Cash transfer in Brazil and nutritional outcomes: a systematic review

Martins, Ana Paula Bortoletto; Canella, Daniela Silva; Baraldi, Larissa Galastri; Monteiro, Carlos Augusto

doi:10.1590/S0034-8910.2013047004557

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Brasil

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Reviews • Rev. Saúde Pública 47 (6) • Dec 2013 • https://doi.org/10.1590/S0034-8910.2013047004557 copy

Cash transfer in Brazil and nutritional outcomes: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE

: To analyze the influence of conditional cash transfer programs on diet and nutrition outcomes among beneficiary families in Brazil.

METHODS

: A systematic review of literature was carried out with original evaluation studies conducted in Brazil, including all types of clinical trials and observational studies. The search was conducted in PubMed, Scopus, Web of Science and LILACS databases for papers published since 1990. The studies were analyzed according to the program evaluated, participants, study design, location, principal conclusions, confounding factors and methodological limitations. They were classified according to outcomes (nutritional status, dietary intake and food security) and level of evidence for the association with conditional cash transfer programs (adequacy or plausibility).

RESULTS

: We found 1,412 non-duplicated papers. Fifteen met the eligibility criteria and twelve evaluated the Bolsa Família program. Five plausibility studies and two adequacy analyses indicated a positive influence of conditional cash transfer programs on nutritional status of the beneficiary children. The conditional cash transfer programs influence on dietary intake was analyzed in one population-based adequacy study and three cross-sectionals plausibility researches in different municipalities. All of them indicated that beneficiaries had higher food intake than non-beneficiaries. The three cross-sectional plausibility analyses suggest a positive influence of conditional cash transfer programs on the food security of the beneficiaries. The main methodological limitations found were using cross-sectional analysis and difficulties in data collection, small sample sizes and limitations of the instruments used.

CONCLUSIONS

: The few studies found indicated a positive association between Brazilian conditional cash transfer programs and improvements in the recipients’ diet and nutrition. Greater efforts to widen and qualify evaluations are needed in order to assess more comprehensively the impact of conditional cash transfer programs in Brazil.

Income; Government Programs; Poverty; Food Consumption; Nutritional Status; Nutritional Epidemiology; Food Security; Review

Authors/ Program	Participants	Study design	Local and data	Outcome	Main conclusions	Methodological limitations
Plausibility study with internal control
Morris et al ¹⁴14 . Morris SS, Olinto P, Flores R, Nilson EAF, Figueiró AC. Conditional cash transfers are associated with a small reduction in the rate of weight gain of preschool children in northeast Brazil. J Nutr . 2004;134(9):2336-41. PBA	1,347 children under 7 included in the PBA and 483 excluded due to administrative errors (measurements taken); 472 children receiving and 158 excluded under 3 years old (reported measurements)	Cross-sectional study and retrospective cohort study	4 municipalities in the Northeast 2002	Z-sores for weight/age, difference in weight gain 6 months after staring to receive PBA	Children included had lower z-score for weight/age than those excluded. Each additional month in the PBA (total of 6 months) was associated with 31 g less weight gain after adjusting for socioeconomic characteristics.	Possible bias from the receipt of another benefit (School Grant) by the beneficiaries of the PBA. Lack of a measure of weight and height prior to the start of the program. Sample of only four municipalities in the Northeast.
Plausibility study with external control
Paes-Sousa et al ¹⁷17 . Paes-Sousa R, Santos LMP, Miazaki ES. Effects of a conditional cash transfer programme on child nutrition in Brazil. Bull World Health Organ . 2011;89(7):496-503. DOI:10.2471/BLT.10.084202 https://doi.org/10.2471/BLT.10.084202... PBF	22.375 children under 5 years old from areas with low socioeconomic levels (included and not included in the PBF)	4 cross-sectional studies	419 municipalities in Brazil (4 Chamadas Nutricionais) 2005/2006	Z score for weight/age and height/age	Children included in the PBF showed 26% greater chance of having appropriate height/age and weight/age. Greater effect among children older than 35 months, after adjusting for socioeconomic characteristics.	Cross-sectional study has inherent limitations. Unable to determine the time of exposure to the program or the possible biases related to participation in programs other than the PBF. Some variables not assessed could explain residual confounding such as family income, food consumption and nutritional status before entry into the program.
Piperata et al ²⁰20 . Piperata BA, Spence JE, Da-Gloria P, Hubbe M. The nutrition transition in Amazonia: rapid economic change and its impact on growth and development in Ribeirinhos. Am J Phys Anthropol . 2011;146(1):1-13. DOI:10.1002/ajpa.21459 https://doi.org/10.1002/ajpa.21459... PBF	469 individuals in 2002 429 individuals in 2009 Sub-sample of 204 individuals (longitudinal)	2 cross-sectional and one longitudinal study	7 rural communities in 2 municipalities in Pará 2002 and 2009	Z score for weight/age and height/age in individuals aged under 18	Significant positive effect of PBF on the difference in height/age between the two studies for both sexes and for males, after adjusting for socioeconomic characteristics.	The doubt remained as to whether the effect came from the cash transfer itself or from another aspect of the PBF, such as the conditionalities. Small sample size.
Oliveira et al ¹⁵15 . Oliveira FCC, Cotta RMM, Ribeiro AQ, Sant’Ana LFR, Priore SE, Franceschini SCC. Estado nutricional e fatores determinantes do déficit estatural em crianças cadastradas no Programa Bolsa Família. Epidemiol Serv Saude . 2011;20(1):7-18. DOI:10.5123/S1679-49742011000100002 https://doi.org/10.5123/S1679-4974201100... PBF	443 children aged from 6 to 84 months (262 included and 184 not included), with per capita income < R$ 120.00	Cross-sectional study	One municipality in the Southeast 2007	Malnutrition (z-score for weight/age and height/age < -2)	There were no statistically significant differences between the prevalence of malnutrition among the groups for any anthropometric index, after adjusting for socioeconomic characteristics.	Inclusion of siblings of children selected to compose the study.
Oliveira et al ¹⁶16 . Oliveira FCC, Cotta RMM, Sant’Ana LFR, Priore SE, Franceschini SCC. Programa Bolsa Família e estado nutricional infantil: desafios estratégicos. Cienc Saude Coletiva . 2011;16(7):3307-16. DOI:10.1590/S1413-81232011000800030 https://doi.org/10.1590/S1413-8123201100... PBF	443 children aged from 6 to 84 months registered to receive the PBF (184 not included and 262 included)	Cross-sectional study	One municipality in the Southeast 2007	Z-score for weight/age and height/age and BMI/age	There were no statistically significant differences between the nutritional status of children included in the PBF and the length of time receiving the benefit, without adjusting for other factors.	The prevalence rates cannot be extrapolated for all Brazilians. Cross-sectional analysis means it cannot be guaranteed that the results represent the effect of the program or whether they already existed before the PBF started.
Saldiva et al ²⁵25 . Saldiva SRDM, Silva LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do Programa Bolsa Família. Rev Nutr. 2010;23(2):221-9. DOI:10.1590/S1415-52732010000200005 https://doi.org/10.1590/S1415-5273201000... PBF	411 families and 164 children under 5 (included and not included in the PBF)	Cross-sectional study	One municipality in the Northeast 2005	Z-score for weight/height, weight/age and height/age	There were no statistically significant differences between the nutritional status of children and being included in the PBF, without adjusting for other factors.	No limitations indicated.
Paula et a ¹⁸18 . Paula DV, Botelho LP, Zanirati VF, Lopes ACS, Santos LC. Avaliação nutricional e padrão de consumo alimentar entre crianças beneficiárias e não beneficiárias de programas de transferência de renda, em escola municipal do Município de Belo Horizonte, Estado de Minas Gerais, Brasil, em 2009. Epidemiol Serv Saude . 2012;21(3):385-94. DOI:10.5123/S1679-49742012000300004. https://doi.org/10.5123/S1679-4974201200... l PBF	115 children aged from 6 ato10 years old	Cross-sectional study	1 municipal school of a municipality in the Southeast 2009	Stunted (height/age index) and BMI/age	3.0% of stunted in children not in the de PBF and 0% in children included in the de PBF (p = 0.28). Increased risk of overweight or overweight of 27.6% in those not included and 16.2% in those included in the PBF (p = 0.16).	Not possible to evaluate association between doing physical exercise and nutritional status. Minimum sample size not calculated. Small sample size. Study carried out in one municipal school in Belo Horizonte.
Studies of accuracy
Lima et al ⁹9 . Lima FEL, Rabito EI, Dias MRMG. Estado nutricional de população adulta beneficiária do Programa Bolsa Família no município de Curitiba, PR. Rev Bras Epidemiol. 2011;14(2):198-206. DOI:10.1590/S1415-790X2011000200002 https://doi.org/10.1590/S1415-790X201100... PBF	747 adults included in the PBF	Population based cross-sectional study	One municipality in the South 2006/2007	Excess weight (BMI > 25 kg/m²) risk of CVD (waist circumference).	Prevalence of 29.0% overweight and 27.1% obesity. Higher chance of being overweight in men, being over 40 and being single. 46.2% of adults at increased risk of CVD.	No limitations indicated.
Silva ²⁸28 . Silva DAS. Sobrepeso e obesidade em crianças de cinco a dez anos de idade beneficiárias do Programa Bolsa Família no estado de Sergipe, Brasil. Rev Paul Pediatr. 2011;29(4):529-35. DOI:10.1590/S0103-05822011000400010 https://doi.org/10.1590/S0103-0582201100... PBF	79,795 children aged 5 to 10 years old, receiving the PBF (DATASUS/ SISVAN records).	3 cross-sectional studies	State of Sergipe 2008 to 2010	Prevalence of overweight and obesity by sex, year of study and each health region.	Prevalence of overweight in girls went from 12.2% in 2008 to 13.2% in 2010 and obesity from 11.0% to 11.9%. In males, prevalence of overweight went from 12.4% to 13.2% and obesity form 11.0% to 15.1%. Higher prevalence in regions with lower HDI.	Use of secondary data meant not controlling for possible data input and recording errors, as well as possible underreporting.

Authors/ Program	Participants	Study design	Time and place	Outcome	Main conclusions	Methodological limitations
Plausibility study with external control
Piperata et al ¹⁹19 . Piperata BA, Ivanova SA, Da-Gloria P, Veiga G, Polsky A, Spence JE, et al. Nutrition in transition: dietary patterns of rural Amazonian women during a period of economic change. Am J Hum Biol . 2011;23(4):458-69. DOI:10.1002/ajhb.21147 https://doi.org/10.1002/ajhb.21147... PBF	30 women in 2002 and 52 women in 2009 and a subsample of 20 women (longitudinal)	2 cross-sectional studies and a longitudinal study	7 rural communities in 2 municipalities in Pará 2002 and 2009	Quantity of calories, protein (g), carbohydrates (g) and lipids (g) and adequacy of protein consumption.	Higher protein intake and adequate protein consumption among PBF recipients, without adjusting for other factors.	Time required to collect data on food intake and dispersion of households in the region limited sample size. Data did not reflect food consumption patterns of communities in other places and with other economic subsistence strategies.
Saldiva et al ²⁵25 . Saldiva SRDM, Silva LFF, Saldiva PHN. Avaliação antropométrica e consumo alimentar em crianças menores de cinco anos residentes em um município da região do semiárido nordestino com cobertura parcial do Programa Bolsa Família. Rev Nutr. 2010;23(2):221-9. DOI:10.1590/S1415-52732010000200005 https://doi.org/10.1590/S1415-5273201000... PBF	411 families and 164 children under 5 (included in PBF or otherwise)	cross-sectional study	1 municipality in the Northeast 2005	Frequency of consumption of 23 foodstuffs and classification of high or low intake for fruit, vegetables, beans, meat and soft drinks, candies and other sweets.	Positive and statistically significant association between consumption of soft drinks, candies and other sweets and receiving PBF, after adjusting for socioeconomic variables.	No limitations indicated.
Paula et al ¹⁸18 . Paula DV, Botelho LP, Zanirati VF, Lopes ACS, Santos LC. Avaliação nutricional e padrão de consumo alimentar entre crianças beneficiárias e não beneficiárias de programas de transferência de renda, em escola municipal do Município de Belo Horizonte, Estado de Minas Gerais, Brasil, em 2009. Epidemiol Serv Saude . 2012;21(3):385-94. DOI:10.5123/S1679-49742012000300004. https://doi.org/10.5123/S1679-4974201200... PBF	115 children aged 6 to 10 years old	cross-sectional study	1 municipal school and I municipality in the Southeast 2009	Qualitative questionnaire on one day’s consumption (preferences and eating habits and children’s satisfaction with fruit, soft drinks, rice and beans and vegetables)	80.0% of the children receiving the PBF had five meals a day, compared with 52.1% non-PBF (p = 0.01). Significant differences were identified (p < 0.05) with regards intake of different foods, as morning and afternoon snacks between PBF and non-PBF children.	Only one day’s food intake was evaluated, does not show habitual intake. Not possible to evaluate association between doing physical activity and nutritional status. Minimum sample size not calculated, resulting in a small sample.
Study of accuracy
Lignani et al ⁸8 . Lignani JB, Sichieri R, Burlandy L, Salles-Costa R. Changes in food consumption among the Programa Bolsa Família participant families in Brazil. Public Health Nutr . 2011;14(5):785-92. DOI:10.1017/S136898001000279X https://doi.org/10.1017/S136898001000279... PBF	Those responsible for the benefit (women in 93.6% of cases) in 5,000 Brazilian residences.	Population based cross-sectional study	Brazil 2007	Recipients’ perceptions of changes in their food intake for 16 food groups.	Families reported higher intake of all food groups. The length of time they had received the PBF had no effect on the changes in the diet. Higher intake of all food groups the greater the financial dependence on the PBF.	No limitations indicated.
Lima et al ⁹9 . Lima FEL, Rabito EI, Dias MRMG. Estado nutricional de população adulta beneficiária do Programa Bolsa Família no município de Curitiba, PR. Rev Bras Epidemiol. 2011;14(2):198-206. DOI:10.1590/S1415-790X2011000200002 https://doi.org/10.1590/S1415-790X201100... PBF	747 PBF recipients aged 19 and over, (91.4% of interviewees were women)	Population based cross-sectional study	1 municipality in the South 2006/2007	Diet Quality Index (DQI)	According to the DQI, 52.9% were classified as having an inadequate diet, 45.8% with a diet in need of change and 1.3% with an adequate diet. Median consumption of meat and beans was high (> 8 points), although two thirds of the population did not eat fruit every day, 46.0% did not eat vegetables and 43.9% did not consume milk or dairy products.	Using a 24hr recall to evaluate diet quality. Cross-sectional design, meant that consumption before receiving the benefit could not be assessed.

Authors/ Program	Participants	Study design	Time and place	Outcome	Main conclusions	Methodological limitations
Plausibility study with external control
Segal-Correa et al ²⁷27 . Segall-Corrêa AM, Marin-Leon L, Helito H, Pérez-Escamilla R, Santos LMP, Paes-Sousa R. Transferência de renda e segurança alimentar no Brasil: análise dos dados nacionais. Rev Nutr . 2008;21(Supl):39s-51s. Set of programs	56,037 Brazilian households with per capita income below R$ 260.00	Cross-sectional study	Brazil (secondary data from the 2004 PNAD)	Food security or mild and moderate or severe FI (EBIA)	Increasing the value of the cash transfer by R$ 10.00 increases the family’s chance of food security by 8.0%, after adjusting for sociodemographic variables.	Cross-sectional study means no conclusions could be drawn on the effects of the program.
Vianna et al ³⁰30 . Vianna RPT, Segall-Corrêa AM. Insegurança alimentar das famílias residentes em municípios do interior do estado da Paraíba, Brasil. Rev Nutr. 2008;21(Supl):111s-22s. School grant, Gas Tickets, Food grant, Family grant	4,533 families	Population based cross-sectional study	14 municipalities in Paraiba in 2005	Food security, mild and moderate or severe FI (EBIA)	Comparing families with per capita income < R$25.00, a lower prevalence of severe FI in families registered in the CCTP (reduction of 4.8%), after adjusting for income.	It was not possible to classify the families on more than one minimum wage/month. These data were not sufficient to evaluate the impact of these programs as there were no parameters for comparing the situation observed.
Dias et al ³3 . Dias MM, Machado HM, Ferreira CS, Oliveira VL, Gomes AP, Cantaluppi ETC. Situação de insegurança alimentar de famílias beneficiárias de programas de transferência de renda na unidade de saúde da família comunidade São João Baptista, Petrópolis/ Rio de Janeiro. Rev APS . 2012;15(2):199-205. PBF, municipal program Cesta Cheia, Família Feliz – Full basket, happy family	172 families receiving Programas Bolsa Família and Cesta Cheia, Família Feliz	Population based cross-sectional study	1 primary health care unit in a municipality in the Southeast 2009	Food security, mild and moderate or severe FI (EBIA)	28.0% were found to have food security and 12.0% to have severe food insecurity. Increased income lead to significant drops in food insecurity (p < 0.01).	Cross-sectional study means causal relationships between the dependent variable (food insecurity) and the independent variables cannot be proved.

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[1] Correspondence
: Ana Paula Bortoletto Martins. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde. Faculdade de Saúde Pública – USP. Av. Dr. Arnaldo, 715. 01246-904 São Paulo, SP, Brasil. E-mail: anapbmartins@gmail.com