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

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.

Income Segregation, Conditional Cash Transfers, and Breast Cancer Mortality Among Women in Brazil

“…Women who did not receive BFP showed a 17% higher risk of dying from breast cancer than BFP recipients. The positive association of the BFP with health has been demonstrated in other Brazilian studies, including reductions in perinatal outcomes, child and maternal mortality, suicide rates, cardiovascular diseases, and communicable diseases, such as leprosy and tuberculosis . However, no studies to our knowledge have investigated the association of the BFP or any other cash-transfer program with breast cancer outcomes or mortality.…”

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

“…Therefore, the difference in the outcome between the intervention groups is practically random near the threshold. PSM is a method that has been used in large electronic health records [ 10 , 32 ]. It allows for matching where a true case-control design was not possible, which is usually the case for electronic health records of the type we will use in this project.…”

“…The Brazilian Cash Transfer Program, “Bolsa Família Program” (BFP), is one of the largest conditional cash transfer programs worldwide, which appears to have had an important public health impact. Studies indicate that BFP has promoted social inclusion and strengthened human capital among the poorest, reducing poverty and inequalities, besides increasing school attendance among youth and reduced violence, factors that are associated with mental health [ 5 , 7 , 10 , 16 ]. A recent study found that municipalities with higher coverage of the BFP had lower suicide, indicating that this program may have some reduction effect [ 7 ].…”

Is suicide a mental health, public health or societal problem?

“…The link between unemployment, poverty, economic inequality and suicide, and the benefits of economic amelioration, has been reported in several studies over the years, though evidence establishing direct causality appears to be weak [36–41]. The effectiveness of direct cash transfers in preventing suicides reinforces the case for such strategies [42,43,44 ▪▪ ].…”