brazil between 2000 and 2020, and to compare these with the non-Indigenous population. Methods: This ecological study used Indigenous suicide data collected from all regions of Brazil during a 21-year period, between 2000 and 2020. We used suicide estimates from the Mortality Information System (SIM), available at the Brazilian Health Ministry website (DATASUS). Suicide mortality rates by state and region were calculated using the estimated Indigenous population from the 2010 census, and estimated population proportions for the other years. We performed a trend analysis and compared trends in suicide between the Indigenous and non-Indigenous population during the period studied. Findings: Suicide rates among Indigenous Brazilians have reached more than two and a half times the levels for the overall Brazilian population in 2020 (17.57 suicide deaths versus 6.35 suicide deaths per 100,000 inhabitants, respectively). The Central-West region of Brazil had the highest suicide rates among Indigenous Brazilians over the study period, reaching 58.8 deaths/100,000 inhabitants in 2008. The younger age group (10-24 years old) had the highest suicide rates for all the years studied. Time-series analyses showed a trend of statistically significant increases in suicide rates in Brazil for both the Indigenous and non-Indigenous population during the study period. The North region, and specifically Amazonas state, has shown a decisive increase in suicide rates among the Indigenous populations. The suicide rate for Indigenous people in Brazil, excluding cases in Amazonas and Mato Grosso do Sul states, were similar to those for the entire Brazilian population, showing that the Indigenous peoples who are the most vulnerable to suicide reside in these locations. Interpretation: While there were statistically significant increases in suicide rates for all Brazilians over the study period, they remained alarmingly high among Indigenous people, compared to their non-Indigenous counterparts. The high suicide rates among Indigenous people, and younger individuals in particular (aged between 10 and 24), reinforces the need for specific prevention strategies for these populations. Further studies should be concentrated on determining risk factors in distinct ethnic groups, specifically within regions experiencing an elevated risk, such as the states of Amazonas and Mato Grosso do Sul. Funding: Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number R01MH128911-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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.

Social Inequalities in Mental Health and Self-Perceived Health in the First Wave of COVID-19 Lockdown in Latin America and Spain: Results of an Online Observational Study.

COVID-19 lockdowns greatly affected the mental health of populations and collectives. This study compares the mental health and self-perceived health in five countries of Latin America and Spain, during the first wave of COVID 19 lockdown, according to social axes of inequality. This was a cross-sectional study using an online, self-managed survey in Brazil, Chile, Ecuador, Mexico, Peru, and Spain. Self-perceived health (SPH), anxiety (measured through GAD-7) and depression (measured through PHQ-9) were measured along with lockdown, COVID-19, and social variables. The prevalence of poor SPH, anxiety, and depression was calculated. The analyses were stratified by gender (men = M; women = W) and country. The data from 39,006 people were analyzed (W = 71.9%). There was a higher prevalence of poor SPH and bad mental health in women in all countries studied. Peru had the worst SPH results, while Chile and Ecuador had the worst mental health indicators. Spain had the lowest prevalence of poor SPH and mental health. The prevalence of anxiety and depression decreased as age increased. Unemployment, poor working conditions, inadequate housing, and the highest unpaid workload were associated with worse mental health and poor SPH, especially in women. In future policies, worldwide public measures should consider the great social inequalities in health present between and within countries in order to tackle health emergencies while reducing the health breach between populations.

First identification of Culex flavivirus (Flaviviridae) in Brazil.

INTRODUCTION: Culex flavivirus (CxFV) was first isolated in 2007 from Culex pipiens in Japan and then identified in several other countries. Characterization of the CxFV showed that all strains are related to the cell fusing agent virus. In this manuscript we report the first identification of CxFV in South America. MATERIAL AND METHODS: We have collected Culex sp. mosquitoes using BG-Sentinel traps and manual aspirators. They were pooled according to genus, species, sex and location. Viral RNA was extracted and multiplex nested PCR was performed to test the presence of Flavivirus. The positive samples were isolated in C6/36 cells and sequenced for phylogenetic analyses. RESULTS: 265 female Culex mosquitoes pooled in 83 pools were tested with specific CxFV, Saint Louis encephalitis virus (SLEV) and West Nile virus (WNV) primers. Our sequence data indicated maximum sequence similarity of 97% with CxFV. DISCUSSION: In this study we report the circulation of CxFV in an urban setting where SLEV had previously caused an outbreak. In terms of public health, this is an important finding due to the assumption that the previous exposition of mosquitoes to CxFV might lessen the susceptibility of these mosquitoes to other flaviviruses.

Interpersonal violence and depression in Brazil: A cross-sectional analysis of the 2019 National Health Survey.

Depression and interpersonal violence are issues of increasing public health concern globally, especially in low-and-middle income countries. Despite the known relationship between interpersonal violence and an increased risk of depression, there is a need to further characterise the experience of depression in those who have experienced violence, to better develop screening and treatment interventions. A cross-sectional analysis was conducted on responses from the 2019 Brazilian National Health Survey. The prevalence of depression (both clinician-diagnosed, and Patient Health Questionnaire (PHQ-9) screened) were estimated by type of violence experienced in the preceding 12 months (none, physical violence, sexual violence, physical and sexual violence, or threat of violence). Logistic regression models assessed the associations between violence and depression after adjusting for socioeconomic and demographic factors. Of 88,531 respondents, 8.1% experienced any type of violence. Compared to those not experiencing violence, those who experienced any type of violence had a higher prevalence of clinician-diagnosed or PHQ-9-screened depression (e.g. the prevalence of clinician-diagnosed depression was 18.8% for those experiencing sexual violence compared to 9.5% for those not experiencing violence). Both undiagnosed and untreated depression were also more prevalent in those experiencing any type of violence. In logistic regression models, any experience of violence was associated with a higher odds of depression (e.g. aOR = 3.75 (95% CI: 3.06-4.59) for PHQ-9-detected depression). Experiencing violence was also associated with a higher likelihood of having depression which was undiagnosed (e.g. in those who experienced sexual violence: aOR of 3.20, 95% CI 1.81-5.67) or untreated (e.g. in those who experienced physical and sexual violence: aOR = 8.06, 95% CI 3.44-18.9). These findings highlight the need to consider screening for depression in those affected by violence, and to prioritise mental healthcare in communities affected by violence.

Patterns of multimorbidity and some psychiatric disorders: A systematic review of the literature.

Objective: The presence of two or more chronic diseases results in worse clinical outcomes than expected by a simple combination of diseases. This synergistic effect is expected to be higher when combined with some conditions, depending on the number and severity of diseases. Multimorbidity is a relatively new term, with the first fundamental definitions appearing in 2015. Studies usually define it as the presence of at least two chronic medical illnesses. However, little is known regarding the relationship between mental disorders and other non-psychiatric chronic diseases. This review aims at investigating the association between some mental disorders and non-psychiatric diseases, and their pattern of association. Methods: We performed a systematic approach to selecting papers that studied relationships between chronic conditions that included one mental disorder from 2015 to 2021. These were processed using Covidence, including quality assessment. Results: This resulted in the inclusion of 26 papers in this study. It was found that there are strong associations between depression, psychosis, and multimorbidity, but recent studies that evaluated patterns of association of diseases (usually using clustering methods) had heterogeneous results. Quality assessment of the papers generally revealed low quality among the included studies. Conclusions: There is evidence of an association between depressive disorders, anxiety disorders, and psychosis with multimorbidity. Studies that tried to examine the patterns of association between diseases did not find stable results. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021216101, identifier: CRD42021216101.

Evaluating the impact of social determinants, conditional cash transfers and primary health care on HIV/AIDS: Study protocol of a retrospective and forecasting approach based on the data integration with a cohort of 100 million Brazilians.

BACKGROUND: Despite the great progress made over the last decades, stronger structural interventions are needed to end the HIV/AIDS pandemic in Low and Middle-Income Countries (LMIC). Brazil is one of the largest and data-richest LMIC, with rapidly changing socioeconomic characteristics and an important HIV/AIDS burden. Over the last two decades Brazil has also implemented the world's largest Conditional Cash Transfer programs, the Bolsa Familia Program (BFP), and one of the most consolidated Primary Health Care (PHC) interventions, the Family Health Strategy (FHS). OBJECTIVE: We will evaluate the effects of socioeconomic determinants, BFP exposure and FHS coverage on HIV/AIDS incidence, treatment adherence, hospitalizations, case fatality, and mortality using unprecedently large aggregate and individual-level longitudinal data. Moreover, we will integrate the retrospective datasets and estimated parameters with comprehensive forecasting models to project HIV/AIDS incidence, prevalence and mortality scenarios up to 2030 according to future socioeconomic conditions and alternative policy implementations. METHODS AND ANALYSIS: We will combine individual-level data from all national HIV/AIDS registries with large-scale databases, including the "100 Million Brazilian Cohort", over a 19-year period (2000-2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Design (RDD), Random Administrative Delays (RAD) and Propensity Score Matching (PSM), combined with multivariable Poisson regressions for cohort analyses. Moreover, we will explore in depth lagged and long-term effects of changes in living conditions and in exposures to BFP and FHS. We will also investigate the effects of the interventions in a wide range of subpopulations. Finally, we will integrate such retrospective analyses with microsimulation, compartmental and agent-based models to forecast future HIV/AIDS scenarios. CONCLUSION: The unprecedented datasets, analyzed through state-of-the-art quasi-experimental methods and innovative mathematical models will provide essential evidences to the understanding and control of HIV/AIDS epidemic in LMICs such as Brazil.

Main and moderated effects of multimorbidity and depressive symptoms on cognition.

OBJECTIVE: Multimorbidity, or the occurrence of two or more chronic conditions, is a global challenge, with implications for mortality, morbidity, disability, and life quality. Psychiatric disorders are common among the chronic diseases that affect patients with multimorbidity. It is still not well understood whether psychiatric symptoms, especially depressive symptoms, moderate the effect of multimorbidity on cognition. METHODS: We used a large (n=2,681) dataset to assess whether depressive symptomatology moderates the effect of multimorbidity on cognition using structural equation modelling. RESULTS: It was found that the more depressive symptoms and chronic conditions, the worse the cognitive performance, and the higher the educational level, the better the cognitive performance. We found a significant but weak (0.009; p = 0.04) moderating effect. CONCLUSION: We have provided the first estimate of the moderating effect of depression on the relation between multimorbidity and cognition, which was small. Although this moderation has been implied by many previous studies, it was never previously estimated.

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

BACKGROUND: Physical, emotional, and social changes, including exposure to poverty, abuse, or violence, increases youth vulnerability to mental illness. These factors interfere with development, limit opportunities, and hamper achievement of a fulfilling life as adults. Addressing these issues can lead to improved outcomes at the population level and better cost-effectiveness for health services. Cash transfer programs have been a promising way to address social drivers for poor mental health. However, it is still unclear which pathways and mechanisms explain the association between socioeconomic support and lower mental illness among youth. Therefore, we will evaluate the effect of social drivers on youth mental health-related hospitalizations and suicide, test mechanisms and pathways of a countrywide socioeconomic intervention, and examine the timing of the intervention during the life course. METHODS: We will combine individual-level data from youth national hospitalization, mental health disorders and attempted suicide, suicide registries and notifications of violence, with large-scale databases, including "The 100 Million Brazilian Cohort", over an 18-year period (2001-2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Designs, Propensity Score Matching and difference-in-differences, combined with multivariable regressions for cohort analyses. We will run multivariate regressions based on hierarchical analysis approach to evaluate the association between important social drivers (mental health care, demographic and economic aspects) on mental health-related hospitalizations and suicide among youth. Furthermore, we will perform microsimulations to generate projections regarding how mental health-related hospitalizations and suicide trends will be in the future based on the current state, and how BFP implementation scenarios will affect these trends. DISCUSSION: The results of this project will be of vital importance to guide policies and programs to improve mental health and reduce mental health-related hospitalizations and suicide in youth. It will provide information to improve the effectiveness of these programs worldwide. If cash transfers can decrease mental health problems among youth and reduce suicide.