Effect of the Bolsa Familia Programme on the outcome of tuberculosis treatment: a prospective cohort study

Abstract

Background Social protection interventions might improve tuberculosis outcomes and could help to control the epidemic in Brazil. The aim of this study was to evaluate the independent effect of the Bolsa Familia Programme (BFP) on tuberculosis treatment outcomes in Brazil. Methods We prospectively recruited and followed up individuals (aged ≥18 years) who initiated tuberculosis treatment at 42 health-care centres across seven cities in Brazil, between March 1, 2014, and April 30, 2017. Patients were interviewed at health-care centres and information about individual characteristics, socioeconomic status, living conditions, lifestyle, and comorbidities was recorded. Patients were separated into two groups according to BFP beneficiary status: BFP (exposed) or non-BFP (not exposed). Treatment outcome (cure, dropout, death, or development of drug-resistant tuberculosis or treatment failure) was recorded after 6 months of therapy. Pearson's χ² test and ANOVA were used to compare tuberculosis treatment outcomes between the two groups, and we estimated the propensity score of being a beneficiary of the BFP using a logit model. We used multinomial regression models to evaluate the effect of the BFP on tuberculosis treatment outcomes. Findings 1239 individuals were included in the study, of whom 196 (16%) were beneficiaries of the BFP and 1043 (84%) were not. After 6 months of treatment, 912 (87%) of 1043 patients in the non-BFP group and 173 (88%) of 196 patients in the BFP group were cured of tuberculosis, 103 (10%) patients in the non-BFP group and 17 (9%) patients in the BFP group had dropped out, and 25 (3%) patients in the non-BFP group and six (3%) patients in the BFP group had died. Three (<1%) of 1043 patients in the non-BFP group developed drug-resistant tuberculosis. Being a BFP beneficiary had a positive effect for cure (average effect 0•076 [95% CI 0•037 to 0•11]) and a negative effect for dropout (-0•070 [-0•105 to 0•036]) and death (-0•002 [-0•021 to 0•017]). Interpretation BFP alone had a direct effect on tuberculosis treatment outcome and could greatly contribute to the goals of the WHO End TB Strategy. Funding Brazilian National Council for Scientific and Technological Development (CNPq) and Brazilian Ministry of Health Department of Science and Technology (DECIT).

Associação entre desfecho do tratamento, características sociodemográficas e benefícios sociais recebidos por indivíduos com tuberculose em Salvador, Bahia, 2014-2016*

“…These findings corroborate those of previous studies that have found positive associations of government direct income transfer programs with success/cure following treatment. 14,15,16 The association between social protection strategies and successful treatment and cure of individuals with TB was also observed in a meta-analysis of studies carried out in Brazil and in other countries with similar levels of income and disease burden. 11 Among the limitations of our study, we include (i) the absence of data on the length of time and/or discontinuity of benefit receipt during treatment, given that such information was obtained at the time of diagnosis, (ii) the absence of measurement of the frequency of receipt of each benefit and the number of beneficiaries in each family affected by the disease and (iii) the possibility of non-response bias, since some participants were reluctant to report receipt of benefits for fear of losing them.…”

“…2,10 Despite scarce knowledge on access and coverage of social programs and benefits for people with TB, recent evidence has pointed to their direct 15 or indirect positive effects on the improvement of treatment outcomes of these individuals, especially the poorest ones. As these findings relate only to the Bolsa Família program, [13][14][15][16] new studies are needed to investigate the effects of other social protection benefits on TB indicators. The Bolsa Família program is the most relevant social program in Brazil and one of the largest in the world.…”

“…Recent studies have demonstrated that the Bolsa Família Program (PBF) has contributed to the reduction in TB 13 incidence and a greater proportion of cure among people affected by TB in Brazil. 14,15 An example of this is the success achieved in the treatment of individuals living in Rio de Janeiro, one of Brazil's state capitals with the worst TB indicators. 16 Although PBF assists approximately 14 million Brazilian families, it is not aimed at people with TB: slightly more than 13% of individuals affected by the disease are beneficiaries of the program.…”

Social protection interventions could improve tuberculosis treatment outcomes

“…Areas with high BFP coverage have been shown to correlate with lower incidence of tuberculosis, but the association between the BFP programme and tuberculosis treatment outcomes is less clear. 8 The authors analysed the treatment outcomes of 1239 individuals treated for tuberculosis, of whom 196 (16%) patients qualified for and received BFP and 1043 (84%) patients did not. The findings suggest that although the proportion of patients who were cured of tuberculosis in the BFP group was not significantly different from that of patients in the non-BFP group (173 [88%] of 196 patients vs 912 [87%] of 1043 patients, p=0•774), propensity score matching showed that rate of cure was 7•6% higher and the proportion of patients who dropped out was 7% lower in the BFP group than the non-BFP group and these differences were statistically significant.…”

“…www.thelancet.com/lancetgh Vol 7 February 2019 score matching analysis was used to overcome this limitation by estimating the conditional probability of an individual being beneficiary on the basis of their observed characteristics. 8 However, as a result of the relatively small sample size of the BFP beneficiaries used for propensity score matching, the possibility of residual confounding from covariates that are mostly missing or remain unbalanced cannot be ruled out.…”