ABSTRACT:

Objective:

To compare the distribution of chronic non-communicable diseases (CNCD) indicators among adult female beneficiaries and non-beneficiaries of the Bolsa Família Program (BFP) in Brazilian capitals.

Methods:

Analysis of Vigitel telephone survey data in 2016 and 2017. Gross and adjusted prevalence ratios (PR) and their respective confidence intervals were estimated using Poisson Regression model.

Results:

Women with BF have lower schooling, are young people, live more frequently in the Northeast and North of the country. Higher prevalence of risk factors were found in woman receiving BF. The adjusted PR of the BF women were: smokers (PR = 1.98), overweight (PR = 1.21), obesity (PR = 1.63), fruits and vegetables (PR = 0.63), consumption of soft drinks (PR = 1.68), bean consumption (PR = 1.25), physical activity at leisure (PR = 0.65), physical activity at home (PR = 1.35), time watching TV (PR = 1.37), self-assessment of poor health status (PR =2.04), mammography (PR = 0.86), Pap smears (PR = 0.91), hypertension (PR = 1.46) and diabetes (PR = 1,66). When women were compared among strata of the same schooling, these differences were reduced.

Conclusion:

Worst indicators among women receiving BF reflect social inequalities inherent in this most vulnerable group. The study also shows that BF is being targeted at the most vulnerable women.

Keywords:
Socioeconomic factors; Noncommunicable Diseases; Health Surveys; Health Evaluation; Cash Transfer; Social Programmes

INTRODUCTION

Chronic non-communicable diseases (CNCD) are considered the main causes of death and disability in the world population, responsible for high costs and financial burdens on individuals, societies and health systems¹1. Malta DC, Campos MO, Oliveira MM de, Iser BPM, Bernal RTI, Claro RM, et al. Prevalência de fatores de risco e proteção para doenças crônicas não transmissíveis em adultos residentes em capitais brasileiras, 2013. Epidemiol Serv Saúde 2015; 24(3): 373-87. http://doi.org/10.5123/s1679-49742015000300004
https://doi.org/http://doi.org/10.5123/s... ^,22. Malta DC, Stopa SR, Szwarcwald CL, Gomes NL, Silva Júnior JB, Reis AAC dos. A vigilância e o monitoramento das principais doenças crônicas não transmissíveis no Brasil - Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 3-16. http://doi.org/10.1590/1980-5497201500060002
https://doi.org/http://doi.org/10.1590/1... . Studies show that CNCDs affect quality of life and well-being³3. Mpofu JJ, de Moura L, Farr SL, Malta DC, Iser BM, Ivata Bernal RT, et al. Associations between noncommunicable disease risk factors, race, education, and health insurance status among women of reproductive age in Brazil - 2011. Prev Med Rep 2016; 3: 333-7. http://doi.org/10.1016/j.pmedr.2016.03.015
https://doi.org/http://doi.org/10.1016/j... ^,44. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Genebra: World Health Organization; 2013 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665... , as well as the importance of social determinants, particularly poverty, in the occurrence of CNCDs, with the worst indicators in the most vulnerable and socially marginalized population⁵5. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, et al. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36: 408-25. http://doi.org/10.1057/jphp.2015.29
https://doi.org/http://doi.org/10.1057/j... ^,66. Malta DC, Duncan BB, Barros MB de A, Katikireddi SV, Souza FM de, Silva AG da, et al. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Ciênc Saúde Coletiva 2018; 23(10): 3115-22. http://doi.org/10.1590/1413-812320182310.25222018
https://doi.org/http://doi.org/10.1590/1... ^,77. Barreto ML. Desigualdades em Saúde: uma perspectiva global. Ciênc Saúde Coletiva 2017; 22(7): 2097-108. http://doi.org/10.1590/1413-81232017227.02742017
https://doi.org/http://doi.org/10.1590/1... . In addition, health inequities cause unequal possibilities related to the scientific and technological advances that have occurred in this area, changing the chances of exposure to the factors that determine health and illness, further expanding inequalities and the risks of illness and death⁷7. Barreto ML. Desigualdades em Saúde: uma perspectiva global. Ciênc Saúde Coletiva 2017; 22(7): 2097-108. http://doi.org/10.1590/1413-81232017227.02742017
https://doi.org/http://doi.org/10.1590/1... .

In this regard, several social protection strategies have been used in the world to promote social mobility and face the problem of hunger and misery. Among them, conditional cash transfer (CCTs) programs have stood out for their contractual design and governance structure, which promotes the individual’s positive behavior, as a central element, and not care ⁸8. Roque DM, Ferreira MAM. O que realmente importa em programas de transferência condicionada de renda? Abordagens em diferentes países. Saúde Soc 2015; 24(4): 1193-207. http://doi.org/10.1590/s0104-12902015138971
https://doi.org/http://doi.org/10.1590/s... .

In the Brazilian context, the Bolsa Família Program (BFP) was created by the federal government through Provisional Measure No. 132⁹9. Sperandio N, Rodrigues CT, Franceschini S do CC, Priore SE. Impacto do Programa Bolsa Família no consumo de alimentos: estudo comparativo das regiões Sudeste e Nordeste do Brasil. Ciênc Saúde Coletiva 2017; 22(6): 1771-80. http://doi.org/10.1590/1413-81232017226.25852016
https://doi.org/http://doi.org/10.1590/1... ^,1010. Suzart AS, Ferreira AP, Lemos GCSM, Correa GTB, Bonfatti RJ, Oliveira MHB. Repercussões do programa bolsa família na segurança alimentar e nutricional: um estudo de caso. Rev Baiana Saúde Pública 2017; 41(3). http://doi.org/10.22278/2318-2660.2017.v41.n3.a2525
https://doi.org/http://doi.org/10.22278/... . The program is a social welfare action, being one of the largest direct cash transfer programs in the world and, by legal definition, women are the preferred holders for receiving the benefit (Law No. 10,836/2004)¹¹11. Bartholo L. Bolsa Família e autonomia feminina: o que nos dizem os estudos qualitativos? Centro Internacional de Políticas para o Crescimento Inclusivo [Internet]. 2016 [acessado em 6 jan. 2019]. Disponível em: Disponível em: https://www.ipc-undp.org/pub/port/PRB57PT_Bolsa_Familia_e_autonomia_feminina.pdf
https://www.ipc-undp.org/pub/port/PRB57P... ^,1212. Corgozinho KDS. A política social e a feminização do cuidado no Programa Bolsa Família: invenção das tradições? Emancipação 2015; 15(1): 97-114. http://doi.org/10.5212.v.15i1.0006
https://doi.org/http://doi.org/10.5212.v... .

Since 2006, the Surveillance System for Risk and Protection Factors for Chronic Diseases by Telephone Survey (Vigitel) has been monitoring indicators of these diseases through telephone surveys. In 2016, a specific question was added about receiving the BFP benefit in order to monitor vulnerable populations in relation to CNCD indicators, especially women, who make up more than 90% of the beneficiary population¹¹11. Bartholo L. Bolsa Família e autonomia feminina: o que nos dizem os estudos qualitativos? Centro Internacional de Políticas para o Crescimento Inclusivo [Internet]. 2016 [acessado em 6 jan. 2019]. Disponível em: Disponível em: https://www.ipc-undp.org/pub/port/PRB57PT_Bolsa_Familia_e_autonomia_feminina.pdf
https://www.ipc-undp.org/pub/port/PRB57P... ^,1212. Corgozinho KDS. A política social e a feminização do cuidado no Programa Bolsa Família: invenção das tradições? Emancipação 2015; 15(1): 97-114. http://doi.org/10.5212.v.15i1.0006
https://doi.org/http://doi.org/10.5212.v... .

Thus, this is the first study to analyze national data on CNCD risk factors among women beneficiaries of the BFP by telephone survey. It is noteworthy that this is a gap in the national literature, given the vulnerability of this public and the evidence that CNCDs and their risk factors (RF) are more frequent in the low-income population⁶6. Malta DC, Duncan BB, Barros MB de A, Katikireddi SV, Souza FM de, Silva AG da, et al. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Ciênc Saúde Coletiva 2018; 23(10): 3115-22. http://doi.org/10.1590/1413-812320182310.25222018
https://doi.org/http://doi.org/10.1590/1... ^,1313. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, et al. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1,7 million men and women. Lancet 2017; 389(10075): 1229-37. http://doi.org/10.1016/s0140-6736(16)32380-7
https://doi.org/http://doi.org/10.1016/s... .

The aim of the present study was to compare the distribution of CNCD indicators among adult women beneficiaries and non-beneficiaries of the BFP in Brazilian capitals and the Federal District.

METHODS

This is a population-based epidemiological study with a cross-sectional design, with data from Vigitel, years 2016 and 2017, from the 26 Brazilian capitals and the Federal District. The surveyed population was comprised of adult women (≥ 18 years and over). Approximately two thousand interviews are carried out per capital, about 54 thousand interviews each year¹⁴14. Brasil. Ministério da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: Ministério da Saúde, 2018.^. In the current study, 3,330 women benefiting from the PBF and 63,152 non-beneficiaries were studied. Data on the sample design can be read in other publications¹⁴14. Brasil. Ministério da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: Ministério da Saúde, 2018.^,1515. Bernal RTI, Iser BPM, Malta DC, Claro RM. Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel): mudança na metodologia de ponderação. Epidemiol Serv Saúde 2017; 26(4): 701-12. http://doi.org/10.5123/s1679-49742017000400003
https://doi.org/http://doi.org/10.5123/s... .

In 2016, the following question was introduced: “Do you or someone in your family who lives at home receive Bolsa Família (BF)?”. This is the first study to analyze this question. Currently, 92% of women are the beneficiary of the family, regardless of the type of family arrangement to which they belong¹²12. Corgozinho KDS. A política social e a feminização do cuidado no Programa Bolsa Família: invenção das tradições? Emancipação 2015; 15(1): 97-114. http://doi.org/10.5212.v.15i1.0006
https://doi.org/http://doi.org/10.5212.v... . Thus, indicators from the Vigitel database for adult women were analyzed.

The prevalences were compared, with the respective 95% confidence intervals (95% CI) of the following indicators:

For this analysis, it was necessary to join the Vigitel 2016 and 2017 databases and select only the women who received or did not receive the BFP benefit. The choice to study two years was a methodological option to increase the sample size of women who received the benefit.

It was necessary to calculate post-stratification weights, since the sample of adults interviewed by Vigitel was extracted from the register of residential telephone lines existing in each city, which only allows, strictly, inferences for the adult population residing in households covered by fixed telephone network. Thus, the use of post-stratification weights aims to minimize the addiction resulting from the low coverage of landline registrations, especially in the North and Northeast regions¹⁴14. Brasil. Ministério da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: Ministério da Saúde, 2018.^,1515. Bernal RTI, Iser BPM, Malta DC, Claro RM. Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel): mudança na metodologia de ponderação. Epidemiol Serv Saúde 2017; 26(4): 701-12. http://doi.org/10.5123/s1679-49742017000400003
https://doi.org/http://doi.org/10.5123/s... .

In order to construct the post-stratification weights of this subsample of women, the estimate of the female population with or without PBF obtained by the 2016 National Household Sample Survey (PNAD) was used as the reference population¹⁶16. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios: síntese de indicadores 2015. Rio de Janeiro: IBGE; 2016. 108 p.. The variables age, education and region were used in the construction of the weights, as these characteristics are associated with the possession of the PBF. Weights were obtained using the rake method¹⁵15. Bernal RTI, Iser BPM, Malta DC, Claro RM. Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel): mudança na metodologia de ponderação. Epidemiol Serv Saúde 2017; 26(4): 701-12. http://doi.org/10.5123/s1679-49742017000400003
https://doi.org/http://doi.org/10.5123/s... .

The descriptive analyzes consisted of calculating the distribution of the proportions of women who receive and do not receive the benefit of the PBF, according to sociodemographic characteristics and NCD indicators. The prevalence and the prevalence ratio of the indicators were analyzed among the population with and without PBF, using the Poisson regression model with robust variance, with adjustment for age. A stratified analysis was also carried out according to the different schooling strata (zero to eight years, nine to 11 years and 12 years and more), comparing women with the same level of education, beneficiaries or not of the PBF, with adjustment for age. Data analysis was performed using the Statistical Software for Professional (Stata) statistical program, using the commands of the survey module, taking into account the weights and, therefore, the sample’s representativeness.

The Vigitel survey was approved by the National Commission for Ethics in Research for Human Beings, of the Ministry of Health, opinions 13.081/2008 and 355.590/2013. The signature of the Free and Informed Consent Form (ICF) in this survey was replaced by the verbal consent of the interviewee at the time of the telephone call.

RESULTS

Among the 66,482 women studied in 2016 and 2017, 3,330 live in households that received BF during the study period, and these residents are concentrated mainly in the Northeast and North regions - 1,674 (50.3%) and 922 (27.7%), respectively. There is also a greater proportion of these beneficiaries between the ages of 25 to 54 years old (2,046/61.4%), without education and/or with incomplete elementary school (926/27.8%) and complete high school and or incomplete higher education (1,538/46.19%) (Table 1).

The distribution of CNCD risk and protection factors for women with and without BFP, in the group of 26 capitals, and the estimated prevalence ratios (PR) are shown in Table 2. In general, higher prevalence of risk factors and lower frequencies of protective factors were found in women benefiting from the BFP.

The age-adjusted prevalence ratio (PR) for female smokers was 1.98 (95% CI 1.61 - 2.43). Overweight and obesity were higher among women with PBF: PR = 1.21 and 1.63 (95% CI 1.14 - 1.29; 1.44 - 1.85), respectively. Regarding eating habits, the recommended consumption of fruits and vegetables was lower among women with GMP (PR = 0.63; 95% CI 0.54 - 0.73), but there was a higher consumption of beans (PR = 1.25; 95% CI 1.18 - 1.32) and soft drinks (PR = 1.68; 95% CI 1.43 - 1.98). Women benefiting from PBF had less practice of PA during leisure (PR = 0.65; 95% CI 0.57 - 0.75); higher PA at home (PR = 1.35; 95% CI 1.29 - 1.41); longer time watching TV (PR = 1.37; 95% CI 1.21 - 1.55); worse self-assessment of health status (PR = 2.04; 95% CI 1.56 - 2.66); lower coverage of mammography (PR = 0.86; 95% CI 0.79 - 0.94) and Pap smear (PR = 0.91; 95% CI 0.87 - 0.95); and higher prevalence of self-reported morbidities, such as hypertension and diabetes (PR = 1.46 and 1.66; 95% CI 1.29 - 1.64; 1.29 - -2.07, respectively). There were no statistically significant differences between the prevalence of beneficiaries and non-beneficiaries for alcohol abuse (Table 2).

Table 3 shows the prevalence, PR and age-adjusted PR of CNCD risk and protection factors among women with and without BFP from the same age-adjusted level of education (zero to eight years of study). Women who are beneficiaries of the BFP with low education have a higher prevalence of tobacco use (PR = 1.51; 95% CI 1.16 - 1.97), a higher prevalence of obesity (PR = 1.24; 95% CI 1.06 - 1.45), lower recommended consumption of fruits and vegetables (PR = 0.71; 95% CI 0.56 - 0.89), less PA practice at leisure (PR = 0.79; 95% CI 0.63 - 0 , 98) and worse self-assessment of health status (PR = 1.46; 95% CI 1.07 - 1.97). As a protection indicator, there was a higher consumption of beans (PR = 1.09; 95% CI 1.01 - 1.17).

In Table 4, women with and without BFP with average schooling (nine to 11 years of study) are compared, adjusted for age. The adjusted PR shows that women benefiting from the BFP have worse indicators, such as: smoking (PR = 1.54; 95% CI 1.14 - 2.09), overweight (PR = 1.11; 95% CI 1.02 - 1.21), obesity (PR = 1.29; 95% CI 1.08 - 1.54), lower recommended consumption of fruits and vegetables (PR = 0.81; 95% CI 0.67 - 0.97), less practice of leisure-time physical activity (PR = 0.82; 95% CI 0.71 - 0.95), greater PA at home (PR = 1.18; 95% CI 1.11 - 1.25), state self-assessment poor health (PR = 1.69; 95% CI 1.16 - 2.44) and higher self-reported prevalence of diabetes (PR = 1.60; 95% CI 1.22 - 2.10). As a protective factor, greater consumption of beans was observed (PR = 1.13; 95% CI 1.06 - 1.21).

Table 5 contains the prevalence and PR of the risk and protective factors for CNCDs among women with and without BFP with schooling of 12 years or more, adjusted for age. Among women beneficiaries of the BFP with a high level of education, the differences were reduced, but worse performance was still found for overweight (PR = 1.27; 95% CI 1.01 - 1.61), soft drink consumption (PR = 2.01; 95% CI 1.30 - 3.12) and self-reported hypertension (PR = 1.67; 95% CI 1.07 - 2.60). The other variables did not show significant differences.

DISCUSSION

This is the first study that analyzes data from Vigitel for adult women who are beneficiaries of the BFP. This population is more vulnerable and has a lower family income. Among the sociodemographic indicators, the study highlighted: less education, greater concentration in the Northeast Region and younger population, among women beneficiaries of BFP. Among the indicators analyzed here, in general, the prevalence of risk factors was higher among women who receive the BFP benefit. They have a higher prevalence of smoking, overweight and obesity, less consumption of fruits and vegetables, higher consumption of soft drinks, however, on the other hand, the consumption of beans was higher. These women also had less PA practice during leisure time, however greater PA at home, or performing heavy cleaning tasks at home, in addition to more time watching TV. They had a worse self-assessment of their health status considered poor, less coverage of mammography and Pap smears and higher prevalence of self-reported morbidities (hypertension and diabetes). The study points out worse indicators in the poorest populations.

These differences decreased when women between strata with the same education were compared. When comparing the women beneficiaries of the PBF with 12 years or more of study with the others, the prevalence of risk factors was reduced, and the differences found were: higher prevalence of overweight, higher consumption of soft drinks and higher prevalence of hypertension self-reported among women with BFP. All other variables were similar, revealing that education is a major protective factor for women’s health.

These data highlight the importance of social determinants, particularly poverty, in the occurrence of CNCDs, with the worst indicators in the most vulnerable population⁵5. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, et al. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36: 408-25. http://doi.org/10.1057/jphp.2015.29
https://doi.org/http://doi.org/10.1057/j... ^,1717. Barros MBA, Lima MG, Medina LPB, Szwarcwald CL, Malta DC. Social inequalities in health behaviors among Brazilian adults: National Health Survey, 2013. Int J Equity Health. 2016; 15: 148. http://doi.org/10.1186/s12939-016-0439-0
https://doi.org/http://doi.org/10.1186/s... .

The prevalence of smoking indicators was higher among women beneficiaries of BFP. Studies indicate that populations with higher education, income and better socioeconomic conditions have lower prevalence of tobacco use¹⁸18. Giovino GA, Mirza EM, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012; 380(9842): 668-79. http://doi.org/10.1016/s0140-6736(12)61085-x
https://doi.org/http://doi.org/10.1016/s... , which has been explained by the greater access to information on the harms of this habit. It is noteworthy that the differences disappeared among more educated women, showing that their disadvantage can be overcome through greater investment in education.

Foods such as fruits and vegetables are considered protective and prevent cardiovascular diseases and cancers⁴4. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Genebra: World Health Organization; 2013 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665... ^,1919. Jaime PC, Stopa SR, Oliveira TP, Vieira ML, Szwarcwald CL, Malta DC. Prevalência e distribuição sociodemográfica de marcadores de alimentação saudável, Pesquisa Nacional de Saúde, Brasil 2013. Epidemiol Serv Saúde 2015; 24(2): 267-76. http://doi.org/10.5123/s1679-49742015000200009
https://doi.org/http://doi.org/10.5123/s... . Vigitel’s recommended consumption of fruits and vegetables (FLV) is a proxy for what would be recommended by the World Health Organization, or the daily consumption of 400g/day of fruits and vegetables¹⁴14. Brasil. Ministério da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: Ministério da Saúde, 2018.^,1919. Jaime PC, Stopa SR, Oliveira TP, Vieira ML, Szwarcwald CL, Malta DC. Prevalência e distribuição sociodemográfica de marcadores de alimentação saudável, Pesquisa Nacional de Saúde, Brasil 2013. Epidemiol Serv Saúde 2015; 24(2): 267-76. http://doi.org/10.5123/s1679-49742015000200009
https://doi.org/http://doi.org/10.5123/s... ^,2020. World Health Organization. From burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle-income countries: executive summary 2011 [Internet]. Genebra: World Health Organization ; World Economic Forum; 2011 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://www.who.int/nmh/publications/best_buys_summary/en/
http://www.who.int/nmh/publications/best... .

Likewise, beans are a protective food, as they are rich in fiber and nutrients, resulting in greater satiety and obesity prevention²¹21. Velásquez-Meléndez G, Mendes LL, Pessoa MC, Sardinha LMV, Yokota RT de C, Bernal RTI, et al. Tendências da frequência do consumo de feijão por meio de inquérito telefônico nas capitais brasileiras, 2006 a 2009. Ciênc Saúde Coletiva 2012; 17(12): 3363-70. http://doi.org/10.1590/s1413-81232012001200021
https://doi.org/http://doi.org/10.1590/s... , and are recommended by the Food Guide for the Brazilian Population, which recognizes its role in the national culinary tradition²²22. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2. ed. Brasília: Ministério da Saúde ; 2014.. Because it is a lower cost food and has an important participation in traditional Brazilian cuisine, its consumption is higher among lower income populations. On the contrary, soft drinks, fats, sugars and salt are foods that increase the risk of CNCD⁴4. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Genebra: World Health Organization; 2013 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665... ^,2020. World Health Organization. From burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle-income countries: executive summary 2011 [Internet]. Genebra: World Health Organization ; World Economic Forum; 2011 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://www.who.int/nmh/publications/best_buys_summary/en/
http://www.who.int/nmh/publications/best... ^,2222. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2. ed. Brasília: Ministério da Saúde ; 2014..

The study pointed out that women from the BFP have less consumption of FLV and more of soft drinks; the exception was beans. The Strategic Action Plan to Combat CNCDs encourages countries to adopt measures to regulate ultra-processed foods with a high sugar, salt and fat content, as well as measures that can increase production and consumption and reduce prices of fresh food such as vegetables⁴4. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Genebra: World Health Organization; 2013 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665... ^,2222. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2. ed. Brasília: Ministério da Saúde ; 2014.. These measures would bring great benefits to the population⁴4. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Genebra: World Health Organization; 2013 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665... ^,2222. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2. ed. Brasília: Ministério da Saúde ; 2014., especially to the poorest, such as women beneficiaries of the BFP and their families. It is also noteworthy that having more education brought important benefits to the diet of the women studied here, regardless of the economic level.

Leisure-time PA was less practiced by women benefiting from the PBF, in contrast to domestic PA, represented by heavy cleaning, as well as longer TV time or sedentary leisure. Leisure time PA is associated with populations with high education and income, due to greater access to spaces for PA practice and greater knowledge about the benefits of PA²³23. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U, et al. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012; 380(9838): 247-57. http://doi.org/10.1016/s0140-6736(12)60646-1
https://doi.org/http://doi.org/10.1016/s... . On the contrary, PA practices during work and commuting to work are associated with low-income populations. In a special way, PA in the home is more affectionate to women, due to a macho aspect of Brazilian society, which considers that domestic activities should be performed by women²⁴24. Florindo AA, Hallal PC, Moura EC, Malta DC. Prática de atividades físicas e fatores associados em adultos, Brasil, 2006. Rev Saúde Pública 2009; 43(Supl. 2): 65-73. http://doi.org/10.1590/S0034-89102009000900009
https://doi.org/http://doi.org/10.1590/S... . It was also found that in the analysis stratified by education, these differences were reduced, pointing out that it is possible to change this reality, investing in public policies of access to public spaces for PA practice, as well as improving the population’s income and education, aiming to decrease these inequalities⁵5. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, et al. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36: 408-25. http://doi.org/10.1057/jphp.2015.29
https://doi.org/http://doi.org/10.1057/j... . Data from the National Health Survey indicate that overweight affects more than half of women, and obesity, 24%, revealing the extent of the problem in the country²⁵25. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas [Internet]. Rio de Janeiro: IBGE ; 2014 [acessado em 6 jan. 2019]. Disponível em: Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
ftp://ftp.ibge.gov.br/PNS/2013/pns2013.p... . Also, obesity can affect the achievement of the global goal of reducing CNCD mortality²⁶26. The GBD 2015 Obesity Collaborators. Health Effects of Overweight and Obesity in 195 Countries over 25 Years. N Engl J Med 2017; 377: 13-27. http://doi.org/10.1056/NEJMoa1614362
https://doi.org/http://doi.org/10.1056/N... . The study shows that, although it is a widespread problem, it is even more serious among women beneficiaries of PBF, especially with low education.

Studies indicate that the prevalence of at least one chronic disease increased with age and was higher among women²⁷27. Barros MB de A, César CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Ciênc Saúde Coletiva 2006; 11(4): 911-26. http://doi.org/10.1590/s1413-81232006000400014
https://doi.org/http://doi.org/10.1590/s... , in addition to the presence of multimorbidities (two diseases and three or more diseases)²⁸28. Azevedo ALS de, Silva RA da, Tomasi E, Quevedo L de Á. Doenças crônicas e qualidade de vida na atenção primária à saúde. Cad Saúde Pública 2013; 29(9): 1774-82. http://doi.org/10.1590/s0102-311x2013001300017
https://doi.org/http://doi.org/10.1590/s... ^,2929. Theme Filha MM, Souza Junior PRB de, Damacena GN, Szwarcwald CL. Prevalência de doenças crônicas não transmissíveis e associação com autoavaliação de saúde: Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 83-96. http://doi.org/10.1590/1980-5497201500060008
https://doi.org/http://doi.org/10.1590/1... .

Self-assessment of poor health status was more frequent among women beneficiaries of BFP, but, when stratified by schooling, in strata with 12 or more years of study, this difference disappeared, which is in accordance with the literature²⁹29. Theme Filha MM, Souza Junior PRB de, Damacena GN, Szwarcwald CL. Prevalência de doenças crônicas não transmissíveis e associação com autoavaliação de saúde: Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 83-96. http://doi.org/10.1590/1980-5497201500060008
https://doi.org/http://doi.org/10.1590/1... . This indicator is classically associated with worse health and life conditions, low income and the elderly population, and is an important predictor of mortality³⁰30. Molarius A, Berglund K, Eriksson C, Lambe M, Nordström E, Eriksson HG, et al. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 2007; 17(2): 125-33. http://doi.org/10.1093/eurpub/ckl070
https://doi.org/http://doi.org/10.1093/e... ^,3131. Barros MB de A, Zanchetta LM, Moura EC de, Malta DC. Auto-avaliação da saúde e fatores associados, Brasil, 2006. Rev Saúde Pública 2009; 43(Supl. 2): 27-37. http://doi.org/10.1590/s0034-89102009000900005
https://doi.org/http://doi.org/10.1590/s... .

The study showed that hypertension and diabetes morbidities were more prevalent among women with BFP, or low income, which has been confirmed in other studies, both by Vigitel, pointing out that the prevalence of hypertension in the population with low education was three times as high³²32. Malta DC, Bernal RTI, Andrade SSC de A, Silva MMA da, Velasquez-Melendez G. Prevalence of and factors associated with self-reported high blood pressure in Brazilian adults. Rev de Saúde Pública 2017; 51(Supl. 1). http://doi.org/10.1590/s1518-8787.2017051000006
https://doi.org/http://doi.org/10.1590/s... than for diabetes³³33. Malta DC, Bernal RTI, Iser BPM, Szwarcwald CL, Duncan BB, Schmidt MI. Factors associated with self-reported diabetes according to the 2013 National Health Survey. Rev Saúde Pública 2017; 51(Supl. 1). http://doi.org/10.1590/s1518-8787.2017051000011, with frequencies up to four times higher in the population with low education. Also, in international studies³⁵35. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Supl. 1). http://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/http://doi.org/10.1590/s... , an association was found between educational level and diabetes mellitus, after adjusting the variables income and occupation³⁴34. Maty SC, Everson-Rose SA, Haan MN, Raghunathan TE, Kaplan GA. Education, income, occupation, and the 34-year incidence (1965-99) of Type 2 diabetes in the Alameda County Study. Int J Epidemiol 2005; 34(6): 1274-81. http://doi.org/10.1093/ije/dyi167
https://doi.org/http://doi.org/10.1093/i... . The explanations for this finding are schooling, as a proxy for socioeconomic level, and less access to health promotion practices, such as healthy eating, PA, access to medicines and health services¹⁷17. Barros MBA, Lima MG, Medina LPB, Szwarcwald CL, Malta DC. Social inequalities in health behaviors among Brazilian adults: National Health Survey, 2013. Int J Equity Health. 2016; 15: 148. http://doi.org/10.1186/s12939-016-0439-0
https://doi.org/http://doi.org/10.1186/s... ^,3535. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Supl. 1). http://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/http://doi.org/10.1590/s... .

The coverage of preventive cancer exams was lower among women beneficiaries of PBF, with frequencies below that recommended by the Strategic Action Plan for Coping with Chronic Diseases in Brazil, which foresees reaching 75% of mammography coverage and 85% of Pap smears in 2022³⁶36. Malta DC, Morais Neto OL de, Silva Junior JB da. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saúde 2011; 20(4): 425-38. http://doi.org/10.5123/s1679-49742011000400002
https://doi.org/http://doi.org/10.5123/s... . It is noteworthy that the prevalence of oncotic cytology (Pap smear) is higher, possibly because they are performed by the Family Health Strategy, through the Unified Health System (SUS) ³⁵35. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Supl. 1). http://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/http://doi.org/10.1590/s... .

Alcohol abuse did not differ between the two groups of women, but, when stratified for 12 years, it was slightly higher among women with higher income, which is consistent with other studies¹⁴14. Brasil. Ministério da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: Ministério da Saúde, 2018..

The study highlights health inequities, which are the worst indicators in the population benefiting from BFP, revealing the importance of social determinants in the health-disease process. Higher income populations have easier access to health services and promotion practices⁴4. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Genebra: World Health Organization; 2013 [acessado em 6 jan. 2019]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665... ^,55. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, et al. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36: 408-25. http://doi.org/10.1057/jphp.2015.29
https://doi.org/http://doi.org/10.1057/j... . These results reflect the importance of investments in improving living conditions and education, which can directly interfere with health indicators.

Cash transfer programs are fundamental in tackling inequalities, especially with regard to strengthening actions related to gender, in the production of equity³⁷37. Moreira NC, Ferreira MAM, Lima AATFC, Ckagnazaroff IB. Empoderamento das mulheres beneficiárias do Programa Bolsa Família na percepção dos agentes dos Centros de Referência de Assistência Social. Rev Adm Pública 2012; 46(2): 403-23. http://dx.doi.org/10.1590/S0034-76122012000200004
https://doi.org/http://dx.doi.org/10.159... . The study showed greater vulnerability of this population, which should also be prioritized by health services, in positive discrimination with regard to access to services, educational practices and public policies for health promotion. Thus, this study may contribute to the definition of health policies aimed at the prevention and control of these diseases.

Among the limits of the study, the use of telephone interviews stands out, seeking to reduce this bias using post-stratification weights. The fact that the information is self-reported can also result in information bias, although national and international experience highlights that variables such as arterial hypertension and health status assessment can obtain good estimates using this methodology, in addition to presenting advantages such as speed of information, sensitivity and low cost³⁸38. Moreira JP de L, Almeida RMVR de, Rocha NC dos S, Luiz RR. Correção da prevalência autorreferida em estudos epidemiológicos com grandes amostras. Cad Saúde Pública 2016; 32(12). http://doi.org/10.1590/0102-311x00050816
https://doi.org/http://doi.org/10.1590/0... . Due to the reduced number of interviews with BFP, it was decided to analyze 2016 and 2017, reducing the standard error of the estimates. Another limitation is the fact that the respondent is not the beneficiary of the program, since the question is about the benefit in the family. In this case, a proxy of the results is made. In addition, the cross-sectional design of the study does not allow the establishment of a temporal cause and effect relationship.

CONCLUSION

The study showed differences in risk and protection factors among women, with worse indicators among those who receive the BFP benefit. It is noteworthy that this does not reflect a causal relationship between receiving BFP and having a worse performance, but rather the social inequalities inherent to this most vulnerable group, characterized by little access to healthy food, places to practice PA, health services and practices health promotion, in addition to differences in schooling and less information about disease prevention and health promotion practices.

The study also shows that the BFP is being targeted at women with the worst indicators, demonstrating the importance of this program, which works on social determinants of health and the reduction of inequalities, and the use of Vigitel in this assessment.

References

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