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Review 1: "The Effect of Conditional Cash Transfers on Tuberculosis Incidence and Mortality is Determined by Ethnoracial and Socioeconomic Factors: A Cohort Study of 54 Million Individuals in Brazil"

Reviewers highlight the study's valuable insights into the health benefits of conditional cash transfer programs. However, one reviewer notes that more methodological details and robustness checks are needed.

Published onMay 17, 2024
Review 1: "The Effect of Conditional Cash Transfers on Tuberculosis Incidence and Mortality is Determined by Ethnoracial and Socioeconomic Factors: A Cohort Study of 54 Million Individuals in Brazil"

RR:C19 Evidence Scale rating by reviewer:

  • Potentially informative. The main claims made are not strongly justified by the methods and data, but may yield some insight. The results and conclusions of the study may resemble those from the hypothetical ideal study, but there is substantial room for doubt. Decision-makers should consider this evidence only with a thorough understanding of its weaknesses, alongside other evidence and theory. Decision-makers should not consider this actionable, unless the weaknesses are clearly understood and there is other theory and evidence to further support it.

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Review: Brazil’s Bolsa Familia conditional cash transfer program for low income families has previously been found to have beneficial effects across numerous health domains. This study analyzes effects on tuberculosis incidence and mortality, and the degree to which those effects may be larger in populations with lower socioeconomic status. This is a valuable study objective.

Members of the authorship team have published related papers on Bolsa Familia, including e.g. a well-cited 2013 paper in The Lancet, “Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities.” More relevant are their 2022 International Journal of Epidemiology paper, “Impact of Brazil's Bolsa Família Programme on cardiovascular and all-cause mortality: a natural experiment study using the 100 Million Brazilian Cohort,” and 2023 PLoS Medicine paper “Relationship between the Bolsa Família national cash transfer programme and suicide incidence in Brazil: A quasi-experimental study.” These latter two papers in strong peer-reviewed journals use the same impressively large dataset (the 100 Million Brazilian Cohort) and apparently similar methods as in this paper to estimate Bolsa Familia effects on cause-specific mortality, lending confidence in the current paper. 

However, confidence in the current paper is limited by the sparse discussion of methods details in the currently available preprint manuscript posted at SSRN. The paper does refer to an appendix, but the appendix was not available to me at the time of this review. I have two specific sets of concerns that are not well addressed. First, the sample is not clearly described, nor are analyses presented on the characteristics of the large proportion of individuals selected out of the analyses for various reasons. 

Second, the quasi-experimental methods for causal inference are insufficiently described. The analysis used an inverse probability of treatment weighting (IPTW) approach, but there are no details provided regarding the IPTW weight construction or specification tests regarding its appropriateness for this analysis. Furthermore, I would have more confidence if the current analyses were to show robustness to accounting for dynamics as Bolsa Familia coverage status changes over time. I suspect that the IPTW methods in this paper may be similar to those reported in the above-cited papers, in which case it is plausible that the analyses are based on a quasi-experimental design of similar strength to those earlier peer-reviewed papers. But in the absence of those details, it is currently impossible to assess the reliability of the reported causal estimates in the manuscript version that I reviewed.

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