Fatima Marinho Ministry of Health Brazil 01-Sep-2014

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1 PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form ( and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. Some articles will have been accepted based in part or entirely on reviews undertaken for other BMJ Group journals. These will be reproduced where possible. ARTICLE DETAILS TITLE (PROVISIONAL) AUTHORS Early socioeconomic position and self-rated health among civil servants in Brazil: a cross-sectional analysis from the Pró-Saúde cohort study Guimarães, Joanna; Werneck, Guilherme; Faerstein, Eduardo; Lopes, Claudia; Chor, Dora VERSION 1 - REVIEW Nobuo Nishi, MD, PhD, MSc, MBA Chief, Center for International Collaboration and Partnership, National Institute of Health and Nutrition, Japan 06-Jun Socioeconomic environment may be different between men and women. I suspect that gender differences were observed in the results. 2. No data were shown on household per capita monthly income in the text or in the table. Average income should be described in the results. Furthermore, the reason for failure to use equivalent disposable income should be stated. Fatima Marinho Ministry of Health Brazil 01-Sep-2014 The manuscript is interesting, well structured, and deals with the key theme of adult morbidity and poverty in Rio de Janeiro, Brazil, part of a cohort study in a public university. The manuscript is very relevant and its methods, results and discussion are well done. I really enjoyed the manuscript. However, I have few comments that could benefit readers. 1- The study population was described as non-faculty civil servants or people in technical administrative positions. It is not clear who this population is, what kind of work this group does. It would be helpful if the authors did a short description of the study population occupation in order to provide a better picture of the study subject. 2- The variable type of area which the participant lived at the age

2 12 has two categories: rural/small cities and large cities. I suggest that the authors state the definition of small and large cities because it needs an objective definition. What is small or large depends on the person s perception; someone that lives in a country that has a small population could consider a city with 30 thousand inhabitants to be a large city, while in a country with a very large population like China, a city with 200 thousand could be considered small. 3- On page 14 line 16, I would say that, in Brazil, over 50 years ago and in the 2010 census, rural areas are poorer than urban centers. 4- The results are very interesting for countries that have implemented cash transfer programs like Brazil, Mexico, Colombia, Argentina etc. Could this kind of public policy that aims to reduce poverty at childhood have an impact in the SRH in adulthood? Could the authors make some comments about this kind of public policy? VERSION 1 AUTHOR RESPONSE Reviewer: 1 Reviewer Name Nobuo Nishi, MD, PhD, MSc, MBA Institution and Country Chief, Center for International Collaboration and Partnership, National Institute of Health and Nutrition, Japan Please state any competing interests or state None declared : None declared 1. Socioeconomic environment may be different between men and women. I suspect that gender differences were observed in the results. In our data, men and women have shown similar distributions regarding socioeconomic environment and, in addition, the relationship between early socioeconomic position (SEP) and selfrated health was not substantially different among men and women. Furthermore, the focus of our study, as demonstrated in our theoretical model, was to investigate if the potential effect of early SEP on adult self-rated health could be explained though current SEP and not if this association is moderated by gender. Anyway, considering this relevant observation from the reviewer, we made the following change in the text to make this point clear for the readers (Results section, page 11, line 1): We found similar results across gender strata, then the analysis were performed adjusting for gender. 2. No data were shown on household per capita monthly income in the text or in the table. Average income should be described in the results. Furthermore, the reason for failure to use equivalent disposable income should be stated.

3 Thanks for the recommendation. We agree and included the average income in the Results section (page 8, line 17): The average household per capita monthly income was US$468. With respect to the failure to use equivalent disposable income (for instance, OECD equivalence scale), we thank for the suggestion. However, we consider this would not be appropriate for this specific study. The problem is that the denominator that we used for calculating per capita income is not the size of the household, but the number of persons that depend on the total income. In Brazil, it is common that dependants include elderly people and young adults (sons and daughters) that do not live in the same household. Therefore, applying the usual weights for those people would not be that obvious, since they do not share the same household needs (housing space, electricity, food, etc). Reviewer: 2 Reviewer Name Fatima Marinho Institution and Country Ministry of Health Brazil Please state any competing interests or state None declared : None declared. The manuscript is interesting, well structured, and deals with the key theme of adult morbidity and poverty in Rio de Janeiro, Brazil, part of a cohort study in a public university. The manuscript is very relevant and its methods, results and discussion are well done. I really enjoyed the manuscript. However, I have few comments that could benefit readers. 1- The study population was described as non-faculty civil servants or people in technical administrative positions. It is not clear who this population is, what kind of work this group does. It would be helpful if the authors did a short description of the study population occupation in order to provide a better picture of the study subject. We agree and included a brief description of the participant`s occupational characteristics (Methods, Study design and population, page 5, line 25): Cohort participants are mainly routine non-manual workers (eg, nurses and administrative clerical and information technology staff), professional workers (eg, physicians and managers) and manual workers (eg, janitors, cooks, security personnel, or other similar jobs). (Lopes CS et al. Job strain and other work conditions: relationships with psychological distress among civil servants in Rio de Janeiro, Brazil. Soc Psychiatry Psychiatr Epidemiol 2010) 2- The variable type of area which the participant lived at the age 12 has two categories: rural/small cities and large cities. I suggest that the authors state the definition of small and large cities because it needs an objective definition. What is small or large depends on the person s perception; someone that lives in a country that has a small population could consider a city with 30 thousand inhabitants to be a large city, while in a country with a very large population like China, a

4 city with 200 thousand could be considered small. We thank for the suggestion. According to IBGE (Brazilian Institute of Geography and Statistics), (available in: %20RJ/RBG/RBG%201946%20v8_n3.pdf), small cities in Brazil are those with up to 50 thousand inhabitants. The others were considered as large cities. To take care of the reviewer s comment, now in the Discussion section (page 13, line 23) the text reads as follows: Our results also indicate that living in a rural area or small town (ie, city with up to 50 thousand inhabitants) at the age of 12 was associated with a higher risk of worse SRH, even after adjusting for current characteristics (education and income). 3- On page 14 line 16, I would say that, in Brazil, over 50 years ago and in the 2010 census, rural areas are poorer than urban centers. Thanks for this important correction. Rural areas in Brazil, by the end of the twentieth century, have demonstrated a great socioeconomic development. At the same time, urban centers have undergone a process of increasing poverty and growing of slum areas. Actually we wanted to emphasize that these large differences (larger than today) between rural and urban areas over 50 years ago could possibly explain the negative impact of having lived at that time in rural areas or small cities, in adult health. We agree and modified the text accordingly (Discussion section, page 14, line 9): In Brazil, over 50 years ago, during the childhood and adolescence of the studied cohort, socioeconomic differences between rural areas and urban centers were markedly wider than today. Rural areas had fewer The results are very interesting for countries that have implemented cash transfer programs like Brazil, Mexico, Colombia, Argentina etc. Could this kind of public policy that aims to reduce poverty at childhood have an impact in the SRH in adulthood? Could the authors make some comments about this kind of public policy? This is a very important and pragmatical point in developing countries. The Bolsa Familia Programme is a widespread Brazilian programme, which transfers cash to poor families when they comply with conditions related to health and education (Rasella et al. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet 2013). Besides the acquisition of goods due to the financial incentives, the conditions that programme subscribers need to fulfil can induce them to seek public health, education and social assistance services. Specifically, the programme use financial incentives to change behaviours among impoverished families that have impact on later health: keep them from child labour; motivate them to have their children complete high school; and stimulate families to use health services (Paes-Sousa et al. Effects of a conditional cash transfer programme on child nutrition in Brazil. Bull World Health Organ 2011).

5 It is well known the important role of education as a predictor of health in adult life. Childhood health is also considered an important factor in the mechanism that relates early socioeconomic position to adult health. On the whole, all of the exposures evaluated in our study are related to situations of vulnerability in early life, which might be alleviated by cash transfer programs. On the other hand, government authorities need to provide good services in education, health and in the labour market, so that this public policy have a positive impact on adult health. In view of the importance of this issue raised by the reviewer, we included a brief statement in the final of the Discussion section (page 16, line 18), and reference #41 was included on page 22: Cash transfer programmes, which transfers cash to poor families when they comply with conditions related to health and education of their children (eg, Brazil s Bolsa Familia programme), have shown a positive impact in this sense (Rasella et al., 2013)." VERSION 2 REVIEW Nobuo Nishi, MD, PhD, MSc, MBA Chief, Center for International Collaboration and Partnership, National Institute of Health and Nutrition, Japan 15-Oct-2014 The manuscript has been revised appropriately. Fatima Marinho Ministry of Health of Brazil 28-Oct-2014 Authors attended all the issues raised in the previous review. For me the manuscript is good enough to be published. It was a pleasure reviewing this manuscript.