Title: NIHR Global Health Research Group on Social Policy and Health Inequalities led by the University of Glasgow
Funder: Department of Health and Social Care

Abstract: Strengthening data linkage to reduce health inequalities in low and middle income countries: building on the Brazilian 100 million cohort Environment The Institute of Health and Wellbeing (IHW) is co-located in the colleges of medicine and social sciences in the University of Glasgow (GU). Within IHW, the Social and Public Health Sciences Unit (SPHSU) is core funded by the MRC. The IHW and SPHSU focus on the social determinants of health (SDH), the evaluation of the impact of non-health sector programmes on health, and the use of linked data from health and other sectors. GU is at the forefront of data linkage, with Pell being Deputy Director of Farr Scotland. As the availability of linked data on health and its social determinants is improving in many low and middle income countries (LMICs), we are uniquely positioned to begin to understand how to improve population health and reduce inequalities in health on a global scale and to build capacity in such research. SPHSU and IHW provide an excellent scientific environment with dedicated lectures and tailored seminars to build academic and non-academic skills. SPHSU has a knowledge team supporting communications, public engagement, and knowledge transfer/exchange. GU will contribute financially to this programme through investigator time and supporting study visits as detailed in Justification of costs. Background Brazil has a history of introducing welfare policies to alleviate poverty. Rigorous evaluation of these policies may help to determine ‘what works’ to improve health across LMICs. This is timely since many LMICs are considering developing and reforming welfare policy. Brazil also has high quality linked health and social data covering a huge population, with the potential to link further data from other sources. It is the unique combination of the existence of welfare policies and the data with which they can be assessed that makes Brazil the ideal country to partner us in this project. The 100 Million (100M) cohort in Brazil brings together social security data (payments for welfare and other government support) with mainly infectious diseases health outcomes data for 114 million people in Brazil. We will add to these data to allow SDH research into the increasing epidemic of non-communicable diseases (NCDs) in LMICs. We will address many of the sustainable development goals (SDGs), and will monitor progress towards these. We will exploit opportunities afforded by the newly established 100M cohort. First, we will expand the range of data available, allowing a greater array of SDH to be studied. Second, we will conduct natural experiment studies to evaluate the health and equity impacts of specific policies. Third, we will build research capacity within Brazil and GU to ensure this work is sustainable. Collaborators We have started building a good working relationship between GU and Fundação Oswaldo Cruz (Fiocruz) teams through a research visit to Salvador to develop this proposal. Fiocruz has previously worked with the LSHTM, including setting up the 100M cohort. We will strengthen these relationships by holding face-to-face meetings embedded within week-long study visits, as well as maintaining regular contact through videoconference. We will agree a formal contract for conducting the research between the institutions to minimise potential risks. We will jointly develop a training course on robust evaluation methods for public health, running this course and developing it into a summer school will help maintain relationships over the long term. Training Our vision is to build a research workforce within GU, Brazil and other LMICs with skills to study SDH using linked data, particularly to evaluate policies. First, we will improve researchers’ understanding of global health and enable them to gain specific skills including research methods and uses of the 100M cohort by arranging short visits for researchers between institutions. Second, GU will host longer stays for PhD students from Brazil, offering them training (e.g. MPH course modules) and research opportunities (e.g. analysis of UK cross-sectoral welfare data). Third, we will run a course in Brazil on multilevel modelling (developed by Leyland) – a valuable statistical method for analysing the SDH. Lastly, aim 4 will develop new training on policy evaluation targeted at researchers from all LMICs. Aims, objectives, methods & timing Aim 1: Expand the scope of linked data research by adding data sources to the 100M cohort. [Yrs 1-2] O1: Add geographical information to the 100M cohort. Geolocation information will be purchased from Google. A process for automatic geocoding will be developed by a geographer working with a computer scientist to apply ‘deep machine learning’ to assign each cohort member to a census tract (mean population 1500 individuals) based on individual addresses. This process will be conducted on a state-by-state basis to make it manageable, enabling optimisation of processes as this progresses and making data available incrementally for linkage and analysis. The extent of the data that cannot be automatically geocoded will be assessed and appropriate action taken. O2: Develop an area-based deprivation index and describe inequalities in mortality for the population of Brazil. Available data at the census tract level include demographics (age, sex, ethnicity), socioeconomic characteristics (education, income) and amenities (access to clean water, sanitation infrastructure, housing type). A deprivation measure will be created using dimension reduction identifying those unique items correlating with mortality. Mortality rates per small area will be calculated (using death records and census data) and measures of socioeconomic and ethnic inequality for Brazil estimated based on these areas. The deprivation index will be appended to the 100M cohort, expanding the range of possible analyses, and made widely available. O3: Link additional data sources to the 100M cohort, focusing on NCDs. Discussions have started to link several key datasets but resources to expand existing infrastructure are required to achieve this and have been requested in this proposal. We will focus on linking mortality and hospitalisation records (including ICD-10 codes to identify underlying disease) and national registers (hypertension and diabetes). We will also link further data on the SDH – namely, the ‘Minha Casa, Minha Vida’ database (MCMV: a subsidised housing programme providing 2.5 million new houses). Aim 2: Evaluate the impact of welfare programmes on population health and health inequalities. [Yrs 2-3] O4: Assess the impact of Bolsa Familia (BF: the world’s largest conditional cash transfer programme) on cardiovascular and cerebrovascular health. We will use natural experiment methods (including difference-in-difference and regression discontinuity) to investigate the overall intervention effect, and to assess how effects differ by urbanicity, ethnicity, gender and socioeconomic position. Individual-level BF data are currently part of the 100M cohort. Outcomes will be obtained from mortality and hospitalisation records. O5: Evaluate the impact of a subsidised housing programme on tuberculosis, childhood mortality, cardiovascular and cerebrovascular outcomes. MCMV data will be linked to the 100M cohort, with a similar analytical approach as for O4 for these specific outcomes. Ethics committee approval has already been obtained to link all of the databases required in this project. Aim 3/O6: Measure the progress in Brazil against the SDG targets for NCDs, showing progress in by socioeconomic group as defined by the area deprivation index developed in O2. Similarly, monitor progress against and inequalities in the NCD National Plan for the Reduction of Mortality and Risk Factors. [Yrs 2-3] Aim 4/O7: Build research capacity in public health programme evaluation among academics and policymakers. A training course on evaluation design and analysis for an international audience of academics and policy-makers will be developed and delivered twice during the project. [Yrs 2-3] Aim 5/O8: Develop and maintain bi-directional relationships with stakeholders nationally and at local level through regular meetings, seminars and other events and participation in the Steering Group. Also develop an international stakeholder group as a virtual network. [Yrs 1-3] Six month delivery targets Agree contracts between GU, LSHTM and Fiocruz Finalise and agree the structure, governance and working procedures of the group Develop and agree detailed operational plans with milestones for the eight work packages that will deliver O1-O8 Hold the first face-to-face group management meeting Agree terms of reference of the Steering Group Complete scoping review of variables available to create a deprivation index for Brazil Sustainability plan 1) Important new resources will be added to 100M cohort that will be available subsequently. 2) The area deprivation measure created will be available for wider use by researchers and policy-makers. 3) The project involves the evaluation of major welfare programmes in Brazil. The outcomes of these evaluations may influence policy in Brazil and other countries. 4) The course on policy evaluation will continue to be delivered and developed into an international summer school after the project ensuring continued collaboration between the teams. 5) Capacity in global health research will be built in all teams during the project through the training programme and in the wider research and policy communities through the delivery of courses. 6) Towards the end of the project we will seek funding for further relevant research prioritised by the stakeholders. Suitable directions for further work include extending the data linkage to cover different diseases and commercial data, and evaluating other policies introduced at a national or local level

Lay abstract: Among the 206 million people living in Brazil there is a substantial number of poor people. Brazil has a history of introducing welfare policies designed to lift people out of poverty; finding out whether these have worked needs rigorous evaluation, important not just for Brazil but other countries too. Such changes in social circumstances have the potential to lead to an immediate improvement in health. The 100 Million (100M) cohort in Brazil brings together social security data (payments for welfare and other government support) with health outcomes focusing on infectious diseases for 114 million people. We will link further data to enable research on the social determinants of health (the conditions in which people are born, grow, live, work and age) and investigate the increasing problem of non-communicable diseases (e.g. heart disease and stroke) in Brazil. We will look at outcomes prioritised by the World Health Organisation such as preventable deaths in young children, maternal mortality and premature mortality from non-communicable diseases. Our main goal is to improve population health in Brazil by studying the social determinants of health and improving our understanding of how to reduce inequalities in low and middle income countries. Improving the health of the poorest people in a country is not just a matter of social justice, it is also key to improving the health of the population as a whole. The lessons learned in Brazil may be applicable to other low and middle income countries meaning this work could have a global impact. Our programme has five aims: Aim 1: Expand the research potential of the 100M cohort by adding further data: geographical information including an indicator of the deprivation of each person’s area of residence (created as part of this project) and data on non-communicable diseases from hospitals and other sources. Aim 2: Evaluate the impact of specific policies (a welfare programme and a subsidised housing programme) on health and health inequalities. Aim 3: Measure Brazil’s progress against the Sustainable Development Goals on non-communicable diseases for different social groups. Aim 4: Build research capacity in the evaluation of public health programmes internationally through the development and delivery of a course. Aim 5: Develop and maintain a strong relationship with stakeholders, including policy makers and practitioners, so that analyses and results are focused, useful, timely and accessible. This will maximise the opportunity for action to be taken as a result of this research and will lead to the joint production of future research. We are seeking funding for three years but the programme will be sustained beyond this term as follows. 1) We will add new resources to the 100M cohort that will be available after the project has finished. 2) The area deprivation measure will be made available for wider use by researchers and policy makers. 3) The evaluation of the two programmes will provide important information (for Brazil and other countries) as to the ability of such programmes to reduce health inequalities. 4) We will continue to deliver the course on policy evaluation beyond the lifetime of this project. 5) We will build capacity in global health research, and this additional capacity will exist after the project finishes. 6) Towards the end of the project we will seek funding to develop into a Global Health Unit undertaking the evaluation of further programmes identified as priorities by the stakeholders.

Research activity codes: 8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE