Work as a social determinant of health in high-income countries: past, present, and future.

This paper, the first in a three-part Series on work and health, provides a narrative review of research into work as a social determinant of health over the past 25 years, the key emerging challenges in this field, and the implications of these challenges for future research. By use of a conceptual framework for work as a social determinant of health, we identified six emerging challenges: (1) the influence of technology on the nature of work in high-income countries, culminating in the sudden shift to telework during the COVID-19 pandemic; (2) the intersectionality of work with gender, sexual orientation, age, race, ethnicity, migrant status, and socioeconomic status as codeterminants of health disparities; (3) the arrival in many Organisation for Economic Co-operation and Development countries of large migrant labour workforces, who are often subject to adverse working conditions and social exclusion; (4) the development of precarious employment as a feature of many national labour markets; (5) the phenomenon of working long and irregular hours with potential health consequences; and (6) the looming threat of climate change's effects on work. We conclude that profound changes in the nature and availability of work over the past few decades have led to widespread new psychosocial and physical exposures that are associated with adverse health outcomes and contribute to increasing disparities in health. These new exposures at work will require novel and creative methods of data collection for monitoring of their potential health impacts to protect the workforce, and for new research into better means of occupational health promotion and protection. There is also an urgent need for a better integration of occupational health within public health, medicine, the life sciences, and the social sciences, with the work environment explicitly conceptualised as a major social determinant of health.

Open access publishing - noble intention, flawed reality.

For two decades, the international scholarly publishing community has been embroiled in a divisive debate about the best model for funding the dissemination of scientific research. Some may assume that this debate has been thoroughly resolved in favour of the Open Access (OA) model of scientific publishing. Recent commentaries reveal a less settled reality. This narrative review aims to lay out the nature of these deep divisions among the sector's stakeholders, reflects on their systemic drivers and considers the future prospects for actualising OA's intended benefits and surmounting its risks and costs. In the process, we highlight some of inequities OA presents for junior or unfunded researchers, and academics from resource-poor environments, for whom an increasing body of evidence shows clear evidence of discrimination and injustice caused by Article Processing Charges. The authors are university-appointed researchers working the UK and South Africa, trained in disciplines ranging from medicine and epidemiology to social science and digital science. We have no vested interest in any particular model of scientific publication, and no conflicts of interest to declare. We believe the issues we identify are pertinent to almost all research disciplines.

Why Canada Is in Court to Protect Healthcare for All: Global Implications for Universal Health Coverage.

Countries worldwide are currently endeavoring to safeguard the long-term health of their populations through implementing Universal Health Coverage (UHC), in line with the United Nation's 2015-30 Sustainable Development Goals (SDGs). Canada has some of the world's strongest legislation supporting equitable access to care for medically necessary hospital and physician services based on need, not ability to pay. A constitutional challenge to this legislation is underway in British Columbia (BC), led by a corporate plaintiff, Cambie Surgeries Corporation (CSC). This constitutional challenge threatens to undermine the high bar for UHC protection that Canada has set for the world, with potential adverse implications for equitable international development. CSC claims that BC's healthcare law-the Medicare Protection Act (MPA)-infringes patients' rights under Canada's constitution, by essentially preventing physicians who are enrolled in BC's publicly-funded Medicare plan from providing expedited care to patients for a private fee. In September 2020, after a trial that ran for 3.5 years and included testimony by more than 100 witnesses from around the world, the court dismissed the plaintiffs' claim. Having lost their case in the Supreme Court of BC, the plaintiffs' appealed in June 2021. The appellate court's ruling and reasons for judgment are expected sometime in 2021. We consider the evidence before the court from the perspective of social epidemiology and health inequalities, demonstrating that structural features of a modern society that exacerbate inequalities, including inequitable access to healthcare, can be expected to lead to worse overall societal outcomes.

A simple tool for comparing benefits and 'costs' of COVID-19 exit strategies.

BACKGROUND: Governments and health policymakers are now looking for strategies to lift the COVID-19 lockdown, while reducing risk to the public. METHODS: We propose the population attributable risk (PAR) as an established epidemiological tool that could support decision-making through quickly estimating the main benefits and costs of various exit strategies. RESULTS: We demonstrate the feasibility of use of PAR using pandemic data, that were publicly available in mid-May 2020 from Scotland and the US, to estimate the proportion of COVID-19 hospital admissions which might be avoided, and the proportion of adverse labour market effects - for various scenarios - based on maintaining the lockdown for those of certain ages with and without comorbidities. CONCLUSION: These calculations could be refined and applied in different countries to inform important COVID-19 policy decisions, using routinely collected data.

The Social Determinants of Health: Time to Re-Think?

Twelve years have now passed since the influential WHO Report on the Social Determinants of Health (SDoH) in 2008. A group of senior international public health scholars and decision-makers met in Italy in mid-2019 to review the legacy of the SDoH conceptual framework and its adequacy for the many challenges facing our field as we enter the 2020s. Four major categories of challenges were identified: emerging "exogenous" challenges to global health equity, challenges related to weak policy and practice implementation, more fundamental challenges related to SDoH theory and research, and broader issues around modern research in general. Each of these categories is discussed, and potential solutions offered. We conclude that although the SDoH framework is still a worthy core platform for public health research, policy, and practice, the time is ripe for significant evolution.

Changing relative and absolute socioeconomic health inequalities in Ontario, Canada: A population-based cohort study of adult premature mortality, 1992 to 2017.

BACKGROUND: This study aimed to characterize trends in absolute and relative socioeconomic inequalities in adult premature mortality between 1992 and 2017, in the context of declining population-wide mortality rates. We conducted a population-based cohort study of all adult premature deaths in Ontario, Canada using provincial vital statistics data linked to census-based, area-level deprivation indices for socioeconomic status. METHODS: The cohort included all individuals eligible for Ontario's single-payer health insurance system at any time between January 1, 1992 and December 31, 2017 with a recorded Ontario place of residence and valid socioeconomic status information (N = 820,370). Deaths between ages 18 and 74 were used to calculate adult premature mortality rates per 1000, stratified by provincial quintile of material deprivation. Relative inequalities were measured using Relative Index of Inequality (RII) measures. Absolute inequalities were estimated using Slope Index of Inequality (SII) measures. All outcome measures were calculated as sex-specific, annual measures for each year from 1992 to 2017. RESULTS: Premature mortality rates declined in all socioeconomic groups between 1992 and 2017. Relative inequalities in premature mortality increased over the same period. Absolute inequalities were mostly stable between 1992 and 2007, but increased dramatically between 2008 and 2017, with larger increases to absolute inequalities seen in females than in males. CONCLUSIONS: As in other developed countries, long-term downward trends in all-cause premature mortality in Ontario, Canada have shifted to a plateau pattern in recent years, especially in lower- socioeconomic status subpopulations. Determinants of this may differ by setting. Regular monitoring of mortality by socioeconomic status is the only way that this phenomenon can be detected sensitively and early, for public health attention and possible corrective action.

How community resources mitigate the association between household poverty and the incidence of adverse childhood experiences.

OBJECTIVES: To assess what proportion of the association between household low income and incidence of adverse childhood experiences (ACE) would be eliminated if all households had access to housing, transportation and childcare services, breastfeeding counselling, and parks. METHODS: Using Growing Up in Scotland birth cohort data (N = 2816), an inverse probability-weighted regression-based mediation technique was applied to assess associations between low-income status (< £11,000 in 2004/5), resource access, and cumulative 8-year ACE incidence (≥ 1, ≥ 3 ACEs). Resource access was measured based on households' self-reported difficulties (yes/no) in accessing housing, transportation, childcare, and breastfeeding counselling, and park proximity (within 10 min from the residence). RESULTS: The protective effects of resources were heterogeneous. Only access to transportation was associated with lower ACE incidence in both low- and higher-income households. If all had access to transportation, 21% (95% CI 3%, 41%) of the income-based inequality in incidence of 3 or more ACEs could be eliminated. CONCLUSIONS: While second best to the elimination of child poverty, measures to improve families' access to community resources such as transportation may mitigate the effects of poverty on ACE incidence.

Unmet Health Care Needs Among Young Transgender Women at Risk for HIV Transmission and Acquisition in Two Urban U.S. Cities: The LifeSkills Study.

Purpose: The physical health care needs of transgender women are not being adequately addressed in the United States. The current study adds to the literature on the state of health care among young transgender women (YTW) by describing the occurrence of unmet health needs among a sample of YTW and providing unique data on psychosocial and demographic factors associated with access to adequate care. Methods: Baseline data were analyzed from Project LifeSkills, an intervention study funded by the National Institutes of Health (NIH). YTW (N=300) between the ages of 16 and 29 were recruited from the Boston and Chicago metropolitan areas between 2012 and 2015. Data were collected on health care experiences, indicators of social marginalization, and sociodemographic information. The final analytic sample (N=273) was restricted to participants with complete data; participants that were removed did not significantly differ demographically from the final analytic sample retained. Bivariate logistic regression models examined the association between having unmet health care needs and sociodemographics, social marginalization, and health care utilization indicators. A final adjusted multivariable logistic regression model was constructed with independent variables that were statistically significant in bivariate models. Results: Overall, nearly a quarter (23%) of YTW indicated that they had unmet health care needs. In the final multivariable model adjusted for enrollment city, avoiding health care due to cost (adjusted odds ratio [aOR]=1.98, 95% confidence interval [CI]=1.05-3.76) and experiencing prior transgender-specific discrimination in a medical setting (aOR=4.54, 95% CI=2.30-8.95]) were associated with a greater odds of having unmet health care needs. Conclusion: YTW face significant barriers to accessing health care in the United States. Among this sample, prior experiences of discrimination and inability to afford health care increased YTW odds of having unmet health care needs. Efforts to improve the unmet health care needs among YTW should promote access to affordable, gender-affirming care.

Impact of abolishing prescription fees in Scotland on hospital admissions and prescribed medicines: an interrupted time series evaluation.

OBJECTIVES: To identify whether the abolition of prescription fees in Scotland resulted in: (1) Increase in the number (cost to NHS) of medicines prescribed for which there had been a fee (inhaled corticosteroids). (2) Reduction in hospital admissions for conditions related to those medications for which there had been a fee (asthma or chronic obstructive pulmonary disease (COPD))-when both are compared with prescribed medicines and admissions for a condition (diabetes mellitus) for which prescriptions were historically free. DESIGN: Natural experimental retrospective general practice level interrupted time series (ITS) analysis using administrative data. SETTING: General practices, Scotland, UK. PARTICIPANTS: 732 (73.6%) general practices across Scotland with valid dispensed medicines and hospital admissions data during the study period (July 2005-December 2013). INTERVENTION: Reduction in fees per dispensed item from April 2008 leading to the abolition of the fee in April 2011, resulting in universal free prescriptions. PRIMARY AND SECONDARY OUTCOMES: Hospital admissions recorded in the Scottish Morbidity Record - 01 Inpatient (SMR01) and dispensed medicines recorded in the Prescribing Information System (PIS). RESULTS: The ITS analysis identified marked step reductions in adult (19-59 years) admissions related to asthma or COPD (the intervention group), compared with older or young people with the same conditions or adults with diabetes mellitus (the counterfactual groups). The prescription findings were less coherent and subsequent sensitivity analyses found that both the admissions and prescriptions data were highly variable above the annual or seasonal level, limiting the ability to interpret the findings of the ITS analysis. CONCLUSIONS: This study did not find sufficient evidence that universal free prescriptions was a demonstrably effective or ineffective policy, in terms of reducing hospital admissions or reducing socioeconomic inequality in hospital admissions, in the context of a universal, publicly administered medical care system, the National Health Service of Scotland.

Credibility of subgroup analyses by socioeconomic status in public health intervention evaluations: An underappreciated problem?

There is increasing interest amongst researchers and policy makers in identifying the effect of public health interventions on health inequalities by socioeconomic status (SES). This issue is typically addressed in evaluation studies through subgroup analyses, where researchers test whether the effect of an intervention differs according to the socioeconomic status of participants. The credibility of such analyses is therefore crucial when making judgements about how an intervention is likely to affect health inequalities, although this issue appears to be rarely considered within public health. The aim of this study was therefore to assess the credibility of subgroup analyses in published evaluations of public health interventions. An established set of 10 credibility criteria for subgroup analyses was applied to a purposively sampled set of 21 evaluation studies, the majority of which focussed on healthy eating interventions, which reported differential intervention effects by SES. While the majority of these studies were found to be otherwise of relatively high quality methodologically, only 8 of the 21 studies met at least 6 of the 10 credibility criteria for subgroup analysis. These findings suggest that the credibility of subgroup analyses conducted within evaluations of public health interventions' impact on health inequalities may be an underappreciated problem.

Canadian report card on health equity across the life-course: Analysis of time trends and cross-national comparisons with the United Kingdom.

Addressing social determinants of health (SDoH) has been acknowledged as an essential objective for the promotion of both population health and health equity. Extant literature has identified seven potential areas of investment to address SDoH: investments in sexual and reproductive health and family planning, early learning and child care, education, universal health care, as well as investments to reduce child poverty, ensure sustainable economic development, and control health hazards. The aim of this paper is to produce a 'report card' on Canada's success in reducing socioeconomic and health inequities pertaining to these seven policy domains, and to assess how Canadian trends compare to those in the United Kingdom (UK), a country with a similar health and welfare system. Summarising evidence from published studies and national statistics, we found that Canada's best successes were in reducing socioeconomic inequalities in early learning and child care and reproductive health-specifically in improving equity in maternal employment and infant mortality. Comparative data suggest that Canada's outcomes in the latter areas were like those in the UK. In contrast, Canada's least promising equity outcomes were in relation to health hazard control (specifically, tobacco) and child poverty. Though Canada and the UK observed similar inequities in smoking, Canada's slow upward trend in child poverty prevalence is distinct from the UK's small but steady reduction of child poverty. This divergence from the UK's trends indicates that alternative investment types and levels may be needed in Canada to achieve similar outcomes to those in the UK.

The impact of eliminating primary school tuition fees on child marriage in sub-Saharan Africa: A quasi-experimental evaluation of policy changes in 8 countries.

BACKGROUND: Child marriage harms girls' health and hinders progress toward development goals. Randomized studies have shown that providing financial incentives for girls' education can effectively delay marriage, but larger-scale interventions are needed in light of slow progress toward curbing the practice. Many sub-Saharan African countries eliminated primary school tuition fees over the past two decades, resulting in massive increases in enrolment. We measured the effect of these policies on the probability of primary school completion and of marriage before 15 and 18 years of age. METHODS: We used Demographic and Health Surveys to assemble a dataset of women born between 1970 and 2000 in 16 countries. These data were merged with longitudinal information on the timing of tuition fee elimination in each country. We estimated the impact of fee removal using fixed effects regression to compare changes in the prevalence of child marriage over time between women who were exposed to tuition-free primary schooling and those who were not. RESULTS: The removal of tuition fees led to modest average declines in the prevalence of child marriage across all of the treated countries. However, there was substantial heterogeneity between countries. The prevalence of child marriage declined by 10-15 percentage points in Ethiopia and Rwanda following tuition elimination but we found no evidence that the removal of tuition fees had an impact on child marriage rates in Cameroon or Malawi. Reductions in child marriage were not consistently accompanied by increases in the probability of primary school completion. CONCLUSIONS: Eliminating tuition fees led to reductions in child marriage on a national scale in most countries despite challenges with implementation. Improving the quality of the education available may strengthen these effects and bolster progress toward numerous other public health goals.

Economic policy and the double burden of malnutrition: cross-national longitudinal analysis of minimum wage and women's underweight and obesity.

OBJECTIVE: To examine changes in minimum wage associated with changes in women's weight status. DESIGN: Longitudinal study of legislated minimum wage levels (per month, purchasing power parity-adjusted, 2011 constant US dollar values) linked to anthropometric and sociodemographic data from multiple Demographic and Health Surveys (2000-2014). Separate multilevel models estimated associations of a $10 increase in monthly minimum wage with the rate of change in underweight and obesity, conditioning on individual and country confounders. Post-estimation analysis computed predicted mean probabilities of being underweight or obese associated with higher levels of minimum wage at study start and end. SETTING: Twenty-four low-income countries. SUBJECTS: Adult non-pregnant women (n 150 796). RESULTS: Higher minimum wages were associated (OR; 95 % CI) with reduced underweight in women (0·986; 0·977, 0·995); a decrease that accelerated over time (P-interaction=0·025). Increasing minimum wage was associated with higher obesity (1·019; 1·008, 1·030), but did not alter the rate of increase in obesity prevalence (P-interaction=0·8). A $10 rise in monthly minimum wage was associated (prevalence difference; 95 % CI) with an average decrease of about 0·14 percentage points (-0·14; -0·23, -0·05) for underweight and an increase of about 0·1 percentage points (0·12; 0·04, 0·20) for obesity. CONCLUSIONS: The present longitudinal multi-country study showed that a $10 rise in monthly minimum wage significantly accelerated the decline in women's underweight prevalence, but had no association with the pace of growth in obesity prevalence. Thus, modest rises in minimum wage may be beneficial for addressing the protracted underweight problem in poor countries, especially South Asia and parts of Africa.

Who will have Sustainable Employment After a Back Injury? The Development of a Clinical Prediction Model in a Cohort of Injured Workers.

Purpose Our objective was to develop a clinical prediction model to identify workers with sustainable employment following an episode of work-related low back pain (LBP). Methods We used data from a cohort study of injured workers with incident LBP claims in the USA to predict employment patterns 1 and 6 months following a workers' compensation claim. We developed three sequential models to determine the contribution of three domains of variables: (1) basic demographic/clinical variables; (2) health-related variables; and (3) work-related factors. Multivariable logistic regression was used to develop the predictive models. We constructed receiver operator curves and used the c-index to measure predictive accuracy. Results Seventy-nine percent and 77 % of workers had sustainable employment at 1 and 6 months, respectively. Sustainable employment at 1 month was predicted by initial back pain intensity, mental health-related quality of life, claim litigation and employer type (c-index = 0.77). At 6 months, sustainable employment was predicted by physical and mental health-related quality of life, claim litigation and employer type (c-index = 0.77). Adding health-related and work-related variables to models improved predictive accuracy by 8.5 and 10 % at 1 and 6 months respectively. Conclusion We developed clinically-relevant models to predict sustainable employment in injured workers who made a workers' compensation claim for LBP. Inquiring about back pain intensity, physical and mental health-related quality of life, claim litigation and employer type may be beneficial in developing programs of care. Our models need to be validated in other populations.

Do minimum wages improve early life health? Evidence from developing countries.

The impact of legislated minimum wages on the early-life health of children living in low and middle-income countries has not been examined. For our analyses, we used data from the Demographic and Household Surveys (DHS) from 57 countries conducted between 1999 and 2013. Our analyses focus on height-for-age z scores (HAZ) for children under 5 years of age who were surveyed as part of the DHS. To identify the causal effect of minimum wages, we utilized plausibly exogenous variation in the legislated minimum wages during each child's year of birth, the identifying assumption being that mothers do not time their births around changes in the minimum wage. As a sensitivity exercise, we also made within family comparisons (mother fixed effect models). Our final analysis on 49 countries reveal that a 1% increase in minimum wages was associated with 0.1% (95% CI = -0.2, 0) decrease in HAZ scores. Adverse effects of an increase in the minimum wage were observed among girls and for children of fathers who were less than 35 years old, mothers aged 20-29, parents who were married, parents who were less educated, and parents involved in manual work. We also explored heterogeneity by region and GDP per capita at baseline (1999). Adverse effects were concentrated in lower-income countries and were most pronounced in South Asia. By contrast, increases in the minimum wage improved children's HAZ in Latin America, and among children of parents working in a skilled sector. Our findings are inconsistent with the hypothesis that increases in the minimum wage unconditionally improve child health in lower-income countries, and highlight heterogeneity in the impact of minimum wages around the globe. Future work should involve country and occupation specific studies which can explore not only different outcomes such as infant mortality rates, but also explore the role of parental investments in shaping these effects.

Minimum Wage and Overweight and Obesity in Adult Women: A Multilevel Analysis of Low and Middle Income Countries.

OBJECTIVES: To describe the relationship between minimum wage and overweight and obesity across countries at different levels of development. METHODS: A cross-sectional analysis of 27 countries with data on the legislated minimum wage level linked to socio-demographic and anthropometry data of non-pregnant 190,892 adult women (24-49 y) from the Demographic and Health Survey. We used multilevel logistic regression models to condition on country- and individual-level potential confounders, and post-estimation of average marginal effects to calculate the adjusted prevalence difference. RESULTS: We found the association between minimum wage and overweight/obesity was independent of individual-level SES and confounders, and showed a reversed pattern by country development stage. The adjusted overweight/obesity prevalence difference in low-income countries was an average increase of about 0.1 percentage points (PD 0.075 [0.065, 0.084]), and an average decrease of 0.01 percentage points in middle-income countries (PD -0.014 [-0.019, -0.009]). The adjusted obesity prevalence difference in low-income countries was an average increase of 0.03 percentage points (PD 0.032 [0.021, 0.042]) and an average decrease of 0.03 percentage points in middle-income countries (PD -0.032 [-0.036, -0.027]). CONCLUSION: This is among the first studies to examine the potential impact of improved wages on an important precursor of non-communicable diseases globally. Among countries with a modest level of economic development, higher minimum wage was associated with lower levels of obesity.

"It Looks Like an Adult Sweetie Shop": Point-of-Sale Tobacco Display Exposure and Brand Awareness in Scottish Secondary School Students.

INTRODUCTION: As further restrictions have been placed on tobacco advertising and promotions, point-of-sale (PoS) displays of cigarettes in shops have become an increasingly important source of young people's exposure to tobacco products. This study explored the relationship between PoS displays of cigarettes and brand awareness among secondary school students in Scotland. METHODS: Cross-sectional school surveys (n = 1406) and focus groups (n = 86) were conducted with S2 (13-14 years) and S4 (15-16 years) students in four schools of differing socioeconomic status in 2013, prior to the PoS display ban in large shops. Adjusted negative binomial regression analysis examined associations between brand awareness and exposure variables (visiting tobacco retailers, noticing displays of tobacco products). RESULTS: Students visiting small shops more frequently (relative rate ratio [RRR] 1.19, 95% confidence interval [CI] 1.01-1.41) and those who noticed cigarette displays in small shops (RRR 1.24, 95% CI 1.03-1.51) and large supermarkets (RRR 1.15, 95% CI 1.01-1.30) had higher brand awareness. The focus groups supported these findings. Participants described PoS tobacco displays as being eye-catching, colorful and potentially attractive to young people. CONCLUSIONS: This mixed-methods study showed that higher cigarette brand awareness was significantly associated with regularly visiting small shops and noticing PoS displays in small and large shops, even when students' smoking status, smoking in their social networks, leisure activities, and demographics were included as confounding variables. This highlights the importance of PoS displays of tobacco products in increasing brand awareness, which is known to increase youth smoking susceptibility, and thus the importance of implementing PoS display bans in all shops. IMPLICATIONS: As increasing restrictions have been placed on tobacco promotion in many countries, PoS displays of cigarettes in shops have become an important source of young people's exposure to tobacco products and marketing. This mixed-methods study showed that prior to the PoS display ban in Scotland, and controlling for other factors, 13- and 15-year olds who regularly visited small shops and those who noticed PoS displays in small and large shops, had a higher awareness of cigarette brands. This highlights the importance of PoS displays in increasing youth brand awareness, which increases smoking susceptibility, and thus the need for comprehensive bans on PoS displays which cover all shops.