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

['Daiane Borges Machado', 'Centre For Data', 'Knowledge Integration For Health', 'Cidacs', 'Gonçalo Moniz Institute', 'Oswaldo Cruz Foundation', 'Fiocruz', 'Salvador', 'Department Of Global Health', 'Social Medicine']

Date: 2022-06

Abstract 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.

Author summary Why was this study done? Suicide is a serious global public health problem and ranks in the top 20 leading causes of death worldwide.

Socioeconomic factors have been consistently associated with suicide, but there is limited evidence on the impact of socioeconomic interventions to reduce suicide rate. What did the researchers do and find? This study investigates the association of the world’s largest conditional cash transfer programme on suicide rates in a cohort comprising half of the Brazilian population.

We observed that beneficiaries of the cash transfer program had a lower suicide rate than nonbeneficiaries, and that this association was stronger among women and individuals aged between 25 and 59. What do these findings mean? 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 COVID-19 pandemic and war in Ukraine.

Citation: Machado DB, Williamson E, Pescarini JM, Alves FJO, Castro-de-Araujo LFS, Ichihara MY, et al. (2022) Relationship between the Bolsa Família national cash transfer programme and suicide incidence in Brazil: A quasi-experimental study. PLoS Med 19(5): e1004000. https://doi.org/10.1371/journal.pmed.1004000 Academic Editor: Yuan-Pang Wang, University of Sao Paulo Medical School, BRAZIL Received: September 13, 2021; Accepted: April 26, 2022; Published: May 18, 2022 Copyright: © 2022 Machado et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All data supporting the findings presented were obtained from the Centro de Integração de Dados e Conhecimentos para Saúde (CIDACS). Importantly, restrictions apply to access to the data, which contains sensitive information, were licensed for exclusive use in the current study and, due to privacy regulations from the Brazilian Ethics Committee are not openly available. Upon reasonable request and with express permission from CIDACS (mail to [email protected]) and approval from an ethical committee, controlled access to the data is possible. The dataset is registered under the following DOI handle: https://hdl.handle.net/20.500.12196/CIDACS/65, which provides metadata and a register of all versions of the database. Funding: This work was supported by the National Institute Of Mental Health of the National Institutes of Health (grant number R01MH128911 awarded to the first author - "DBM"), also by the Medical Research Council (grant number MC_PC_MR/T03355X/1, awarded to the last author - "MLB"), and Wellcome Trust (grant number 201912/B/16, awarded to the last author - "MLB"). The funders had no role in the study design, data collection, and analysis, decision to publish, or preparation of the manuscript. URL of funders' websites: https://www.nimh.nih.gov/ https://www.ukri.org/councils/mrc/ https://wellcome.org/. Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: VP is an Academic Editor on PLOS Medicine’s editorial board. All of the authors declare that they have approved the final version. Abbreviations: ATT, average treatment effect on the treated; BFP, Bolsa Família programme; CCT, conditional cash transfer; Covid-19, Coronavirus Disease 2019; IML, Medical-Legal Institute; IPTW, inverse probability of treatment weighting; IRR, incidence rate ratio; PS, propensity score; PSM, propensity score matching; PYR, person-years at risk; RDD, regression discontinuity design; ROC, receiver operating characteristic; SIM, Mortality Information System; SMD, standardised mean difference; WHO, World Health Organization

Introduction Suicide is a serious global public health problem. It is among the top 20 leading causes of death worldwide, with approximately 800,000 deaths per year globally. Suicide causes more deaths than malaria, breast cancer, war, or homicide [1]. The age-standardised suicide rate worldwide is 10.5 per 100,000 inhabitants [1], with a wide variety around the world, and is 6.1 in Brazil [2]. The World Health Organization (WHO) recommends that suicide prevention should become a higher priority on the global public health agenda [3]. However, the best interventions to prevent suicide at the population level remain unclear. There is growing evidence that economic recessions lead to a rise in suicide rates in various countries [4–6], including Brazil [7]. The Coronavirus Disease 2019 (COVID-19) pandemic is expected to lead to a severe global recession, increasing poverty, and resulting in massive unemployment worldwide [8], with possible global increases in suicide rates in the coming years [9,10], which is already occurring in Japan [11]. Suicide prevention interventions may help to mitigate this increase, if proven effective. Social and economic factors, such as poverty, economic uncertainty, unemployment, and income inequality, have been consistently associated with increased suicide rates [12–17], including the young population [18]. Therefore, socioeconomic interventions, such as cash transfer programmes, could potentially decrease suicide rates by improving beneficiaries’ welfare, and reducing known risk factors for suicide, such as financial problems, family instability, and alcohol consumption [3,16,19,20]. However, evidence on the impact of socioeconomic interventions to reduce suicide rates is limited, due to small sample sizes, difficulties in conducting randomised trials, due to difficulties recruiting people, high costs, ethical issues, and data availability [19,21–23]. In 2004, Brazil implemented one of the largest poverty alleviation programmes in the world—the “Bolsa Família” programme (BFP), a conditional cash transfer (CCT). By 2015, approximately 46 million people had benefited from the programme [24]. It has 3 main aims: an income supplement guarantee for the immediate relief of poverty; access to public services (improving families’ education, health, and civic participation); and productive inclusion, which involves job skills training, to increase individual capacity to seek jobs and job opportunities [25]. Brazil’s continental size, and the availability of data, create a unique opportunity to investigate the association of a CCT programme with suicide, and other relevant health outcomes [26,27]. Based on current knowledge, we hypothesise that BFP, and similar programmes, could protect against suicide. Therefore, this study aims to investigate the association of a large CCT programme with the reduced occurrence of suicide.

Discussion The study results consistently found that lower suicide rates occurred in the group of BFP beneficiaries, when compared to nonbeneficiaries. The association remained strong following adjustment for other measured variables, and after generating a propensity score-matched cohort. BFP was associated with 56% lower suicide rates, and all of the sensitivity tests showed similar results. To the best of our knowledge, our study is the first using individual-level data to show that a large-scale cash transfer programme is associated with lower suicide rates. There has been a growing awareness that social and economic factors play a role in determining suicide [23,38–41]. A recent systematic review of low- and middle-income countries showed that approximately 62% of all studies identified the association of suicide with general poverty measures [41]. An ecological study conducted in Indonesia reported a reduction in suicide associated with a CCT programme [19], with a decrease of approximately 18% in suicide rates in the subdistricts where it was implemented [19]. In Brazil [21], an ecological study found a 6% decrease in municipalities with higher BFP coverage. However, both studies were ecological, while our research evaluated the association of the Brazilian BFP with suicide in a large, individual dataset, which allowed an evaluation of the association of the programme with reduced suicide among those who received the benefit. It is plausible that BFP could help to prevent suicide, since poverty is directly related to factors that can lead to suicide, such as unemployment, financial strain, family instability, or violence, as well as a greater predisposition to mental disorders, such as alcoholism and depression [7,11,14,21,23,39,46–50]. A recent systematic review summarised the causal evidence and mechanisms for the relationship between poverty and common mental illnesses [49]. It explained that poverty increases worry, early-life conditions, violence, and crime, and these affect mood and anxiety disorders, while mood and anxiety disorders impact productivity, economic decision-making, female empowerment, and child development, which increase the risk of poverty, as a consequence [49]. Poverty may also be a barrier to accessing goods, resources, and services (including mental health services) contributing to the feeling of social injustice generated from inequities [20,51]. Cash transfers could increase beneficiaries’ welfare by providing greater financial stability [19,21] and by immediate poverty alleviation through the transfer of benefits to poor and extremely poor families, as well as improving access to health and social care services [27]. The interconnected nature of these determinants not only with poverty as the target, but also job skills training, access to health services and education (and the conditionality linked to continued access to these services/resources) may have a buffering impact beyond the direct implications of the cash transfer. Through conditionalities, cash transfers play a role in additional access to resources [27], and convey some hopefulness towards future prospects [39,40], which may be of particular importance in suicide prevention. See Supporting information for further details on the potential causal mechanisms (S1 Text and S3 Fig). We have demonstrated the potential public impact of targeting a social determinant, such as poverty, to prevent a phenomenon that has been studied as an exclusively psychiatric matter. When interpersonal problems, psychological, or psychiatric factors are added to socioeconomic stressors, it can make life much harder, especially in low- and middle-income countries, where a large proportion of the population struggles to have their basic needs met. It could also indicate that in these settings, targeting social determinants through a cash transfer programme may have more potential to prevent suicide at the population level than an exclusively clinical approach. Furthermore, our results indicate the need to perform further investigation of the potential of such programmes to help prevent suicide, for example, studies trying to understand the mechanisms and investigating the potential of using a combination of programmes to try to prevent suicide. Priorities in the suicide prevention field should be urgently established, since the current pandemic has increased economic instability, making many people more vulnerable to mental health problems [52–54], including suicidal behaviour [10]. The mental health consequences of this unprecedented situation are likely to affect societies for a considerable time [10]. This may be especially important for hard-hit countries, including Brazil, and those which already have high suicide rates. In Brazil, no consistent evidence of pandemic-related worsening psychopathology has been found, but socioeconomic disadvantages have been associated with increased odds of psychiatric disorders during the COVID-19 pandemic [55]. The overall response to the COVID-19 crisis should consider suicide prevention measures [9]. Programmes targeting poverty during the pandemic may have an impact on reducing suicide in the coming years. Evidence of country-level strategy efficacy is more critical than ever [10]. Strengths and limitations of the study The 100 Million Brazilian Cohort [28] has a wide coverage of the poorest population, where BFP has the greatest impact. Since suicide is a rare event, the size of the analytical cohort provided unprecedented power to evaluate the associations between BFP, suicide overall, and subpopulations. In addition, our analyses remained consistent, with similar point estimates in all of the sensitivity analyses performed. Among the limitations, by selecting 0.92 as the best cutoff point to establish a true linked match, the linked data used for this study may have omitted almost 5% of the suicide cases. However, only including individuals above 0.92 in our cohort (who were considered true matches) was regarded as the best option to reduce false matches. Sensitivity analyses were conducted by including different cutoffs (S1 Table). Income is the main eligibility criteria for BFP and, as a consequence, may be more susceptible to manipulation. Therefore, instead of using self-declared income as a covariate, we included proxy variables that may represent income in Brazil (i.e., material assets or crowding). However, this approach limited the possibility of using the income variable to run regression discontinuity design (RDD) models. Proxies can sometimes introduce errors to the estimations, but our results remained similar in all of the models, when included and not included. An added concern is that suicide can be under-registered, due to stigma [3,20,56]. However, the process used to report unnatural deaths in Brazil reduces the chances of underreporting, or misclassification. All death certificates in Brazil are completed following the international medical certification of cause of death model [57], and deaths due to external causes (suicide, homicide, and accidents) are forwarded to a Medical-Legal Institute (IML) [58], where death certificates are issued and signed by an examining doctor [57]. Diagnoses are based on an autopsy, analyses of the circumstances in which the death occurred, the victim’s personal history, and suicide risk factors [59]. The Brazilian Ministry of Health’s SIM has been recognised as having high quality standards [31,33]. Suicide is a complex multicausal phenomenon and, therefore, many other variables could influence the event, such as previous mental disorders, and access to means of suicide. Although measuring all of these variables would not be feasible in a large study such as this, there is no strong reason to believe that these factors would occur differently among the beneficiary and nonbeneficiary groups. Unmeasured confounders in observational studies could result in biased effect estimates. However, we performed several sensitivity analyses and subgroups analysis to handle uncontrolled confounding. We obtained similar results in standard Poisson models, using next neighbour matching, and kernel matching suggests there is a low chance that bias was introduced from our sampling and/or matching. In addition, we ran models for BFP participation in the original cohort (before matching), and the results were similar (S4 Table). We have stratified our analysis by sex and age groups. For additional studies, stratifying among diverse race groups, and by Brazilian regions, could also answer whether more vulnerable groups and poorer regions would have stronger effects. Future studies could also analyse pathways to identify potential mediators that may make BFP associated with a lower risk of suicide and the long-term effectiveness. Cash transfer programmes mitigate extreme poverty and provide improvements to the beneficiaries’ well-being, potentially protecting individuals from becoming a victim of suicide. Other countries with a similar economic status as Brazil can potentially benefit from introducing similar measures to reduce suicides. These findings convey important considerations for designing and implementing suicide prevention strategies at the population level. They are especially important in the ensuing financial recession, in which rising unemployment levels and suicide rates are predicted to increase.

Acknowledgments The authors would like to thank the data production team at CIDACS/FIOCRUZ, and all of the collaborators for their work on compiling the 100 Million Brazilian Cohort, and providing appreciated input during the study. DBM and JMP had full access to all of the study data and take responsibility for data integrity and accuracy of the analyses.

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