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      Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010–2016

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          Abstract

          Introduction

          Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil.

          Methods

          A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes.

          Results

          There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level.

          Conclusion

          In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.

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          Most cited references97

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          A modified poisson regression approach to prospective studies with binary data.

          G Zou (2004)
          Relative risk is usually the parameter of interest in epidemiologic and medical studies. In this paper, the author proposes a modified Poisson regression approach (i.e., Poisson regression with a robust error variance) to estimate this effect measure directly. A simple 2-by-2 table is used to justify the validity of this approach. Results from a limited simulation study indicate that this approach is very reliable even with total sample sizes as small as 100. The method is illustrated with two data sets.
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            The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health.

            Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism). Public health's commitment to social justice makes it a natural fit with intersectionality's focus on multiple historically oppressed populations. Yet despite a plethora of research focused on these populations, public health studies that reflect intersectionality in their theoretical frameworks, designs, analyses, or interpretations are rare. Accordingly, I describe the history and central tenets of intersectionality, address some theoretical and methodological challenges, and highlight the benefits of intersectionality for public health theory, research, and policy.
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              Poverty and common mental disorders in low and middle income countries: A systematic review.

              In spite of high levels of poverty in low and middle income countries (LMIC), and the high burden posed by common mental disorders (CMD), it is only in the last two decades that research has emerged that empirically addresses the relationship between poverty and CMD in these countries. We conducted a systematic review of the epidemiological literature in LMIC, with the aim of examining this relationship. Of 115 studies that were reviewed, most reported positive associations between a range of poverty indicators and CMD. In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations, using bivariate and multivariate analyses respectively. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal. There are several measurement and population factors that may explain variation in the strength of the relationship between poverty and CMD. By presenting a systematic review of the literature, this paper attempts to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association. The relatively consistent association between CMD and a variety of poverty dimensions in LMIC serves to strengthen the case for the inclusion of mental health on the agenda of development agencies and in international targets such as the millenium development goals. Copyright 2010 Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2023
                2 December 2023
                : 8
                : 12
                : e013327
                Affiliations
                [1 ] departmentPublic Health Policy Evaluation Unit, School of Public Health , Ringgold_4615Imperial College London , London, UK
                [2 ] Instituto de Estudos para Políticas de Saúde , São Paulo, Brazil
                [3 ] departmentNOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center , Ringgold_50106NOVA University Lisbon , Lisboa, Portugal
                [4 ] Health Surveillance Branch, Secretaria Municipal de Saúde do Rio de Janeiro , Rio de Janeiro, Brazil
                [5 ] departmentInstituto de Estudos em Saúde Coletiva , Ringgold_28125Universidade Federal do Rio de Janeiro , Rio de Janeiro, Brazil
                [6 ] departmentPrograma de Pós-graduação em Clínica Médica , Universidade Federal do Rio de Janeiro , Rio de Janeiro, Brazil
                [7 ] departmentInstituto de Saúde Coletiva , Ringgold_28111Universidade Federal da Bahia , Salvador, Brazil
                [8 ] departmentCentro de Estudos Estratégicos , Ringgold_37903Fundação Oswaldo Cruz , Rio de Janeiro, Brazil
                Author notes
                [Correspondence to ] Sophia Medeiros; sophia.medeiros21@ 123456imperial.ac.uk
                Author information
                http://orcid.org/0009-0009-2863-5319
                http://orcid.org/0000-0002-7260-4386
                Article
                bmjgh-2023-013327
                10.1136/bmjgh-2023-013327
                10693873
                38050408
                9a899813-ff6e-4675-b175-c36a27a98b57
                © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/.

                History
                : 06 July 2023
                : 15 October 2023
                Funding
                Funded by: ESRC;
                Award ID: MR/P014593/1
                Funded by: NIHR;
                Award ID: NIHR133252
                Award ID: NIHR150067
                Funded by: UK Department of Health;
                Funded by: UK’s Joint Health Systems Research Initiative;
                Award ID: DFID/MRC/Wellcome
                Funded by: UK Government;
                Categories
                Original Research
                1506
                Custom metadata
                unlocked

                mental health & psychiatry,health systems
                mental health & psychiatry, health systems

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