Abstract

INTRODUCTION

Conditional cash transfer programs (CCTP) are social protection policies aiming for the social inclusion of families in situations of extreme poverty. Due to the widespread poverty in the world, which has complex and multi-dimensional origins, CCTP have been adopted in countless developing countries over the last two decades. ²2 . Das J, Do Q-T, Ozler B. Reassessing conditional cash transfer programs. World Bank Res Obs . 2005;20(1):57-80. DOI:10.1093/wbro/lki005
https://doi.org/10.1093/wbro/lki005... ^{, 29}29 . Silva MOS. O Bolsa Família: problematizando questões centrais na política de transferência de renda no Brasil. Cienc Saude Coletiva. 2007;12(6):1429-39. DOI:10.1590/S1413-81232007000600006
https://doi.org/10.1590/S1413-8123200700...

In Brazil, the first CCTP appeared in the 1990s. However, their territorial and numerical expansion occurred mostly from 2001 onwards, with the creation of federal programs such as: Programa Bolsa Escola (School Grants Program), Programa Bolsa Alimentação (Food Grants Program), Auxílio Gás (Gas Subsidies) and Cartão Alimentação (Food cards). These programs were even more focused on extreme poverty and many of them had conditionalities, such as having the child vaccinated or having minimum school attendance. ^aaMinistério do Desenvolvimento Social e Combate à Fome. Evolução dos recursos dos programas de transferência de renda. Cad SUAS . 2008;3(3). Available from: http://www.mds.gov.br/assistenciasocial/secretaria-nacional-de-assistencia-social-snas/cadernos/cadernos-suas-evolucao-dos-recursos-dos-programas-de-transferencia-de-renda In 2003, federal resources became centered on one single program, the Programa Bolsa Família (PBF – Family Grant Program) which, by the end of 2012, had aided 13.9 million families. ^bbMinistério do Desenvolvimento Social e Combate à Fome, Secretaria de Avaliação e Gestão da Informação. Relatórios de Informações Sociais. Brasília (DF); s.d. [cited 2013 Jan 26]. Available from: http://aplicacoes.mds.gov.br/sagi/RIv3/geral/ The requirement to meet health care conditions, involving monitoring children’s growth and development and vaccinations and pregnant women going to antenatal and postnatal appointments, was expanded from 10.0% of households benefitting from the PBF, in 2005, to around 70.0% in 2011. ^ccMinistério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Coordenação Geral de Alimentação e Nutrição. Acompanhamento das condicionalidades da saúde do Programa Bolsa Família (1ª vigência de 2011). Brasília (DF); 2011. (Nota Técnica 2011). [cited 2012 Sep 12]. Available from: http://189.28.128.100/nutricao/docs/geral/nt2011_vigencia1.pdf

CCTP have made a positive contribution, especially in tackling social inequalities. Between 2001 and 2005, social inequality in Brazil was reduced by around 20.0% in the whole country and by almost 50.0% in the Northeast, where the coverage of such programs is highest. ⁶6 . Hoffman R. Desigualdade da renda e das despesas per capita no Brasil, em 2002-2003 e 2008-2009, e avaliação do grau de progressividade ou regressividade de parcelas da renda familiar. Econ Soc . 2010;19(3):647-61. DOI:10.1590/S0104-06182010000300010
https://doi.org/10.1590/S0104-0618201000... ^{, d}dBarros RP, Carvalho M, Franco S, Mendonça R. A queda recente da desigualdade de renda no Brasil. In: Barros RP, Foguel MN, Ulyssea G, organizadores. Desigualdade de renda no Brasil: uma análise da queda recente. Brasília (DF): IPEA; 2007. v.1, cap 2, p. 107-27. Although there are still few results on the impact of CCTP on the health of the recipients, there is evidence that social inequalities have decreased and purchasing power of the households increased, leading to decreasing levels of malnutrition and infant mortality. ¹³13 . Monteiro CA, Benicio MHA, Konno SC, Silva ACF, Lima ALL, Conde WL. Causes for the decline in child under-nutrition in Brazil, 1996-2007. Rev Saude Publica . 2009;43(1):35-43. DOI:10.1590/S0034-89102009000100005
https://doi.org/10.1590/S0034-8910200900... ^{, 33}33 . Victora CG, Aquino EML, Leal MC, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet . 2011;377(9780):1863-76. DOI:10.1016/S0140-6736(11)60138-4
https://doi.org/10.1016/S0140-6736(11)60... Between 2004 and 2009, it was verified that the PBF had contributed to reducing infant mortality in Brazilian municipalities. ²²22 . Rasella D, Aquino R, Santos CAT, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet . 2013;382(9886):57-64. DOI:10.1016/S0140-6736(13)60715-1
https://doi.org/10.1016/S0140-6736(13)60...

In Brazil, there is consensus on the need to maintain and improve conditional cash transfers. The presence of the CCTP, together with policies to strengthen the Brazilian Unified Health System (SUS) and programs focusing on education and social security, enable the cycle of poverty, generation after generation, to be broken and, therefore, result in improved health condition and quality of life for the population. ²2 . Das J, Do Q-T, Ozler B. Reassessing conditional cash transfer programs. World Bank Res Obs . 2005;20(1):57-80. DOI:10.1093/wbro/lki005
https://doi.org/10.1093/wbro/lki005... ^{, e}eBarreto ML, Teixeira MG, Morais Neto OL, Duarte EC. Considerações finais: programas de transferência de renda e o Sistema Único de Saúde: potencializando o impacto das ações. In: Ministério da Saúde, Secretaria de Vigilância em Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília (DF); 2011. p. 367-72.

Evaluations of the impact of the CCTP on the diet and nutrition up until now have different results. There is only one literature review on the impact of the PBF on food security and nutrition, although this was not systematic and did not analyze the level of evidence of the results obtained. ¹1 . Cotta RMM, Machado JC. Programa Bolsa Família e segurança alimentar e nutricional no Brasil: revisão crítica da literatura. Rev Panam Salud Publica . 2013;33(1):54-60. DOI:10.1590/S1020-49892013000100008
https://doi.org/10.1590/S1020-4989201300...

The aim of this study was to analyze the influence of conditional cash transfer programs on diet and nutrition outcomes among the recipient families.

METHODS

A systematic revision of the literature was performed, centered on the guiding question: “Are conditional cash transfer programs in Brazil capable of affecting the diet and nutrition of the recipient families?”. The presentation of the review was based on the directives of the PRISMA protocol for systematic reviews and meta-analyses. ⁷7 . Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ . 2009;339:b2700. DOI:10.1136/bmj.b2700
https://doi.org/10.1136/bmj.b2700...

Concerning the inclusion criteria, we looked for original studies, performed in Brazil and published in journals indexed in the selected databases, containing at least one outcome related to diet and nutrition, such as dietary intake, food and nutritional security and/or nutritional status of the beneficiary population. Clinical (random or otherwise) or observational (cross-sectional, longitudinal, with and without control group) studies, published after 1990 in Portuguese, Spanish or English were included. It was decided not to include documents from official evaluations of the CCTP.

The search strategy adopted was to consult the Web of Science, Scopus, PubMed and Lilacs databases.

The following search limits were considered: studies involving humans, published in Portuguese, English or Spanish and dated between January 1990 and July 15, 2013. Two sets of search term intersections were combined: cash transfer [cash transfer, cash transfer program, conditional cash transfer, Bolsa Família, Bolsa Alimentação , Nutrition Programs, public policy, poverty, government program, public assistance, income] and diet and nutrition [food, diet, food consumption, food habits, food security, nutritional status, anthropometry, anthropometry measurements, nutritional assessment].

In the search of the PubMed, Web of Science and Scopus databases, the term Brazil was included. The inclusion of this term in LILACS would limited the search, as studies performed in Brazilian municipalities are common in this database and are published in national journals, without mentioning the name of the country.

Each term was individually crossed with the others, guaranteeing the inclusion of all articles related to the topic. The reference lists of the articles were also researched, with the aim of identifying more original studies that had not been found in the search. However, this complementary strategy did not turn up any more results. The articles were selected and organized with EndNoteWeb (version 3.4) software.

First, two of the authors assessed the titles and abstracts of the papers, rejecting those which did not meet the inclusion criteria. To resolve any doubts, the complete text was consulted to confirm the eligibility of the study. If the two evaluators did not agree, another author examined the article. All of the studies were independently judged by the authors, according to the above mentioned criteria.

The papers were systematically reviewed, grouped according to outcome category (food consumption, food and nutritional security and nutritional status). The studies were evaluated according to the CTTP studied, the participants (study population, sample size, control group), study design, time and place conducted, outcome, key conclusions and adjusted for confounding factors, as well as the methodological limitations mentioned by the authors. In addition, the theoretical framework to evaluate programs and health care policies was used to judge the level of evidence provided by the studies and to classify them. They were classified as accuracy, plausibility or probability studies, with the latter two categories considered to have historical, internal or external control. ⁵5 . Habitcht JP, Victora CG, Vaughan JP. Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact. Int J Epidemiol . 1999;28(1):10-8. DOI:10.1093/ije/28.1.10
https://doi.org/10.1093/ije/28.1.10...

Given the heterogeneity of the study designs, outcomes and analyses, a narrative analysis was performed according to the outcome category. For outcomes related to nutritional status, studies which assessed anthropometric data of children and adults were selected; for outcomes concerning food consumption, studies which evaluated food intake, perception of food intake or frequency of food intake were selected. Finally, relating to nutritional security, studies that applied the Brazilian Food Security Scale to evaluate the access to foodstuffs were selected.

RESULTS

The search identified 1,412 non-duplicated documents, of which 1,397 did not meet the eligibility criteria, resulting in 15 articles for analysis. The complete selection process can be found in the Figure .

Nine studies that evaluated the influence of CCTP on nutritional status were selected. The methodology, principal results and methodological limitations of these studies were described, according to the level of evidence obtained ( Table 1 ). All of the studies’ samples were on a municipal, state or regional level, of which four used a control group and adjusted for external factors and only one was population based. Two of the studies were longitudinal analyses and the others were cross-sectional.

Only one of the studies assessed the Programa Bolsa Alimentação (PBA). 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. This study had two stages: a cross-sectional stage and a retrospective cohort. Both stages took place in four municipalities in the Northeast, where the program had been established for less than six months. It was the only study which obtained plausibility evidence with internal control, as the recipient households were compared with others which were eligible to receive the benefit, but had been excluded because of administrative errors in the registration. Anthropometric measurements of the intervention and control groups were taken (individually matched), and up to ten reported weight measurements were recorded from the Child Health Card for a longitudinal sub-analysis (retrospective cohort). It concluded that children included in the PBA had lower initial z-scores and gained less weight (31 g less) compared with children who did not benefit from the first six months of the program.

Plausibility studies with external control, in which the recipients were compared with non-recipients with similar socioeconomic characteristics, predominated in the PBF impact evaluations on nutritional status. One of the studies was originated from surveys that took place during vaccination campaigns in socially vulnerable areas of the country, with around 15 thousand children. 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... In that study, belonging to the PBF increased by 26.0% the chance of the children to have a z-score appropriate for height/age and weight/age, after controlling for external factors. Similarly, another study, carried out in seven rural communities in the North of the country, found an increase of 0.25 in the mean z-score for height/age in children receiving the PBF, after adjusting for socioeconomic factors. 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... This study compared the nutritional status evolution over a five-year period (before and after the establishment of the program) in a sample of around 204 individuals under 18 years old.

In four plausibility studies with external control it was found that the PBF had no effect on the nutritional status of children receiving it. Two of them 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... ^{, 16}16 . 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... used different analytical approaches in a cross-sectional study of a sample of 446 children in a municipality in the Southeast. However, none of the approaches found an association between belonging to the PBF and nutritional status (continuous z-score for weight/age and height/age or categorized as malnourished or otherwise), even after adjusting for external factors. The others were cross-sectional and took place in a city in the Northeast with a sample of 164 children 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... and in the Southeast with a sample of 115 children. 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... Neither found statistically significant differences between mean z-scores for weight/height, weight/age and height/age or in the prevalence of being small for age or overweight for PBF recipients and non-recipients, without adjusting for other factors.

The accuracy studies, which only evaluated the recipients without using a control group, highlighted the need to implement diet and nutrition campaigns aimed at PBF recipients. In a cross-sectional population based study in a municipality in the South of the country, the prevalence of overweight in the adult population was higher than 50.0% and the increased risk for cardiovascular disease was around 30.0%. ¹⁰10 . Lima FEL, Fisberg RM, Uchimura KY, Picheth T. Programa Bolsa-Família: qualidade da dieta de população adulta do município de Curitiba, PR. Rev Bras Epidemiol. 2013;16(1):58-67. DOI:10.1590/S1415-790X2013000100006
https://doi.org/10.1590/S1415-790X201300... The study that assessed regional disparities in the state of Sergipe, using data of the SISVAN/DATASUS, ^ffSistema de Vigilância Alimentar e Nutricional. Departamento de Informática do SUS – SISVAN/DATASUS. Available from: http://tabnet.datasus.gov.br/cgi-win/SISVAN/CNV/notas_sisvan.html from 2008 to 2010,concluded that there was a higher prevalence of overweight or obesity in children receiving the PBF 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... in the regions with lower human development Indices.

The five studies that assessed the relationship between CCTP and food consumption are shown in Table 2 . All of them were cross-sectional studies and only one used a national representative sample, although no comparison with a control group was made.

The three plausibility studies identified had external control groups and evaluated diet diversity of CCTP beneficiaries. 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... ^{, 19}19 . 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... ^{, 25}25 . 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... The first concluded that there had been an increase in amount of protein intake (around 10 g) and that protein intake was appropriate among the recipients of the program, without adjusting for other factors. 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... The second study 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... found an association between being included in the PBF and increased consumption of processed foodstuffs with high concentration of added sugar (the chance of consumption was 3.1 times higher for recipients). In Belo Horizonte, MG, Southeastern Brazil, it was noted that meals were skipped more often and there was greater consumption of cheese, milk, fast-food and sweets in school break times among children receiving the PBF. 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...

One of the accuracy studies assessed the perceptions of PBF recipients regarding their food intake in a representative sample of beneficiary households. After entering the program, the households reported higher intake of all food groups, although no association was found with the period that the benefit was received. Also, the higher the value of the benefit, the higher the intake of all foodgroups. 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... The second study 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... assessed the diets of 747 PBF recipients in a municipality in the South using the Dietary Quality Index (DQI). It was concluded that the majority of recipients’ diets were not adequate. Although the median consumption of beans and meat was high, around 45.0% of the beneficiaries did not consume vegetables, milk and other dairy products. 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...

Another three evaluations of the impact of CCTP on nutritional security of the recipients were identified. All of them were cross-sectional plausibility studies with external control ( Table 3 ). On two of the studies, it was observed that the households in worse situations of nutritional security were selected to receive the benefits. 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. ^{, 30}30 . 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.

In a study of a representative sample in Brazil, it was found that there was a significant increase of 8.0% in the chance of having nutritional security in households which benefitted from the programs existing in 2004 (Food Cards, Continued Benefit, Program for the Eradication of Child Labor and Food Grants), for each R$ 10.00 increase in the value of the benefit, after selecting low income households and adjusting for sociodemographic variables. 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. The study performed in the Northeast found that, there was a decrease of 4.8% in the prevalence of severe food insecurity, adjusted for income, among beneficiary households, when compared with non-beneficiaries. 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. The third study evaluated food insecurity in 172 households, from a primary health care unit in the Southeast. 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. It was verified that 12% of the interviewees were in severe food insecurity, although it was not reported the proportions of recipients and non-recipients of the PBF or the municipal CCTP “Full Basket, Happy Family”.

The majority of methodological limitations highlighted in all of the studies were related to the cross-sectional design of data collection, which meant they were unable to confirm the existence of a causal relationship between belonging to a CCTP and the outcome studied. Also, small sample sizes, difficulties in collecting data and limitations of the instrument used were also noted as limiting factors.

DISCUSSION

This study aimed to systematically review studies evaluating the impact of CCTP on the food intake, nutritional status and food and nutritional security of recipient households in Brazil. Of the studies found, it was noted that the majority of them obtained evidence of plausibility and evaluated the impacts of CCTP on the nutritional status of the recipient households as positive, especially for children. With regard other outcomes, the few evaluations found indicated an association between belonging to a CCTP and increased consumption of different food groups and increased food and nutritional security of the recipients.

On the subject of study design, some carefully selected a control group with similar socioeconomic characteristics to the recipients of the benefit 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. ^{, 19}19 . 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... ^{, 20}20 . 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... and others obtained representative population based samples. 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... ^{, 27}27 . 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. ^{, 30}30 . 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. However, methodological problems were identified in other studies which compromised the interpretation of results and weakened the evidence obtained, such as selecting the sample by convenience, small sample size 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... ^{, 19}19 . 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... ^{, 25}25 . 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... and not adjusting for confounding variables. 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... ^{, 16}16 . 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...

Evidences obtained in plausibility studies are useful and reliable in evaluating the impact of programs and public policies. Although they do not have the maximum internal validity, due to the lack of sampling randomization, they can provide consistent results on the effect of a specific program, when combined with strategies that strengthen the evidence. Among the most commonly used strategies are adopting similar control groups for characteristics which may affect the result, adjusting for confounding effects and analyzing the dose-response effect. Evidence from accuracy studies can be used as tools to monitor the evolution of specific indicators over time, when accompanied by other studies indicating the isolated influence of the program on these indicators. ³¹31 . Victora CG, Habicht JP, Bryce J. Evidence-based public health: moving beyond randomized trials. Am J Public Health . 2004;94(3):400-5. DOI:10.2105/AJPH.94.3.400
https://doi.org/10.2105/AJPH.94.3.400...

It is believed that the probability inference is not needed in evaluating the impact of comprehensive, large-scale CCTP, as can be observed in a controlled and randomized study in Mexico, ²³23 . Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA . 2004;291(21):2563-70. DOI:10.1001/jama.291.21.2563
https://doi.org/10.1001/jama.291.21.2563... due to peculiarities on establishing the Mexican cash transfer program. Performing a study of this type in Brazil would not be viable for ethical reasons, as it would not be possible to select the households receiving (or not) the benefit, and because of the difficulty of controlling the entire complex causal pathway between cash transfers and their effect on the recipients diet and nutrition. ³¹31 . Victora CG, Habicht JP, Bryce J. Evidence-based public health: moving beyond randomized trials. Am J Public Health . 2004;94(3):400-5. DOI:10.2105/AJPH.94.3.400
https://doi.org/10.2105/AJPH.94.3.400...

When evaluating the diet and nutrition status of vulnerable populations, there is no gold standard indicator, but it is possible to obtain a combination of indicators which assess different aspects such as the health, economy, behavior and perception of the individuals studied. In this revision, we selected three nutritional outcomes which were related to income and the combination of which provided a more complete picture of the impact of the CCTP in the diet and nutrition of the recipients. ¹²12 . Mason JB. Keynote paper: measuring hunger and malnutrition. In: Proceedings of the International Scientific Symposium Measurement and Assessment of Food Deprivation and Undernutrition; 2002 Jun 26-28; Rome, Italy. Rome: FAO; 2002 [citado 2012 set 12]. Disponível em: http://www.fao.org/docrep/005/Y4249E/y4249e0d.htm#bm13
http://www.fao.org/docrep/005/Y4249E/y42... The quantitative indicators analyzed were anthropometric (especially in children) and food consumption, which measured the appropriateness of the population’s energy and nutrient intake and its dietary habits.

According to the World Health Organization, nutritional status evaluation using anthropometric measurements is an ideal indicator for studies aiming to investigate inequalities in health care and economic development ³⁵35 . World Health Organization. Physical status: the use and interpretation of anthropometry: report of a WHO Expert Committee. Geneva; 1995. (WHO Technical Report Series, 854). [citado 2013 out 31]. Disponível em: http://www.who.int/childgrowth/publications/physical_status/en/index.html
http://www.who.int/childgrowth/publicati... and so has been used as a classical measure in evaluation studiesof public policies. Nutritional deficiencies in early childhood – strongly associated with conditions of social inequality – can be reversed through overall improvements in living conditions. This phenomenon, known as catch-up, is more successful when the improvements occur in early childhood. ²¹21 . Power C, Parsons T. Nutritional and other influences in childhood as predictors of adult obesity. Proc Nutr Soc . 2000;59(2):267-72. DOI:10.1017/S002966510000029X
https://doi.org/10.1017/S002966510000029... ^{, 35}35 . World Health Organization. Physical status: the use and interpretation of anthropometry: report of a WHO Expert Committee. Geneva; 1995. (WHO Technical Report Series, 854). [citado 2013 out 31]. Disponível em: http://www.who.int/childgrowth/publications/physical_status/en/index.html
http://www.who.int/childgrowth/publicati... Measuring individual food consumption enables accurate dietary data to be obtained, although it requires a high level of logistics and training. These data can be used to validate information obtained in family budget surveys, which provide lower cost representative data on acquisition of foodstuffs on a household level. ⁴4 . Ferro-Luzzi A. Keynote paper: Individual food intake survey methods. In: Proceedings of the International Scientific Symposium Measurement and Assessment of Food Deprivation and Undernutrition; 2002 Jun 26-28; Rome, Italy. Rome: FAO; 2002 [citado 2012 set 12]. Disponível em: http://www.fao.org/docrep/005/Y4249E/y4249e0a.htm#bm10
http://www.fao.org/docrep/005/Y4249E/y42... Both consumption and acquisition of foodstuffs indicate how household income is spent on foodstuffs and how the household behaves when receiving cash transfers.

The third outcome used was evaluating the food and nutritional security of the households using the Brazilian Scale of Food Insecurity. This is a scale which has been translated and adapted for the Brazilian population and evaluates the household’s perceptions about hunger. It is considered a qualitative indicator of the population’s food and nutrition status and a more direct method of evaluating access to an adequate diet. However, this method is still relatively new, which means there are doubts about its ability to assess less severe forms of chronic food insecurity and to be used as a marker of food and nutritional security in evaluating the impact of interventions. ³⁴34 . Webb P, Coates J, Frongillo EA, Rogers BL, Swindale A, Bilinsky P. Measuring household food insecurity: why it’s so important and yet so difficult to do. J Nutr . 2006;136(5):1404S-8S Using the scale is a valid strategy of evaluating perceptions of improvements in food security conditions after receiving the benefit. However, it comprises subjective conceptions,making difficult to control for other variables which could alter this relationship, such as the influence of other public policies in other areas, as well as social assistance.

Other studies evaluating the impact of CCTP on food and nutrition related outcomes were found in the reference lists of the selected papers, but were not included in this review as they were not published in indexed journals. A version of one particular study, cited in in various papers, and presented as a “preliminary and incomplete document” was excluded. ^ggOlinto P, Flores R, Morris S, Veiga A. The Impact of the Bolsa Alimentação Program on food consumption. Presented at the Annual Meeting of the International Association of Agricultural Economists Durban; 2003 Ago 16-22; Durban, South Africa. Available from: http://siteresources.worldbank.org/EXTLACREGTOPPOVANA/Resources/OlintoFloresMorrisVeigaimpactcofbolsadeali entacaoprogram.pdf An effort was made to locate the final publication; however, no response was obtained from the authors and so it was decided not to include it.

It was also decided not to include official documents evaluating CCTP, as they may only highlight such results as favor the continuance of the programs, which would bias the findings of the review. In fact, it was verified that in the evaluations conducted or commissioned by the Federal Government, ^hhSantos LMP, Guanais F, Porto DL, Morais Neto OL, Stevens A, Escalante JJC, et al. Peso ao nascer entre crianças de famílias de baixa renda beneficiárias e não beneficiárias do Programa Bolsa Família da Região Nordeste (Brasil): pareamento entre CadÚnico e Sinasc. In: Ministério da Saúde, Secretaria de Vigilância em Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília (DF); 2011. cap.13, p.271-93. , ⁱiVaitsman J, Paes-Sousa R, organizadores. Avaliação de políticas e programas do MDS: resultados: Bolsa Família e Assistência Social. Brasília (DF): Ministério do Desenvolvimento Social e Combate à Fome, Secretaria de Avaliação e Gestão da Informação; 2007. ^{the CCTP were shown to have positive impact on reducing social inequality in terms of food and nutritional insecurity. Moreover, some studies that are included in this review 14}14 . 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. ^{, 17}17 . 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... used data from research performed by the Federal Government and including official documents would duplicate some results.

The main sources of errors in evaluating the impact of CCTP are the lack of evaluation, the use of inappropriate methods and the lack of evaluating the process and context in which the program operates. ³²32 . Victora CG, Santos IS. Los siete pecados capitales de la evaluación del impacto. Gac Sanit . 2008;22(Supl 1):1-7. DOI:10.1016/S0213-9111(08)76068-0
https://doi.org/10.1016/S0213-9111(08)76... By looking at the set of studies on Brazilian CCTP it is possible to identify some of these errors, especially those involving the lack of process evaluation. It was noted that the CCTP in Brazil were established before planning an evaluation stage. Thus, what was found were merely evaluations using impact indicators, but not evaluating the process (provision, use, coverage). Given the complexity of the influence of CCTP in Brazil, studies on implementation and process evaluations are important in verifying whether the lack of effect is the result of a problem in the program or a problem in the evaluation. ²⁴24 . Rychetnik L, Frommer M, Hawe P, Shiell A. Criteria for evaluating evidence on public health interventions. J Epidemiol Community Health . 2002;56(2):119-27. DOI:10.1136/jech.56.2.119
https://doi.org/10.1136/jech.56.2.119... Such findings can improve the impact of the programs by indicating what needs to be changed. ⁵5 . Habitcht JP, Victora CG, Vaughan JP. Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact. Int J Epidemiol . 1999;28(1):10-8. DOI:10.1093/ije/28.1.10
https://doi.org/10.1093/ije/28.1.10... Of the studies which assessed the implementation of CCTP in Brazil, gaps were identified in the legislation, organization and bureaucratic structure of the municipalities, affecting the performance in the coverage and impact of the PBF ¹¹11 . Magalhães R, Burlandy L, Senna M, Schottz V, Scalercio G. A implementação do programa Bolsa Família: as experiências de São Francisco de Itabapoana e Duque de Caxias. Cienc Saude Coletiva . 2007;12(6):1513-24. DOI:10.1590/S1413-81232007000600013
https://doi.org/10.1590/S1413-8123200700... and other programs which preceded it. ²⁶26 . Santos LMP, Pasquim EM, Santos SMC. Programas de transferência de renda no Brasil: um estudo multidimensional da implementação do Bolsa Escola, Bolsa Alimentação e Cartão Alimentação. Cienc Saude Coletiva . 2011;16(3):1821-34. DOI:10.1590/S1413-81232011000300018
https://doi.org/10.1590/S1413-8123201100...

Overall, the dew studies found indicate a positive association between belonging to a CCTP and improvements in the diet and nutrition of the recipient families in Brazil, although there are no standardized indicators or external validity, making it impossible to conduct a robust evaluation of the relationship between CCTP and the outcomes in question. New studies, using standardized evaluation with methodological rigor and indicators defined and measured appropriately, are needed to clarify the impacts of CCPT on the diet and nutrition of recipients, based on high quality evidence.

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