With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global ...migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.
In response to these issues, the UCL-
Lancet
Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report.
First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health. Migrants generally contribute more to the wealth of host societies than they cost. Our Article shows that international migrants in HICs have, on average, lower mortality than the host country population. However, increased morbidity was found for some conditions and among certain subgroups of migrants, (eg, increased rates of mental illness in victims of trafficking and people fleeing conflict) and in populations left behind in the location of origin. Currently, in 2018, the full range of migrants’ health needs are difficult to assess because of poor quality data. We know very little, for example, about the health of undocumented migrants, people with disabilities, or lesbian, gay, bisexual, transsexual, or intersex (LGBTI) individuals who migrate or who are unable to move.
Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches. The health of people who migrate depends greatly on structural and political factors that determine the impetus for migration, the conditions of their journey, and their destination. Discrimination, gender inequalities, and exclusion from health and social services repeatedly emerge as negative health influences for migrants that require cross-sector responses.
Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms. Attention to migration focuses largely on security concerns. When there is conjoining of the words health and migration, it is either focused on small subsets of society and policy, or negatively construed. International agreements, such as the UN Global Compact for Migration and the UN Global Compact on Refugees, represent an opportunity to ensure that international solidarity, unity of intent, and our shared humanity triumphs over nationalist and exclusionary policies, leading to concrete actions to protect the health of migrants.
Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments. Ultimately, the cost of failing to be health-inclusive could be more expensive to national economies, health security, and global health than the modest investments required.
Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development. Commitments to the health of migrating populations should be considered across all Sustainable Development Goals (SDGs) and in the implementation of the Global Compact for Migration and Global Compact on Refugees. This Commission offers recommendations that view population mobility as an asset to global health by showing the meaning and reality of good health for all. We present four key messages that provide a focus for future action.
Randomized clinical trials (RCT) are accepted as the gold-standard approaches to measure effects of intervention or treatment on outcomes. They are also the designs of choice for health technology ...assessment (HTA). Randomization ensures comparability, in both measured and unmeasured pretreatment characteristics, of individuals assigned to treatment and control or comparator. However, even adequately powered RCTs are not always feasible for several reasons such as cost, time, practical and ethical constraints, and limited generalizability. RCTs rely on data collected on selected, homogeneous population under highly controlled conditions; hence, they provide evidence on efficacy of interventions rather than on effectiveness. Alternatively, observational studies can provide evidence on the relative effectiveness or safety of a health technology compared to one or more alternatives when provided under the setting of routine health care practice. In observational studies, however, treatment assignment is a non-random process based on an individual's baseline characteristics; hence, treatment groups may not be comparable in their pretreatment characteristics. As a result, direct comparison of outcomes between treatment groups might lead to biased estimate of the treatment effect. Propensity score approaches have been used to achieve balance or comparability of treatment groups in terms of their measured pretreatment covariates thereby controlling for confounding bias in estimating treatment effects. Despite the popularity of propensity scores methods and recent important methodological advances, misunderstandings on their applications and limitations are all too common. In this article, we present a review of the propensity scores methods, extended applications, recent advances, and their strengths and limitations.
Brazil has made great progress in reducing child mortality over the past decades, and a parcel of this achievement has been credited to the Bolsa Família program (BFP). We examined the association ...between being a BFP beneficiary and child mortality (1-4 years of age), also examining how this association differs by maternal race/skin color, gestational age at birth (term versus preterm), municipality income level, and index of quality of BFP management.
This is a cross-sectional analysis nested within the 100 Million Brazilian Cohort, a population-based cohort primarily built from Brazil's Unified Registry for Social Programs (Cadastro Único). We analyzed data from 6,309,366 children under 5 years of age whose families enrolled between 2006 and 2015. Through deterministic linkage with the BFP payroll datasets, and similarity linkage with the Brazilian Mortality Information System, 4,858,253 children were identified as beneficiaries (77%) and 1,451,113 (23%) were not. Our analysis consisted of a combination of kernel matching and weighted logistic regressions. After kernel matching, 5,308,989 (84.1%) children were included in the final weighted logistic analysis, with 4,107,920 (77.4%) of those being beneficiaries and 1,201,069 (22.6%) not, with a total of 14,897 linked deaths. Overall, BFP participation was associated with a reduction in child mortality (weighted odds ratio OR = 0.83; 95% CI: 0.79 to 0.88; p < 0.001). This association was stronger for preterm children (weighted OR = 0.78; 95% CI: 0.68 to 0.90; p < 0.001), children of Black mothers (weighted OR = 0.74; 95% CI: 0.57 to 0.97; p < 0.001), children living in municipalities in the lowest income quintile (first quintile of municipal income: weighted OR = 0.72; 95% CI: 0.62 to 0.82; p < 0.001), and municipalities with better index of BFP management (5th quintile of the Decentralized Management Index: weighted OR = 0.76; 95% CI: 0.66 to 0.88; p < 0.001). The main limitation of our methodology is that our propensity score approach does not account for possible unmeasured confounders. Furthermore, sensitivity analysis showed that loss of nameless death records before linkage may have resulted in overestimation of the associations between BFP participation and mortality, with loss of statistical significance in municipalities with greater losses of data and change in the direction of the association in municipalities with no losses.
In this study, we observed a significant association between BFP participation and child mortality in children aged 1-4 years and found that this association was stronger for children living in municipalities in the lowest quintile of wealth, in municipalities with better index of program management, and also in preterm children and children of Black mothers. These findings reinforce the evidence that programs like BFP, already proven effective in poverty reduction, have a great potential to improve child health and survival. Subgroup analysis revealed heterogeneous results, useful for policy improvement and better targeting of BFP.
Cohort Profile: The 100 Million Brazilian Cohort Barreto, Mauricio L; Ichihara, Maria Yury; Pescarini, Julia M ...
International journal of epidemiology,
05/2022, Letnik:
51, Številka:
2
Journal Article
Health technology assessment (HTA) is the systematic evaluation of the properties and impacts of health technologies and interventions. In this article, we presented a discussion of HTA and its ...evolution in Brazil, as well as a description of secondary data sources available in Brazil with potential applications to generate evidence for HTA and policy decisions. Furthermore, we highlighted record linkage, ongoing record linkage initiatives in Brazil, and the main linkage tools developed and/or used in Brazilian data. Finally, we discussed the challenges and opportunities of using secondary data for research in the Brazilian context. In conclusion, we emphasized the availability of high quality data and an open, modern attitude toward the use of data for research and policy. This is supported by a rigorous but enabling legal framework that will allow the conduct of large-scale observational studies to evaluate clinical, economical, and social impacts of health technologies and social policies.
Objective
To explore racial disparities in self-reports of violent victimization and polyvictimization among young girls in Brazil and to analyze the distribution of prevalence rates across race ...groups and the estimated odds of exposure.
Design
Data from girls ages 15 and above (N=14,809) from the 2015 edition of PeNSE (National Adolescent School-based Health Survey) were analyzed. Survey weighted proportions and bivariate and multivariate logistic regressions were used to address the objectives.
Results
Independent of the girls’ age, socioeconomic status, and region of residence, black, indigenous, mixed, and Asian descendant girls (relative to Whites) were more likely to report past experiences of being bullied, suffering physical violence, forced sexual intercourse, and polyvictimization (reporting all three events). Blacks had the highest rates of reporting being bullied and polyvictimization. Asian descendants had the highest reports of physical violence. Indigenous girls had the highest reports of forced sexual intercourse.
Conclusions
This study documented disproportionate risks of violent victimization for young women of color among Brazilian students. The risks were significantly greater for those of darker skin tones and from ethnic minorities.
Implications
These findings can inform the development of programs to protect young women from violence in Brazil and highlight the importance of including anti-racism strategies in such programs.
Racism is a social determinant of health inequities. In Brazil, racial injustices lead to poor outcomes in maternal and child health for Black and Indigenous populations, including greater risks of ...pregnancy-related complications; decreased access to antenatal, delivery, and postnatal care; and higher childhood mortality rates. In this study, we aimed to estimate inequalities in childhood mortality rates by maternal race and skin colour in a cohort of more than 19 million newborns in Brazil.
We did a nationwide population-based, retrospective cohort study using linked data on all births and deaths in Brazil between Jan 1, 2012, and Dec 31, 2018. The data consisted of livebirths followed up to age 5 years, death, or Dec 31, 2018. Data for livebirths were extracted from the National Information System for livebirths, SINASC, and for deaths from the Mortality Information System, SIM. The final sample consisted of complete data for all cases regarding maternal race and skin colour, and no inconsistencies were present between date of birth and death after linkage. We fitted Cox proportional hazard regression models to calculate the crude and adjusted hazard ratios (HRs) and 95% CIs for the association between maternal race and skin colour and all-cause and cause-specific younger than age 5 mortality rates, by age subgroups. We calculated the trend of HRs (and 95% CI) by time of observation (calendar year) to indicate trends in inequalities.
From the 20 526 714 livebirths registered in SINASC between Jan 1, 2012, and Dec 31, 2018, 238 436 were linked to death records identified from SIM. After linkage, 1 010 871 records were excluded due to missing data on maternal race or skin colour or inconsistent date of death. 19 515 843 livebirths were classified by mother's race, of which 224 213 died. Compared with children of White mothers, mortality risk for children younger than age 5 years was higher among children of Indigenous (HR 1·98 95% CI 1·92–2·06), Black (HR 1·39 1·36–1·41), and Brown or Mixed race (HR 1·19 1·18–1·20) mothers. The highest hazard ratios were observed during the post-neonatal period (Indigenous, HR 2·78 95% CI 2·64–2·95, Black, HR 1·54 1·48–1·59), and Brown or Mixed race, HR 1·25 1·23–1·27) and between the ages of 1 year and 4 years (Indigenous, HR 3·82 95% CI 3·52–4·15), Black, HR 1·51 1·42–1·60, and Brown or Mixed race, HR 1·30 1·26–1·35). Children of Indigenous (HR 16·39 95% CI 12·88–20·85), Black (HR 2·34 1·78–3·06), and Brown or Mixed race mothers (HR 2·05 1·71–2·45) had a higher risk of death from malnutrition than did children of White mothers. Similar patterns were observed for death from diarrhoea (Indigenous, HR 14·28 95% CI 12·25–16·65; Black, HR 1·72 1·44–2·05; and Brown or Mixed race mothers, HR 1·78 1·61–1·98) and influenza and pneumonia (Indigenous, HR 6·49 95% CI 5·78–7·27; Black, HR 1·78 1·62–1·96; and Brown or Mixed race mothers, HR 1·60 1·51–1·69).
Substantial ethnoracial inequalities were observed in child mortality in Brazil, especially among the Indigenous and Black populations. These findings demonstrate the importance of regular racial inequality assessments and monitoring. We suggest implementing policies to promote ethnoracial equity to reduce the impact of racism on child health.
MCTI/CNPq/MS/SCTIE/Decit/Bill & Melinda Gates Foundation's Grandes Desafios Brasil, Desenvolvimento Saudável para Todas as Crianças, and Wellcome Trust core support grant awarded to CIDACS-Center for Data and Knowledge Integration for Health.
Preterm births increase mortality and morbidity during childhood and later life, which is closely associated with poverty and the quality of prenatal care. Therefore, income redistribution and ...poverty reduction initiatives may be valuable in preventing this outcome. We assessed whether receipt of the Brazilian conditional cash transfer programme - Bolsa Familia Programme, the largest in the world - reduces the occurrence of preterm births, including their severity categories, and explored how this association differs according to prenatal care and the quality of Bolsa Familia Programme management.
A retrospective cohort study was performed involving the first live singleton births to mothersenrolled in the 100 Million Brazilian Cohort from 2004 to 2015, who had at least one child before cohort enrollment. Only the first birth during the cohort period was included, but born from 2012 onward. A deterministic linkage with the Bolsa Familia Programme payroll dataset and a similarity linkage with the Brazilian Live Birth Information System were performed. The exposed group consisted of newborns to mothers who received Bolsa Familia from conception to delivery. Our outcomes were infants born with a gestational age < 37 weeks: (i) all preterm births, (ii) moderate-to-late (32-36), (iii) severe (28-31), and (iv) extreme (< 28) preterm births compared to at-term newborns. We combined propensity score-based methods and weighted logistic regressions to compare newborns to mothers who did and did not receive Bolsa Familia, controlling for socioeconomic conditions. We also estimated these effects separately, according to the adequacy of prenatal care and the index of quality of Bolsa Familia Programme management.
1,031,053 infants were analyzed; 65.9% of the mothers were beneficiaries. Bolsa Familia Programme was not associated with all sets of preterm births, moderate-to-late, and severe preterm births, but was associated with a reduction in extreme preterm births (weighted OR: 0.69; 95%CI: 0.63-0.76). This reduction can also be observed among mothers receiving adequate prenatal care (weighted OR: 0.66; 95%CI: 0.59-0.74) and living in better Bolsa Familia management municipalities (weighted OR: 0.56; 95%CI: 0.43-0.74).
An income transfer programme for pregnant women of low-socioeconomic status, conditional to attending prenatal care appointments, has been associated with a reduction in extremely preterm births. These programmes could be essential in achieving Sustainable Development Goals.
Abstract Mothers’ and fathers’ conceptualizations of joy, sadness, anger, fear, pride and shame were assessed. Their beliefs regarding the importance of children’s manifestation of those emotions and ...the connection with the profiles of autonomy, relatedness and related-autonomy were also assessed. Sixty mother- father dyads with children up to three years old participated in the study. Questionnaires of parents’ conceptualizations of emotions were used. Most participants considered joy an important emotion to be manifested by children of their kids’ age (with an individual character motivation). However, anger, pride and shame were associated with older children. Mothers’ and fathers’ conceptualizations and beliefs were not divergent. The autonomous-related self model correlated positively with the importance mothers and parents attributed to all studied emotions.
Resumo Foram analisadas concepções de mães e pais sobre alegria, tristeza, raiva, medo, orgulho e vergonha, bem como suas crenças quanto à importância da manifestação dessas emoções por crianças, além da articulação com perfis de autonomia, relação e autonomia-relacionada. Participaram 60 duplas mãe-pai de filhos com até três anos de idade. Aplicado o questionário sobre concepções parentais de emoções, a alegria foi considerada pela maioria dos participantes como manifestada por crianças na idade de seus filhos e importante (com motivação de caráter individual), mas a raiva, o orgulho e a vergonha foram mais consideradas para crianças maiores. Não houve divergência nas concepções e crenças entre mães e pais. O modelo de self autônomo-relacionado correlacionou-se positivamente com a importância que mães e pais atribuíram a todas as emoções estudadas.
Racial discrimination has been associated with worse health status and risky health behavior. Understanding the relationship between racial-based bullying (RBB) — an overlap of bullying and ...interpersonal racial discrimination — and substance use can guide school-based actions to prevent bullying and substance use, but investigations rarely involve Brazilian students. We used data from the National Survey of School Health (PeNSE) 2015, which included 102,072 ninth-grade students from the capital and inland cities in the five regions of Brazil. Students self-reported their race/skin color according to the Brazilian official census. We explored racial and recent RBB differences in recent use of alcohol, tobacco, and other substances marijuana, cocaine, crack, sniffed glue,
loló/lança-perfume
(ether and chloroform blend) by comparing prevalence ratios (estimated with
quasi
-Poisson, crude, and adjusted models by demographic and socioeconomic characteristics) obtained from analyses of imputed data and complete case. We found that RBB prevalence increased according to racial categories associated with darker skin tones; racial differences in the prevalence of RBB were greater among girls than boys. Girls from all racial groups consistently had a higher prevalence of alcohol use than boys. RBB partially explained the recent use of alcohol and tobacco for the minority racial groups and was not associated with the use of other substances. School-based actions should explicitly incorporate anti-racist goals as strategies for substance use prevention, giving particular attention to gender issues in racial discrimination and alcohol use.
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