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Racism, xenophobia, and discrimination are key determinants of health and equity and must be addressed for improved health outcomes. We conclude that far broader, deeper, transformative action is needed compared with current measures to tackle adverse effects of racism on health. To challenge the structural drivers of racism and xenophobia, anti-racist action and other wider measures that target determinants should implement an intersectional approach to effectively address the causes and consequences of racism within a population. Structurally, legal instruments and human rights law provide a robust framework to challenge the pervasive drivers of disadvantage linked to caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour. Actions need to consider the historical, economic, and political contexts in which the effects of racism, xenophobia, and discrimination affect health. We propose several specific actions: a commission that explores how we action the approaches laid out in this paper; building a conversation and a series of events with international multilateral agency stakeholders to raise the issue and profile of racism, xenophobia, and discrimination within health; and using our multiple platforms to build coalitions, expand knowledge, highlight inequities, and advocate for change across the world.

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Intersectionality is a useful tool to address health inequalities, by helping us understand and respond to the individual and group effects of converging systems of power. Intersectionality rejects the notion of inequalities being the result of single, distinct factors, and instead focuses on the relationships between overlapping processes that create inequities. In this Series paper, we use an intersectional approach to highlight the intersections of racism, xenophobia, and discrimination with other systems of oppression, how this affects health, and what can be done about it. We present five case studies from different global locations that outline different dimensions of discrimination based on caste, ethnicity and migration status, Indigeneity, religion, and skin colour. Although experiences are diverse, the case studies show commonalities in how discrimination operates to affect health and wellbeing: how historical factors and coloniality shape contemporary experiences of race and racism; how racism leads to separation and hierarchies across shifting lines of identity and privilege; how racism and discrimination are institutionalised at a systems level and are embedded in laws, regulations, practices, and health systems; how discrimination, minoritisation, and exclusion are racialised processes, influenced by visible factors and tacit knowledge; and how racism is a form of structural violence. These insights allow us to begin to articulate starting points for justice-based action that addresses root causes, engages beyond the health sector, and encourages transnational solidarity.

The consequences for adolescent health due to early life exposure to natural disasters combined with war are not known. We collected data from adolescents aged 12-13 years in Sri Lanka whose mothers were pregnant during the Indian Ocean tsunami in 2004 in a tsunami-affected region (n = 22), conflict-affected region (n = 35), conflict-plus-tsunami-affected region (n = 29), or controls in areas unaffected by either (n = 24). Adjusted BMI-for-age z-scores were 1.3 (95% confidence interval [CI] 0.4, 2.2), 1.0 (95% CI 0.2, 1.9), and 2.0 (95% CI 1.1, 2.9) for conflict, tsunami, and conflict-plus-tsunami, respectively, compared with the control group. Greater skinfold thickness and higher diastolic blood pressure were found in adolescents born in the conflict zone but no differences were found in height, head circumference, and waist circumference, or blood results, with the exception of serum insulin. Being born after a natural disaster or during conflict was associated with increased adolescent BMI and body fat, which are associated with longer-term risk of noncommunicable disease.

Background Evidence-based interventions are needed to reduce depression among adolescents in low- and middle-income countries (LMICs). One approach could be cultural adaptation of psychological therapies developed in high-income countries. We aimed to adapt the World Health Organization’s Group Interpersonal Therapy (IPT) Manual for adolescents with depression in rural Nepal. Methods We used a participatory, multi-stage adaptation process involving: translation and clinical review of the WHO Manual; desk reviews of adaptations of IPT in LMICs, and literature on child and adolescent mental health interventions and interpersonal problems in Nepal; a qualitative study to understand experiences of adolescent depression and preferences for a community-based psychological intervention including 25 interviews with adolescent boys and girls aged 13–18 with depression, four focus group discussions with adolescents, four with parents/caregivers and two with teachers, six interviews with community health workers and one with a representative from a local non-governmental organisation (total of 126 participants); training of IPT trainers and facilitators and practice IPT groups; and consultation with a youth mental health advisory board. We used the Ecological Validity Framework to guide the adaptation process. Results We made adaptations to optimise treatment delivery and emphasise developmental and cultural aspects of depression. Key adaptations were: integrating therapy into secondary schools for delivery by school nurses and lay community members; adding components to promote parental engagement including a pre-group session with the adolescent and parent to mobilise parental support; using locally acceptable terms for mental illness such as udas-chinta (sadness and worry) and man ko samasya (heart-mind problem); framing the intervention as a training programme to de-stigmatise treatment; and including activities to strengthen relationships between group members. We did not adapt the therapeutic goals of IPT and conserved IPT-specific strategies and techniques, making edits only to the way these were described in the Manual. Conclusions Group IPT can be adapted for adolescents in Nepal and delivered through the education system. A randomised controlled trial is needed to assess the impact and costs of the intervention in this setting. Future research in LMICs to adapt IPT for adolescents could use this adapted intervention as a starting point.

Background: Household overcrowding is associated with increased risk of infectious diseases across contexts and countries. Limited data exist linking household overcrowding and risk of COVID-19. We used data collected from the Virus Watch cohort to examine the association between overcrowded households and SARS-CoV-2. Methods: The Virus Watch study is a household community cohort of acute respiratory infections in England and Wales. We calculated overcrowding using the measure of persons per room for each household. We considered two primary outcomes: PCR-confirmed positive SARS-CoV-2 antigen tests and laboratory-confirmed SARS-CoV-2 antibodies. We used mixed-effects logistic regression models that accounted for household structure to estimate the association between household overcrowding and SARS-CoV-2 infection. Results: 26,367 participants were included in our analyses. The proportion of participants with a positive SARS-CoV-2 PCR result was highest in the overcrowded group (9.0%; 99/1,100) and lowest in the under-occupied group (4.2%; 980/23,196). In a mixed-effects logistic regression model, we found strong evidence of an increased odds of a positive PCR SARS-CoV-2 antigen result (odds ratio 2.45; 95% CI:1.43–4.19; p-value=0.001) and increased odds of a positive SARS-CoV-2 antibody result in individuals living in overcrowded houses (3.32; 95% CI:1.54–7.15; p-value Conclusion: Public health interventions to prevent and stop the spread of SARS-CoV-2 should consider the risk of infection for people living in overcrowded households and pay greater attention to reducing household transmission.

For free access to this article, please visit this page: https://linkinghub.elsevier.com/retrieve/pii/S2352464221001942, The global population of unaccompanied minors-children and adolescents younger than 18 years who migrate without their legal guardians-is increasing. However, as data are not systematically collected in any region, if collected at all, little is known about this diverse group of young people. Compared with adult migrants, unaccompanied minors are at greater risk of harm to their health and integrity because they do not have the protection provided by a family, which can affect their short-term and long-term health. This Review summarises evidence regarding the international migration and health of unaccompanied minors. Unaccompanied minors are entitled to protection that should follow their best interests as a primary consideration; however, detention, sometimes under the guise of protection, is a widespread practice. If these minors are provided with appropriate forms of protection, including health and psychosocial care, they can thrive and have good long-term outcomes. Instead, hostile immigration practices persist, which are not in the best interests of the child.

Background Armed conflict has significant impacts on individuals and families living in conflict-affected settings globally. Scholars working to prevent violence within families have hypothesised that experiencing armed conflict leads to an increase in family violence and mental health problems. In this review, we assessed the prevalence of family violence in conflict settings, its association with the mental health of survivors, moderating factors, and the importance of gender relations. Methods Following PRISMA guidelines, we systematically reviewed quantitative and qualitative studies that assessed the prevalence of family violence and the association between family violence and mental health problems, within conflict settings (PROSPERO reference CRD42018114443). Results We identified 2605 records, from which 174 full text articles were screened. Twenty-nine studies that reported family violence during or up to 10 years after conflict were eligible for inclusion. Twenty one studies were quantitative, measuring prevalence and association between family violence and mental health problems. The studies were generally of high quality and all reported high prevalence of violence. The prevalence of violence against women was mostly in the range of 30–40%, the highest reported prevalence of physical abuse being 78.9% in Bosnia and Herzegovina. For violence against children, over three-quarters had ever experienced violence, the highest prevalence being 95.6% in Sri Lanka. Associations were found with a number of mental health problems, particularly post-traumatic stress disorder. The risk varied in different locations. Eight qualitative studies showed how men’s experience of conflict, including financial stresses, contributes to their perpetration of family violence. Conclusions Family violence was common in conflict settings and was associated with mental health outcomes, but the studies were too heterogenous to determine whether prevalence or risk was greater than in non-conflict settings. The review highlights an urgent need for more robust data on perpetrators, forms of family violence, and mental health outcomes in conflict-affected settings in order to help understand the magnitude of the problem and identify potential solutions to address it.

Objectives We investigated whether perceived social support among adolescent students moderated the association between violence exposure and internalising symptoms in São Paulo city, Brazil. Methods We tested the stress-buffering model using data from the cross-sectional school-based, survey São Paulo Project on the Social Development of Children and Adolescents. Internalising symptoms were measured using an adapted version of the Social Behaviour Questionnaire; serious victimisation, being bullied once/week, school violence and community violence, friend and teacher support were scales adapted by the research team; the Alabama Parenting Questionnaire measured parenting style. Linear mixed-effects models were used to quantify moderation effects of (i) social support between violence exposure and internalising symptoms and (ii) gender between violence exposure and internalising symptoms across schools. Results Across schools, being bullied once/week, school violence, and community violence were associated with a significant (p<0.001) increase in internalising symptoms (e.g., bullied b = 5.76, 95% CI 2.26, 9.26; school violence b = 0.48, 95% CI 0.30, 0.67; community violence b = 0.36; 95% CI 0.22, 0.50). Males exposed to all types of violence had significantly lower (p<0.01) internalising symptoms compared to females (e.g., serious victimisation: b = -1.45; 95% CI -2.60, -0.29; school violence b = -0.27; 95% CI -0.30, -0.24; community violence b = -0.23; 95% CI -0.25, -0.20). As a main effect, social support was associated with a significant (p<0.01) decrease in internalising symptoms across schools (e.g., positive parenting b = -2.42; 95% CI -3.12, -1.72; parent involvement b = -2.75; 95% CI -3.32, -2.17; friend support b = -1.05; 95% CI -1.74, -0.34; teacher support b = -0.90; 95% CI -1.58, -0.22). Social support did not moderate the association between violence exposure and internalising symptoms. Conclusions Adolescent students in São Paulo exposed to violence have a higher likelihood of internalising symptoms, compared to those who are not. Support from parents, friends, and teachers, independent of violence, appear to be protective against internalising symptoms, pointing to potential programmes that could improve adolescent mental health.

Peer reviewed: True, Acknowledgements: We thank John Reilly for his advice on data sources and data access; Cara L Eckhardt, Josephine Avila, Igor Y Kon, and Jinzhong Wang from the Eckhardt et al study23; and all staff involved in recruitment and data collection from the included studies. Data gathered from South Africa was supported by South Africa Medical Research Council and National Research Foundation., Objective To evaluate the performance of a UK based prediction model for estimating fat-free mass (and indirectly fat mass) in children and adolescents in non-UK settings. Design Individual participant data meta-analysis. Setting 19 countries. Participants 5693 children and adolescents (49.7% boys) aged 4 to 15 years with complete data on the predictors included in the UK based model (weight, height, age, sex, and ethnicity) and on the independently assessed outcome measure (fat-free mass determined by deuterium dilution assessment). Main outcome measures The outcome of the UK based prediction model was natural log transformed fat-free mass (lnFFM). Predictive performance statistics of R2 , calibration slope, calibration-in-the-large, and root mean square error were assessed in each of the 19 countries and then pooled through random effects meta-analysis. Calibration plots were also derived for each country, including flexible calibration curves. Results The model showed good predictive ability in non-UK populations of children and adolescents, providing R2 values of >75% in all countries and >90% in 11 of the 19 countries, and with good calibration (ie, agreement) of observed and predicted values. Root mean square error values (on fat-free mass scale) were

Summary Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

ObjectivesTo evaluate the quality of adolescent mental health service provision globally, according to the WHO Global Standards of adolescent mental health literacy, appropriate package of services and provider competencies.Design and data sourcesSystematic review of 5 databases, and screening of eligible articles, from 1 January 2008 to 31 December 2020.Study eligibility criteriaWe focused on quantitative and mixed-method studies that evaluated adolescent mental health literacy, appropriate package of services and provider competencies in mental health services, and that targeted depression, anxiety and post-traumatic stress disorder among adolescents (10–19 years). This included adolescents exposed to interventions or strategies within mental health services.Study appraisal and synthesis methodsStudy quality was assessed using the National Institutes for Health Study Quality Assessment Tools. Data were extracted and grouped based on WHO quality Standards.ResultsOf the 20 104 studies identified, 20 articles were included. The majority of studies came from high-income countries, with one from a low-income country. Most of the studies did not conceptualise quality. Results found that an online decision aid was evaluated to increase adolescent mental health literacy. Studies that targeted an appropriate package of services evaluated the quality of engagement between the therapist and adolescent, patient-centred communication, mental health service use, linkages to mental health services, health facility culture and intensive community treatment. Provider competencies focused on studies that evaluated confidence in managing and referring adolescents, collaboration between health facility levels, evidence-based practices and technology use.Conclusions and implicationsThere is limited evidence on quality measures in adolescent mental health services (as conforms to the WHO Global Standards), pointing to a global evidence gap for adolescent mental health services. There are several challenges to overcome, including a need to develop consensus on quality and methods to measure quality in mental health settings.PROSPERO registration numberCRD42020161318.

Background: Household overcrowding is associated with increased risk of infectious diseases across contexts and countries. Limited data exist linking household overcrowding and risk of COVID-19. We used data collected from the Virus Watch cohort to examine the association between overcrowded households and SARS-CoV-2. Methods: The Virus Watch study is a household community cohort of acute respiratory infections in England & Wales that began recruitment in June 2020. We calculated the persons per room for each household and classified accommodation as overcrowded when the number of rooms was fewer than the number of people. We considered two primary outcomes - PCR-confirmed positive SARS-CoV-2 antigen tests and laboratory confirmed SARS-CoV-2 antibodies (Roche Elecsys anti-N total immunoglobulin assay). We used mixed effects logistic regression models that accounted for household structure to estimate the association between household overcrowding and SARS-CoV-2 infection. Results: The proportion of participants with a positive SARS-CoV-2 PCR result was highest in the overcrowded group (6.6%; 73/1,102) and lowest in the under-occupied group (2.9%; 682/23,219). In a mixed effects logistic regression model that included age, sex, ethnicity, household income and geographical region, we found strong evidence of an increased odds of having a positive PCR SARS-CoV-2 antigen result (Odds Ratio 3.72; 95% CI: 1.92, 7.13; p-value < 0.001) and increased odds of having a positive SARS-CoV-2 antibody result in individuals living in overcrowded houses (2.96; 95% CI: 1.13, 7.74; p-value =0.027) compared to people living in under-occupied houses. The proportion of variation at the household level was 75.1% and 74.0% in the PCR and antibody models respectively. Discussion: Public health interventions to prevent and stop the spread of SARS-CoV-2 should consider the much greater risk of infection for people living in overcrowded households and pay greater attention to reducing household transmission. There is an urgent need to better recognise housing as a leading determinant of health in the context of a pandemic and beyond.

Most cross-cultural qualitative research on depression has been descriptive, documenting symptoms and explanatory models. There is a lack of qualitative research testing theoretical models of depression. The interpersonal model conceptualises grief, interpersonal disputes, role transitions and social isolation as the context in which depression develops and is the basis of interpersonal therapy (IPT), which is increasingly used in cross-cultural settings to treat depression. We aimed to qualitatively evaluate to what extent the interpersonal model can explain adolescent depression in Nepal. Data were collected between December 2018 and April 2019 and comprised transcripts from 126 participants: 25 semi-structured interviews with depressed adolescents aged 13–18; four focus group discussions with adolescents (N = 38), four with parents/caregivers (N = 39), and two with teachers (N = 17); and seven semi-structured interviews with health and non-governmental organisation workers. We coded data using an analytical framework comprising deductive codes representing key concepts from the interpersonal model of depression and IPT, including principles, techniques and strategies. Participants mainly related depression to interpersonal problem areas of grief, dispute, role transition and social isolation. Interpersonal disputes were common, and for many adolescents this involved parental physical and emotional abuse. Although role transitions were common few adolescents grieved loss of the prior role. Distress related to social isolation was evident despite close physical proximity and extensive social interaction with family and community members. Adolescents described coping strategies that were similar to strategies central to IPT, e.g. identifying helpful and unhelpful relationships and generating options and ways of managing problems. In conclusion, interpersonal problems are relevant to this population and conceptualisations align with core principles of the interpersonal model of depression. The findings highlight the importance of addressing abuse and maltreatment in depression aetiology. They also inform future cultural adaptations of IPT in Nepal and beyond, including the opportunity to integrate local coping strategies., Highlights • Testing psychological models cross-culturally is important for adapting therapies. • Interpersonal problems trigger depression among adolescents in Nepal. • Experiences of depression align with core principles of interpersonal therapy (IPT). • Few adolescents use IPT strategies to address interpersonal problems. • Models of depression must incorporate poverty, migration and abuse as risk factors.

This Series shows how racism, xenophobia, discrimination, and the structures that support them are detrimental to health. In this first Series paper, we describe the conceptual model used throughout the Series and the underlying principles and definitions. We explore concepts of epistemic injustice, biological experimentation, and misconceptions about race using a historical lens. We focus on the core structural factors of separation and hierarchical power that permeate society and result in the negative health consequences we see. We are at a crucial moment in history, as populist leaders pushing the politics of hate have become more powerful in several countries. These leaders exploit racism, xenophobia, and other forms of discrimination to divide and control populations, with immediate and long-term consequences for both individual and population health. The COVID-19 pandemic and transnational racial justice movements have brought renewed attention to persisting structural racial injustice.

Summary box The disproportionate mortality of COVID-19 and brutality of protective institutions has shifted anti-racism discourses into the mainstream.1 Increased reckoning over categorisations of people demonstrate that racial categories, while imprecise, fluid, time and context-specific, embody hierarchical power. We interrogate categorisations used in the UK, South Africa and the USA; their origins and impact. We emphasise needing to recognise commonality of power structures globally, while acknowledging specificity in local contexts. In identifying such commonality, we encourage use of the term ‘minoritised’ as a universal alternative. Various historical and geographical contexts give rise to categorisations, consistently exposing the use of power in creating separation. The UK term BAME (Black, Asian and minority ethnic) reflects decades of categorising groups of people referred to in the 1940s and 1950s as ‘coloured immigrants’; ‘New Commonwealth immigrants’ or ‘African, Caribbean and Asian’ immigrants. This terminology, highlighted their perceived differences and non-White identity. From the 1960s to the early 1990s, ‘Black’ was used by some, as a political term to highlight the shared history of colonialism and political and cultural entanglement that brought African peoples, people from the Indian subcontinent and Caribbean people of all heritages to Britain. BME (Black and minority ethnic), a governmental …

BackgroundA sizeable cohort of Chinese migrants in high-income non-Asian countries is reaching old age and many will develop life-limiting illnesses. They may benefit from palliative care, which is integrated into universal health coverage in many of these countries, but the uptake of this care among migrant communities remains low. Cultural differences between the Chinese and the host community, and poor language skills may be barriers to access, yet understanding the reasons hindering uptake are obscure.AimsTo understand the cultural perspective of how first generation Chinese migrants and their families perceive the provision of palliative care, to identify what exists which may limit their access in high-income non-Asian countries.DesignA systematic review and three-stage thematic synthesis of qualitative studies. Citations and full texts were reviewed against predefined inclusion criteria. All included studies were appraised for quality.Data sourceMEDLINE, EMBASE, PsycINFO, CINAHL and PubMed were searched to July 2019.ResultsSeven qualitative studies were identified (from USA, UK, Canada and Australia). Across the studies analytical themes that impacted on the use of palliative care services were identified: (1) migrants’ intrinsic perceptions of cultural practices, (2) their expectations of and preparation for care at the end of life, (3) perspectives and influences of family and (4) knowledge and communication with palliative care providers in the host country. Key elements found that challenge access to palliative care services in the host countries were: Chinese culture is rooted in the core values of the family as opposed to the individual; migrants’ limited experience in their place of origin in accessing healthcare; and practical issues including a lack of language skills of their host country.ConclusionsPalliative care services do not always match the needs of Chinese migrants in non-Asian high-income countries. Engagement and education on multiethnic cultural awareness in both the host non-migrant and the migrant communities is needed.

IntroductionViolence against women (VAW) affects one in three women globally. In some countries, women are at much higher risk. We examined risk factors for VAW in countries with the highest 12-month prevalence estimates of intimate partner violence (IPV) to develop understanding of this increased risk.MethodsFor this systematic review, we searched PUBMED, CINAHL, PROQUEST (Middle East and North Africa; Latin America and Iberia; East and South Asia), Web of Science, EMBASE and PsycINFO (Ovid) for records published between 1 January 2000 and 1 January 2021 in English, French and Spanish. Included records used quantitative, qualitative, or mixed-methods, reported original data, had VAW as the main outcome, and focused on at least one of 23 countries in the highest quintile of prevalence figures for women’s self-reported experiences of physical and/or sexual violence in the past 12 months. We used critical interpretive synthesis to develop a conceptual model for associations between identified risk factors and VAW.ResultsOur search identified 12 044 records, of which 241 were included for analysis (2 80 360 women, 40 276 men, 274 key informants). Most studies were from Bangladesh (74), Uganda (72) and Tanzania (43). Several quantitative studies explored community-level/region-level socioeconomic status and education as risk factors, but associations with VAW were mixed. Although fewer in number and representing just one country, studies reported more consistent effects for community-level childhood exposure to violence and urban residence. Theoretical explanations for a country’s high prevalence point to the importance of exposure to other forms of violence (armed conflict, witnessing parental violence, child abuse) and patriarchal social norms.ConclusionAvailable evidence suggests that heightened prevalence of VAW is not attributable to a single risk factor. Multilayered and area-level risk analyses are needed to ensure funding is appropriately targeted for countries where VAW is most pervasive.PROSPERO registration numberThe review is registered with PROSPERO (CRD42020190147).

ObjectiveTo estimate the association between homicide and suicide rates in Brazilian municipalities over a period of 7 years.DesignWe conducted a longitudinal ecological study using annual mortality data from 5507 Brazilian municipalities between 2008 and 2014. Multivariable negative binomial regression models were used to examine the relationship between homicide and suicide rates. Robustness of results was explored using sensitivity analyses to examine the influence of data quality, population size, age and sex on the relationship between homicide and suicide rates.SettingA nationwide study of municipality-level data.ParticipantsMortality data and corresponding population estimates for municipal populations aged 10 years and older.Primary and secondary outcome measuresAge-standardised suicide rates per 100 000.ResultsMunicipal suicide rates were positively associated with municipal homicide rates; after adjusting for socioeconomic and demographic factors, a doubling of the homicide rate was associated with 22% increase in suicide rate (rate ratio=1.22, 95% CI: 1.13 to 1.33). A dose–response effect was observed with 4% increase in suicide rates at the third quintile, 9% at the fourth quintile and 12% at the highest quintile of homicide rates compared with the lowest quintile. The observed effect estimates were robust to sensitivity analyses.ConclusionsMunicipalities with higher homicide rates have higher suicide rates and the relationship between homicide and suicide rates in Brazil exists independently of many sociodemographic and socioeconomic factors. Our results are in line with the hypothesis that changes in homicide rates lead to changes in suicide rates, although a causal association cannot be established from this study. Suicide and homicide rates have increased in Brazil despite increased community mental health support and incarceration, respectively; therefore, new avenues for intervention are needed. The identification of a positive relationship between homicide and suicide rates suggests that population-based interventions to reduce homicide rates may also reduce suicide rates in Brazil.