Abstract
Objective:
To evaluate the association of conditional cash transfer policies to mitigate the food insecurity (FI) among families living in poverty during the COVID-19 pandemic in Ceará, Brazil.
Methods:
An analytical cross-sectional study was carried out through telephone contact during the period of May–July 2021, during the second wave of the COVID-19 pandemic in Ceará. Families in a situation of high social and economic vulnerability participated in this study (monthly per capita income of less than US$16.50). FI was assessed using the EBIA, a Brazilian validated questionnaire. The participation of families in government programs and public policies was also investigated. Logistic regression models were used to assess the association of the several factors assessed with food insecurity.
Results:
The prevalence of any food insecurity in this sample was 89.1% (95% Confidence interval (95% CI: 86.2 – 92.1) and of severe food insecurity, 30.3% (95% CI: 26.0 – 34.6). The Mais Infância card program, adopted as a cash transfer supplement in the state of Ceará, was significantly associated with food insecurity (OR 4.2 (95% CI: 1.7 – 10.2), with a p-value of 0.002. In addition, families affected by job losses due to the COVID-19 pandemic presented higher odds of FI.
Conclusions:
In this study, 89% of evaluated families presented food insecurity. Conditional cash transfer programs were associated with FI. We highlight the need for policies and interventions to reduce the impact of the COVID-19 pandemic on food insecurity. Such policies can adopt appropriate criteria for defining the participants, as well as connect the participants to an appropriate set of broader social protection measures.
Keywords: children, communicable disease, food security, Latin America, maternal health, policy/politics, poverty
Introduction
It is estimated that approximately 820 million people worldwide experience hunger every day, and that more than two billion people have important nutritional deficiencies that directly affect people’s life expectancy (1). In addition, the United Nations have estimated that 24,000 people die every day due to hunger and that only half of children in the 91 assessed countries consume at least the minimum number of meals a day (2). Moderate or severe food insecurity has a prevalence of 23.9% in the world and among the assessed continents in the latest FAO report of 2017, Latin America has the second-worst result, with 23.5%, which represents more than twice the prevalence of the United States and Canada and almost three times that of Europe (3). Brazil is a noteworthy example in the fight against hunger, with the creation of the Zero Hunger Program in 2003, which contributed to the reduction of food insecurity and malnutrition through three main axes: conditional cash transfers, school meals, and programs of encouraging family farming, the latter being particularly important (4). The Program for Food Acquisition from Family Agriculture Production (PAA), for example, has an important impact on achieving the second United Nations sustainable development goal (5).
The COVID-19 global pandemic exceeded 232 million cases worldwide in September 2021, and Brazil has recorded more than 21 million confirmed cases. Aiming to control the transmission of COVID-19, social distancing measures were implemented in several cities in Brazil and around the world, which led to social distancing, the closing of companies and unemployment, in addition to potentially increasing the risk of food insecurity through multiple pathways, including loss of employment and disruption of the food supply chains (6,7). There are estimates that the number of people going through food insecurity has increased from 27 million in 2019 to 41 million in 2021, and that number is expected to increase in the coming years (8). In Brazil, evidence shows that overall food insecurity rates have increased by 15% (9). Social distancing and the closure of commercial establishments were implemented in Ceará, one of the poorest northeastern states in Brazil, after the government decree of March 19, 2020.
Theoretical framework
The causes of food insecurity are complex and multidimensional. They are linked to a series of closely related factors, such as poverty, low access to basic social services and inadequacy of some public policies (10). Social distancing due to the COVID-19 pandemic has led to job losses and reduced household income, which has led to increased food insecurity (11). In this context of increasing poverty and food insecurity, it is essential to assess public policies that are being developed to mitigate the increase of food insecurity. Food insecurity is associated with malnutrition, which in children affects their intellectual and economic development. In turn, this can lead to an intergenerational cycle of malnutrition and affect the economic development of society as a whole (9).
Nevertheless, evidence on food insecurity and public policies to mitigate it among the poorest population are still scarce, particularly in Latin America. To address this evidence gap, we report on the association of public policies to mitigate the food insecurity among families living in poverty during the COVID-19 pandemic in Ceará, Brazil.
Methods
Study population and place
An analytical cross-sectional study was carried out through telephone contact during the period of May–July 2021, during the second wave of the COVID-19 pandemic in Ceará, a state in northeastern Brazil. Interviews were carried out by researchers who were specifically trained for this purpose by the research coordination team, using a standardized form to prevent possible input errors. In case of failure to contact a study participant after up to three attempts on three different days, the interviewers called at commercial establishments close to the informed addresses (such as grocery stores) to ask if someone they knew could call the participant.
Families in a situation of high social and economic vulnerability in the state of Ceará participated in this study. Ceará is a poor state in northeastern Brazil, with an average per capita income of US$150.00. Subsistence agriculture is the predominant economic activity in rural areas of the state. The population of this study comprises families with children up to six years of age in a situation of extreme vulnerability in Ceará, who were selected using three criteria: houses with walls made of inappropriate materials (wattle and daub, straw, reclaimed wood, in the case of rural families), no bathroom or sanitation, and no running water in at least one room (urban dwellings), in addition to a monthly per capita income of less than US$16.50. These families are already the recipients of the Brazilian federal government’s conditional cash transfer program (Bolsa Família). This population was fully registered by the state of Ceará, which has the address and telephone number of all families in this situation—a total of 48,000 families. For this study, 2,000 families were randomly selected for the study participation. This number was obtained considering events with a prevalence of at least 5, a type 1 error of 5%, and a type 2 error of 20%, reaching an estimate of 1,643 families and performing a larger sampling process due to possible losses.
Assessment tools
The study questionnaires in 2017 and 2020 included the Brazilian Food Insecurity Scale (EBIA, Escala Brasileira de Insegurança Alimentar), which is validated in Brazil for food security screening and recommended by the Brazilian Ministry of Social Development and Fight against Hunger (12). In this study, we used the short version of the EBIA that contains five questions, of which answers vary from never experiencing the measured aspect of insecurity to experiencing it every day.
The participation of families that benefitted from government programs and public policies currently effective in the state of Ceará was also investigated. Below we briefly describe each of them:
Ceará Mais Infância card
This is a benefit that gives a monthly aid of R$100.00 (US$16.00), granted by the government of the state of Ceará to families in situations of extreme social vulnerability (as defined above), and who have children aged zero to six years and a per capita income of up to R$89.00 (~ US$15.00).
Cooking gas voucher
This is a benefit granted by the government of the state of Ceará from May 2020, which supplies a cooking gas canister to families in a situation of social vulnerability.
Basic food parcels
This service distributes basic food parcels to families in situations of social vulnerability on a continuous basis since from May 2020. The food parcels are distributed by the state government to the municipal assistance secretariats. The families who benefit from the distribution are those who have the Mais Infância card and those who are registered in municipal assistance programs.
Fresh food
This service distributes ‘fresh’ food: fruit, vegetables, as well as fruit powder and dehydrated soups, since April 2020. The recipients are families with children and young people in a situation of social vulnerability, assisted by NGOs that already had a partnership with the Mais Nutrição, another Ceará state government program.
Emergency aid
The Brazilian government has provided assistance during the COVID-19 pandemic starting in April 2020. This assistance comprised a monthly cash payment of approximately US$120.00 for self-employed and informal workers over 18 years of age who do not receive any other benefit from the federal government (except for the conditional cash transfer program), individuals who did not have formal employment, and for families with a per capita monthly income (per person) up to half the Brazilian minimum wage (approximately US$93.00) or a total monthly family income of up to three times the minimum wage (approximately US$560.00).
Estimation methods for food insecurity
Food insecurity was defined by the confirmation of any of the five questions, and severe food insecurity by a positive response to the most severe item in any of the asked items. The social and economic conditions of the families, participation in public policy programs, as well as demographic data, were assessed by the caregiver self-report. The participant was also asked to inform whether the pandemic had negatively affected the availability of food according to the respondent’s perception.
Statistical analysis
The categorical quantitative results were presented as percentages and counts and the numerical ones as measures of central tendency. Bivariate logistic regression models were used to assess the association of the several factors assessed with food insecurity. Values of p < 0.05 were considered significant. The obtained data were tabulated and analyzed using the software IBM SPSS Statistics for Windows, version 23.0.
Ethics
The study was approved by the Research Ethics Committee of Federal University of Ceará. Free and informed consent was obtained from the research participants, and these were recorded on the online platform.
Results
A total of 429 maternal-child pairs participated in the study during the COVID-19 pandemic (recruitment rate of 26.1%). The prevalence of any food insecurity in this sample was 89.1% (95% Confidence interval (95% CI): 86.2 – 92.1) and of severe food insecurity, 30.3% (95% CI: 26.0 – 34.6), as shown in Figure 1.
Figure 1.
Prevalence of food insecurity and severe food insecurity in families living in poverty.
Table 1 shows the social and economic characteristics of the assessed families and the associations of the factors evaluated with the observed food insecurity. Child gender and age were not statistically associated with food insecurity, as well as the caregiver’s ethnicity/skin color or educational level in this sample. Moreover, the number of people living in the household was also statistically associated with severe food insecurity, with an increased risk as the number of residents increased (p-value of 0.02), but was not associated with food insecurity. The monthly income perceived by the family was not associated with food insecurity. In addition, households that were not affected by the COVID-19 pandemic had lower odds of food insecurity (OR 0.1 (95% CI: 0 – 0.2)) and severe food insecurity (OR 0.3 (95% CI: 0.2 – 0.6)). Finally, families that reported not raising animals or not planting food for their own consumption had higher odds of food insecurity (OR 3.4 and 2.8, respectively) and severe food insecurity (OR 1.7 and 1.8, respectively), all with p-values lower than 0.05 (Table 1).
Table 1.
Social and economic characteristics of families and the presence of mental disorders and their associations with food insecurity. Total n = 429.
| Food insecurity (prevalence) | OR (95%CI) | p-Value | Severe food insecurity (prevalence) | OR (95%CI) | p-Value | |
|---|---|---|---|---|---|---|
| n (%) or mean + SD | n (%) or mean + SD | |||||
| Child’s gender | ||||||
| Female | 200 (89.6) | 1.2 (0.6–2.1) | 0.55 | 65 (29.1) | 0.9 (0.6–1.4) | 0.66 |
| Male | 181 (87.8) | Ref | 64 (31) | Ref | ||
| Child’s age in months | 43.8 + 16.4 | 1.0 (1.0–1.0) | 0.25 | 41.8 + 17.7 | 1.0 (1.0–1.0) | 0.17 |
| What is the caregiver’s skin color/ethnicity? | ||||||
| White | 47 (90.3) | 0.4 (0–3.4) | 0.65 | 15 (28.8) | 0.6 (0.2–1.7) | 0.68 |
| Brown | 317 (90.5) | 0.4 (0.1–3.0) | 108 (30.8) | 0.7 (0.3–1.6) | ||
| Black | 25 (96.1) | Ref | 10 (38.4) | Ref | ||
| Maternal level of schooling | ||||||
| Up to eight years | 205 (93.1) | 1.3 (0.1–11.4) | 0.27 | 78 (35.4) | – | 0.32 |
| 9 to 12 years | 171 (88.6) | 0.8 (0.1–6.3) | 55 (28.4) | – | ||
| More than 12 years | 10 (90.9) | Ref | 0 (0) | Ref | ||
| Does the father of the child under six years live in the same house as you? | ||||||
| No | 159 (95.2) | 2.7 (1.2–6.0) | 0.01 | 61 (36.5) | 1.5 (1.0–2.3) | 0.04 |
| Yes | 235 (88) | Ref | 73 (27.3) | Ref | ||
| If he DOES NOT, does he see or stay with the child sometimes? | ||||||
| No | 56 (98.2) | 3.8 (0.5–31.7) | 0.22 | 25 (43.8) | 1.6 (0.8–3.0) | 0.16 |
| Yes | 103 (93.6) | 36 (32.7) | Ref | |||
| Are you currently working? | ||||||
| Doesn’t work at all (not even housework) | 4 (100) | – | 0.21 | 3 (75) | 6.4 (0.7–62.4) | 0.12 |
| Work from home, for a job outside the home | 17 (77.2) | 0.3 (0.1–0.9) | 3 (13.6) | 0.4 (0.1–1.1) | ||
| Yes, out of the home | 46 (92) | 1.0 (0.4–3.2) | 14 (28) | 0.8 (0.4–1.6) | ||
| Yes, only at home (housework) | 327 (91.3) | Ref | 114 (31.8) | Ref | ||
| Lives in | ||||||
| Rural region | 273 (87.5) | 0.6 (0.3–1.2) | 0.13 | 90 (28.8) | 0.8 (0.5–1.3) | 0.33 |
| Urban region | 113 (92.6) | Ref | 41 (33.6) | Ref | ||
| How many people live in this house besides you? | 3 + 2 | 1.1 (0.9–1.4) | 0.28 | 4 + 2 | 1.2 (1.0–1.3) | 0.02 |
| In all, how much money have people in the family earned in the last month including pension? | 540.7 + 258.4 | 1.0 (1.0–1.0) | 0.32 | 530.0 + 256.0 | 1.0 (1.0–1.0) | 0.47 |
| Does anyone in your household currently have any paid work? | ||||||
| No | 268 (91.4) | 1.3 (0.7–2.5) | 0.48 | 96 (32.7) | 1.3 (0.8–2.0) | 0.22 |
| Yes | 126 (89.3) | Ref | 38 (26.9) | Ref | ||
| Do you think there was a change in food availability after the COVID-19 pandemic? | ||||||
| Didn’t change | 47 (66.1) | 0.1 (0–0.2) | <0.001 | 10 (14) | 0.3 (0.2–0.6) | 0.004 |
| Yes, it increased | 18 (94.7) | 0.8 (0.1–6.6) | 5 (26.3) | 0.7 (0.2–1.9) | ||
| Yes, it decreased | 329 (95.6) | Ref | 119 (34.5) | Ref | ||
| Do you raise animals that are used for consumption by your family? | ||||||
| No | 233 (95.1) | 3.4 (1.7–6.9) | 0.001 | 88 (35.9) | 1.7 (1.1–2.7) | 0.01 |
| Yes | 161 (85.1) | Ref | 46 (24.3) | Ref | ||
| Do you plant foods that are used for consumption by your family? | ||||||
| No | 202 (94.8) | 2.8 (1.4–5.7) | 0.006 | 79 (37) | 1.8 (1.2–2.7) | 0.006 |
| Yes | 192 (86.8) | Ref | 55 (24.8) | Ref | ||
Bold: P-values lower than 0.05.
Table 2 presents the relationship of government welfare programs created during the COVID-19 pandemic and food insecurity. The federal government’s emergency aid was not associated with food insecurity or severe food insecurity, nor was the basic food parcel distribution program. In contrast, the Mais Infância card program, which was adopted as a cash transfer supplement in the state of Ceará, was significantly associated with food insecurity (OR 4.2 (95% CI: 1.7 – 10.2)), with a p-value of 0.002. Additionally, the cooking gas voucher program was also associated with food insecurity (OR 8.7 (95% CI: 3.6 – 20.8)). The fresh food distribution program was not associated with food insecurity.
Table 2.
Participation in government social aid programs and their association with food insecurity. Total n = 429.
| Food insecurity (prevalence) | OR (95% CI) | p-Value | Severe food insecurity (prevalence) | OR (95%CI) | p-Value | |
|---|---|---|---|---|---|---|
| n (%) | n (%) | |||||
| Has anyone in the household received emergency aid from the federal government? | ||||||
| No | 11 (84.6) | 0.5 (0.1–2.5) | 0.44 | 4 (30.7) | 1.0 (0.3–3.3) | 0.99 |
| Yes | 383 (90.9) | Ref | 130 (30.8) | Ref | ||
| Basic food parcels | ||||||
| No | 202 (87.8) | 1.3 (0.7–2.4) | 0.36 | 69 (30) | 1.0 (0.7–1.5) | 0.88 |
| Yes | 192 (90.5) | Ref | 65 (30.6) | Ref | ||
| Mais Infância card | ||||||
| No | 18 (69.2) | 4.2 (1.7–10.2) | 0.002 | 4 (15.3) | 2.5 (0.8–7.4) | 0.10 |
| Yes | 376 (90.3) | Ref | 130 (31.2) | Ref | ||
| Cooking gas voucher | ||||||
| No | 13 (54.1) | 8.7 (3.6–20.8) | <0.001 | 3 (12.5) | 3.1 (0.9–10.9) | 0.06 |
| Yes | 381 (91.1) | Ref | 131 (31.3) | Ref | ||
| Fresh food | ||||||
| No | 352 (88.4) | 2.7 (0.6–11.7) | 0.17 | 123 (30.9) | 0.7 (0.4–1.5) | 0.42 |
| Yes | 42 (95.4) | Ref | 11 (25) | Ref | ||
Bold: P-values lower than 0.05.
Discussion
In this cross-sectional study of families with children living in extreme poverty in the state of Ceará, Brazil, we identified a prevalence of food insecurity of 89% and of severe food insecurity of 30% during the COVID-19 pandemic. Our results also suggest that government programs with participant selection criteria that took into account factors other than income to identify candidates (Mais Infancia card and gas voucher) were associated with food insecurity in families living in poverty. Additionally, we found that the pandemic negatively impacted the food availability of poor families, that the income of these families is not associated with the presence of food insecurity, and that families that have subsistence cultures (such as raising animals and planting for their own consumption) had lower chances of food insecurity.
An increased risk of food insecurity during the COVID-19 pandemic is in accordance with studies in high-income and low- and middle-income country settings (9,13,14). However, our study is one of the first to specifically evaluate families living below the poverty line, and the prevalence found—close to 90%—is much higher than that previously found in the general population of the state of Ceará (30.9%) (10). A study carried out through online questionnaires in Kenya and Uganda (which therefore reached respondents who had access to technological means to answer the questionnaires), identified an increase in food insecurity of 41% on average in both countries, and more than half of the respondents were classified as experiencing food insecurity (15).
In Bangladesh, a study also carried out using electronic forms identified 47% of families that reported food insecurity (16). On the other hand, in Nigeria, 88% of the respondents to a national survey carried out through random phone calls were classified as experiencing food insecurity, reaching 94% in the poorest assessed quintile (17). It is possible that the use of telephone calls, as carried out in our study, has facilitated access to a more vulnerable population, identifying a prevalence of insecurity close to that of the poorest population in the state of Ceará. It should be noted that the per capita Nigerian gross domestic product is one third of that of Brazil (18), and the evidence from this study demonstrates that there may be pockets of high prevalence of food insecurity in higher-income developing countries.
Among the factors associated with food insecurity, there is a vast literature associating family income with food insecurity and the greatest impact of the pandemic on food insecurity increase was associated with the loss of family income (15,19); however, in the present study, family income was not associated with food insecurity. We understand that such association was not observed due to the fact that all families are very poor, and the difference in income between them was not a differential for the occurrence of food insecurity. Nevertheless, the families reported that the pandemic impaired their food availability, perhaps due to the interruption of food supply chains, which can also contribute to the increased risk of food insecurity (16). The presence of the father at home was a protective factor against the odds of food insecurity, with the same effect being identified in Tanzania (20). Poverty itself is associated with parental absence, but as all assessed families are very poor, this study identified that the effect of paternal absence is a negative one on food insecurity, regardless of the income. In addition to the previously mentioned factors, families that survived on subsistence crops, such as raising animals and planting vegetables in their backyards, were associated with a reduction in the odds of food insecurity. Although there is no consensus in the literature on the importance of subsistence agriculture for rescuing families from the cycle of poverty, due to the population’s low educational level and access to capital (21), this study brings new evidence that in a situation of very high food insecurity, subsistence crops can decrease the chances of the latter.
In addition to the abovementioned factors, we identified that two public policies, the Mais Infância card and the gas voucher, were statically associated with food insecurity, suggesting that they reach the population with a higher prevalence of food insecurity, while the government’s emergency aid does not. The main differences between the programs are that the programs that were associated have more robust inclusion criteria (as they include objective criteria, as housing conditions are assessed and emergency aid is based on self-reported income) and the fact that they link the recipients to several other social protection measures of the state government, in addition to the cash transfer program. According to the Ministry of Citizenship of Brazil, approximately 3m recipients of the emergency aid were expected to return the benefit during the annual tax adjustment (or about 5% of the recipients), with a total of R$5.1bn having already been reimbursed to the public treasury (22).
A study carried out in Africa showed similar results, identifying that irregular emergency aid was not associated with the reduction in food insecurity (23). A similar finding was observed in Peru during the COVID-19 pandemic (24). On the other hand, other studies have already identified the importance of well-structured public policies for the reduction of food insecurity in developing countries, especially during the pandemic (10,23,25). The effect of public policies that were initiated during the pandemic may even have the effect of decreasing food insecurity measured before the pandemic, as seen in an online survey study conducted in Tehran (26).
Our study has several limitations. First, as our study is a cross-sectional one, one cannot establish causal relationships, as the occurrence of the outcome may have led to the emergence of exposures. However, it is reasonable to believe that food insecurity, which increased due to the COVID-19 pandemic, emerged after some of the evaluated factors and before others. In addition, the modality of data collection (telephone contact) may have led to an information bias; however, it is not clear the degree to which participants may have over- or underreported food insecurity by telephone, and according to the observed evidence, telephone surveys have shown high rates of food insecurity.
Conclusion
Ceará is a poor state of Brazil, and the average monthly per capita income of US$150.00 can be compared to that of many other developing countries. These findings highlight the need for policies and interventions to reduce the impact of the COVID-19 pandemic on food insecurity and maternal mental health in Brazil. A few potential strategies include public policies such as government COVID-19 assistance programs and direct food provision to families in need. Such policies can adopt appropriate criteria for defining the participants, as well as connect the participants to an appropriate set of broader social protection measures. Measures to minimize the worsening of the socioeconomic condition of these families have been adopted by the government of the state of Ceará and future studies are necessary to assess the impact of these interventions, after the long period of social distancing caused by the COVID-19 pandemic.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Maria Cecília Souto Vidigal Foundation. Porticus América Latina. Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico. Edital Jovens Doutores – Edital nº 02/2017. Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico. Programa Cientista Chefe.
ORCID iD: Hermano Alexandre Lima Rocha 
https://orcid.org/0000-0001-9096-0969
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