New global indicator for workers' health: mortality rate from diseases attributable to selected occupational risk factors.

Through sustainable development goals 3 and 8 and other policies, countries have committed to protect and promote workers' health by reducing the work-related burden of disease. To monitor progress on these commitments, indicators that capture the work-related burden of disease should be available for monitoring workers' health and sustainable development. The World Health Organization and the International Labour Organization estimate that only 363 283 (19%) of 1 879 890 work-related deaths globally in 2016 were due to injuries, whereas 1 516 607 (81%) deaths were due to diseases. Most monitoring systems focusing on workers' health or sustainable development, such as the global indicator framework for the sustainable development goals, include an indicator on the burden of occupational injuries. Few such systems, however, have an indicator on the burden of work-related diseases. To address this gap, we present a new global indicator: mortality rate from diseases attributable to selected occupational risk factors, by disease, risk factor, sex and age group. We outline the policy rationale of the indicator, describe its data sources and methods of calculation, and report and analyse the official indicator for 183 countries. We also provide examples of the use of the indicator in national workers' health monitoring systems and highlight the indicator's strengths and limitations. We conclude that integrating the new indicator into monitoring systems will provide more comprehensive and accurate surveillance of workers' health, and allow harmonization across global, regional and national monitoring systems. Inequalities in workers' health can be analysed and the evidence base can be improved towards more effective policy and systems on workers' health.

Par le biais des objectifs de développement durable 3 et 8 ainsi que d'autres mesures, plusieurs pays se sont engagés à protéger et promouvoir la santé des travailleurs en réduisant l'impact des maladies liées au travail. Mais pour évaluer leurs progrès en la matière, il convient de mettre en place des indicateurs estimant l'impact des maladies liées au travail afin de placer le développement durable et la santé des travailleurs sous surveillance. D'après l'Organisation mondiale de la Santé et l'Organisation internationale du Travail, seulement 363 283 (19%) des 1 879 890 décès liés au travail dans le monde en 2016 découlaient de blessures, tandis que 1 516 607 (81%) d'entre eux étaient causés par des maladies. La plupart des systèmes de surveillance qui s'intéressent à la santé des travailleurs ou au développement durable, comme le cadre mondial d'indicateurs pour les objectifs de développement durable, comportent un indicateur relatif à l'impact des accidents de travail. Cependant, rares sont ceux qui possèdent un indicateur concernant l'impact des maladies professionnelles. Pour combler cette lacune, nous dévoilons un nouvel indicateur mondial: le taux de mortalité dû aux maladies attribuables à certains facteurs de risque professionnels classé par maladie, facteur de risque, sexe et catégorie d'âge. Nous exposons le motif politique de l'indicateur, décrivons l'origine des données et les méthodes de calcul, et communiquons et analysons l'indicateur officiel pour 183 pays. Nous fournissons également des exemples de la façon dont l'indicateur peut être utilisé dans des systèmes nationaux de surveillance de la santé des travailleurs et soulignons ses forces et faiblesses. Nous concluons en affirmant que l'intégration de ce nouvel indicateur dans les systèmes de surveillance offrira un suivi plus complet et précis de la santé des travailleurs et ouvrira la voie à une harmonisation des systèmes mondiaux, nationaux et régionaux. Il est possible d'analyser les inégalités en matière de santé des travailleurs et d'en améliorer les bases factuelles afin d'établir des politiques et systèmes plus efficaces dans ce domaine.

A través de los objetivos de desarrollo sostenible 3 y 8 y de otras políticas, los países se han comprometido a proteger y promover la salud de los trabajadores reduciendo la carga de morbilidad relacionada con el trabajo. Para supervisar los avances en el cumplimiento de estos compromisos, debería disponerse de indicadores que reflejen la carga de morbilidad relacionada con el trabajo, a fin de controlar la salud de los trabajadores y el desarrollo sostenible. La Organización Mundial de la Salud y la Organización Internacional del Trabajo estiman que solo 363 283 (19%) de las 1 879 890 muertes relacionadas con el trabajo a nivel mundial en 2016 se debieron a lesiones, mientras que 1 516 607 (81%) muertes se debieron a enfermedades. La mayoría de los sistemas de vigilancia centrados en la salud de los trabajadores o el desarrollo sostenible, como el marco de indicadores mundiales para los objetivos de desarrollo sostenible, incluyen un indicador sobre la carga de las lesiones laborales. No obstante, pocos de estos sistemas cuentan con un indicador sobre la carga de las enfermedades relacionadas con el trabajo. Para subsanar esta carencia, presentamos un nuevo indicador mundial: la tasa de mortalidad por enfermedades atribuibles a factores de riesgo laborales seleccionados, por enfermedad, factor de riesgo, sexo y grupo de edad. Describimos la justificación política del indicador, describimos sus fuentes de datos y métodos de cálculo, e informamos y analizamos el indicador oficial para 183 países. También proporcionamos ejemplos del uso del indicador en los sistemas nacionales de vigilancia de la salud de los trabajadores y destacamos las ventajas y las limitaciones del indicador. Concluimos que la integración del nuevo indicador en los sistemas de vigilancia proporcionará una vigilancia más exhaustiva y precisa de la salud de los trabajadores, y permitirá la armonización entre los sistemas de vigilancia mundiales, regionales y nacionales. Se podrán analizar las desigualdades en la salud de los trabajadores y se podrá mejorar la base de evidencias para lograr políticas y sistemas más eficaces en materia de salud de los trabajadores.

Modelling the global economic costs of tobacco product waste.

Tobacco smoking continues to cause considerable premature mortality and morbidity worldwide. Most of the approximately six trillion cigarettes sold globally each year are discarded improperly as toxic environmental waste. Tobacco product waste, including cigarette butts, is the most commonly collected waste item worldwide. Of particular concern is the cellulose acetate filter, a poorly degradable plastic additive attached to most commercially manufactured cigarettes. This filter was introduced by the tobacco industry to reduce smokers' perception of harm and risk but it has no health benefit. To inform health policy and practice and improve public health outcomes, governments and society can benefit from cost estimates of preventing, properly disposing of and/or cleaning up tobacco product waste. Estimating the costs of tobacco product waste to communities and responsible authorities could encourage the development of health, environmental and fiscal policy interventions and shift accountability for the costs of tobacco product waste onto the global tobacco industry. To support health and environmental policy-making, we therefore propose an empirical approach to estimate the economic costs of tobacco product waste based on its negative environmental externalities. We first present general estimates for six representative countries and then identify data gaps that need to be addressed to develop global estimates. Interventions against tobacco product waste may be new channels to regulate tobacco products across sectors - for example, health, environment and finance - and consequently reduce overall tobacco use.

Le tabagisme continue à entraîner un taux de morbidité et de mortalité précoce considérable à travers le monde. La plupart des quelque six billions de cigarettes vendues chaque année à l'échelle planétaire ne sont pas correctement éliminées et deviennent une source de pollution environnementale toxique. Les déchets liés aux produits du tabac, notamment les mégots, sont les résidus les plus fréquemment collectés dans le monde. C'est surtout le filtre qui pose problème car il est composé d'acétate de cellulose, un additif plastique difficilement biodégradable que l'on retrouve dans la majorité des cigarettes commercialisées. Ce filtre a été introduit par l'industrie du tabac afin de donner aux fumeurs l'impression qu'ils courent moins de risques, alors qu'il n'a aucun effet bénéfique sur la santé. Les gouvernements et la société pourraient récolter les fruits d'une estimation des coûts engendrés par la prévention, l'élimination correcte et/ou le nettoyage des déchets liés aux produits du tabac, qui leur permettrait de mieux orienter les politiques et pratiques en la matière, mais aussi d'améliorer les résultats de santé publique. Estimer l'impact de ces déchets sur les communautés et les autorités compétentes pourrait encourager à adopter des mesures sanitaires, environnementales et fiscales, et pousser à responsabiliser davantage l'industrie mondiale du tabac vis-à-vis des coûts qu'ils entraînent. En vue de soutenir l'élaboration de politiques sanitaires et environnementales, nous proposons donc une approche empirique visant à déterminer les conséquences économiques des déchets générés par les produits du tabac en nous fondant sur l'influence néfaste qu'ils exercent sur l'environnement. Nous commençons par présenter des estimations globales pour six pays représentatifs, puis nous identifions les lacunes à combler dans les données afin de produire des estimations mondiales. Prendre des mesures de lutte contre ce type de déchets pourrait constituer un nouveau moyen de réglementer les produits du tabac dans différents secteurs comme la santé, l'environnement et les finances par exemple ­ et, par conséquent, faire diminuer la consommation de tabac en général.

El tabaquismo sigue causando una considerable tasa de mortalidad y morbilidad prematura en todo el mundo. La mayor parte de los casi seis billones de cigarrillos que se venden cada año en el mundo se desechan de forma inadecuada como residuos tóxicos para el medio ambiente. Los residuos de los productos del tabaco, incluidas las colillas, son los que más se recogen en todo el mundo. Un aspecto especialmente preocupante es el filtro de acetato de celulosa, un aditivo plástico poco degradable que se adhiere a la mayoría de los cigarrillos fabricados en el mercado. La industria del tabaco introdujo este filtro para reducir la percepción de daño y riesgo de los fumadores, pero no tiene ningún beneficio para la salud. A fin de fundamentar las políticas y prácticas sanitarias y mejorar los resultados en materia de salud pública, los gobiernos y la sociedad se pueden beneficiar de las estimaciones de costes de la prevención, la eliminación adecuada o la limpieza de los residuos de productos del tabaco. La estimación de los costes de los residuos de productos del tabaco para las comunidades y las autoridades responsables podría fomentar el desarrollo de intervenciones de política sanitaria, medioambiental y fiscal y trasladar la responsabilidad de los costes de los residuos de productos del tabaco a la industria del tabaco mundial. Para apoyar la elaboración de políticas sanitarias y medioambientales, se propone un enfoque empírico para estimar los costes económicos de los residuos de los productos del tabaco en función de sus consecuencias negativas para el medio ambiente. En primer lugar, se presentan estimaciones generales para seis países representativos y, a continuación, se identifican las deficiencias de información que se deben abordar para desarrollar estimaciones globales. Las intervenciones contra los residuos de productos del tabaco pueden constituir canales nuevos para regular los productos del tabaco en todos los sectores, por ejemplo, la salud, el medio ambiente y las finanzas, y, en consecuencia, reducir el consumo general de tabaco.

Towards a framework for systematic reviews of the prevalence of exposure to environmental and occupational risk factors.

Exposure prevalence studies (as here defined) record the prevalence of exposure to environmental and occupational risk factors to human health. Applying systematic review methods to the synthesis of these studies would improve the rigour and transparency of normative products produced based on this evidence (e.g., exposure prevalence estimates). However, a dedicated framework, including standard methods and tools, for systematically reviewing exposure prevalence studies has yet to be created. We describe the need for this framework and progress made towards it through a series of such systematic reviews that the World Health Organization and the International Labour Organization conducted for their WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates).We explain that existing systematic review frameworks for environmental and occupational health cannot be directly applied for the generation of exposure prevalence estimates because they seek to synthesise different types of evidence (e.g., intervention or exposure effects on health) for different purposes (e.g., identify intervention effectiveness or exposure toxicity or carcinogenicity). Concepts unique to exposure prevalence studies (e.g., "expected heterogeneity": the real, non-spurious variability in exposure prevalence due to exposure changes over space and/or time) also require new assessment methods. A framework for systematic reviews of prevalence of environmental and occupational exposures requires adaptation of existing methods (e.g., a standard protocol) and development of new tools or approaches (e.g., for assessing risk of bias and certainty of a body of evidence, including exploration of expected heterogeneity).As part of the series of systematic reviews for the WHO/ILO Joint Estimates, the World Health Organization collaborating with partners has created a preliminary framework for systematic reviews of prevalence studies of exposures to occupational risk factors. This included development of protocol templates, data extraction templates, a risk of bias assessment tool, and an approach for assessing certainty of evidence in these studies. Further attention and efforts are warranted from scientific and policy communities, especially exposure scientists and policy makers, to establish a standard framework for comprehensive and transparent systematic reviews of studies estimating prevalence of exposure to environmental and occupational risk factors, to improve estimates, risk assessments and guidelines.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries.

BACKGROUND: Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age, or HIV infection) are a social protection intervention addressing a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided only if recipients follow prescribed behaviours, e.g. use a health service or attend school) is unknown. OBJECTIVES: To assess the effects of UCTs on health services use and health outcomes in children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure, and to compare the effects of UCTs versus CCTs. SEARCH METHODS: For this update, we searched 15 electronic academic databases, including CENTRAL, MEDLINE and EconLit, in September 2021. We also searched four electronic grey literature databases, websites of key organisations and reference lists of previous systematic reviews, key journals and included study records. SELECTION CRITERIA: We included both parallel-group and cluster-randomised controlled trials (C-RCTs), quasi-RCTs, cohort studies, controlled before-and-after studies (CBAs), and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (≥ 18 years) in LMICs. Comparison groups received either no UCT, a smaller UCT or a CCT. Our primary outcomes were any health services use or health outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently screened potentially relevant records for inclusion, extracted data and assessed the risk of bias. We obtained missing data from study authors if feasible. For C-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method using a random-effects model. Where meta-analysis was impossible, we synthesised results using vote counting based on effect direction. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: We included 34 studies (25 studies of 20 C-RCTs, six CBAs, and three cohort studies) involving 1,140,385 participants (45,538 children, 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative syntheses. These analysed 29 independent data sets. The 24 UCTs identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 81.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT; three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection or performance bias, or both). Most studies were funded by national governments or international organisations, or both. Throughout the review, we use the words 'probably' to indicate moderate-certainty evidence, 'may/maybe' for low-certainty evidence, and 'uncertain' for very low-certainty evidence. Health services use We assumed greater use of any health services to be beneficial. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09; I2 = 2%; 5 C-RCTs, 4972 participants; low-certainty evidence). Health outcomes At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (RR 0.79, 95% CI 0.67 to 0.92; I2 = 53%; 6 C-RCTs, 9367 participants; moderate-certainty evidence). UCTs may have increased the likelihood of having been food secure over the previous month, at 13 to 36 months into the intervention (RR 1.25, 95% CI 1.09 to 1.45; I2 = 85%; 5 C-RCTs, 2687 participants; low-certainty evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01; I2 = 79%; 4 C-RCTs, 9347 participants; low-certainty evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. We found no study on the effect of UCTs on mortality risk. Social determinants of health UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.04 to 1.09; I2 = 0%; 8 C-RCTs, 7136 participants; moderate-certainty evidence). UCTs may have reduced the likelihood of households being extremely poor, at 12 to 36 months into the intervention (RR 0.92, 95% CI 0.87 to 0.97; I2 = 63%; 6 C-RCTs, 3805 participants; low-certainty evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, participation in labour, and parenting quality. Healthcare expenditure Evidence from eight cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 36 months into the intervention (low-certainty evidence). Equity, harms and comparison with CCTs The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services or had any illness, or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three. AUTHORS' CONCLUSIONS: This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), two social determinants of health (i.e. the likelihoods of attending school and being extremely poor), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Taxation of the fat content of foods for reducing their consumption and preventing obesity or other adverse health outcomes.

BACKGROUND: Overweight and obesity are increasing worldwide and are considered to be a major public health issue of the 21st century. Introducing taxation of the fat content in foods is considered a potentially powerful policy tool to reduce consumption of foods high in fat or saturated fat, or both. OBJECTIVES: To assess the effects of taxation of the fat content in food on consumption of total fat and saturated fat, energy intake, overweight, obesity, and other adverse health outcomes in the general population. SEARCH METHODS: We searched CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Embase, and 15 other databases and trial registers on 12 September 2019. We handsearched the reference lists of all records of included studies, searched websites of international organizations and institutions (14 October 2019), and contacted review advisory group members to identify planned, ongoing, or unpublished studies (26 February 2020). SELECTION CRITERIA: In line with Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria, we included the following study types: randomized controlled trials (RCTs), cluster-randomized controlled trials (cRCTs), non-randomized controlled trials (nRCTs), controlled before-after (CBA) studies, and interrupted time series studies. We included studies that evaluated the effects of taxes on the fat content in foods. Such a tax could be expressed as sales, excise, or special value added tax (VAT) on the final product or an intermediary product. Eligible interventions were taxation at any level, with no restriction on the duration or the implementation level (i.e. local, regional, national, or multinational). Eligible study populations were children (zero to 17 years) and adults (18 years or older) from any country and setting. We excluded studies that focused on specific subgroups only (e.g. people receiving pharmaceutical intervention; people undergoing a surgical intervention; ill people who are overweight or obese as a side effect, such as those with thyroiditis and depression; and people with chronic illness). Primary outcomes were total fat consumption, consumption of saturated fat, energy intake through fat, energy intake through saturated fat, total energy intake, and incidence/prevalence of overweight or obesity. We did not exclude studies based on country, setting, comparison, or population. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods for all phases of the review. Risk of bias of the included studies was assessed using the criteria of Cochrane's 'Risk of bias' tool and the EPOC Group's guidance. Results of the review are summarized narratively and the certainty of the evidence was assessed using the GRADE approach. These steps were done by two review authors, independently. MAIN RESULTS: We identified 23,281 records from searching electronic databases and 1173 records from other sources, leading to a total of 24,454 records. Two studies met the criteria for inclusion in the review. Both included studies investigated the effect the Danish tax on saturated fat contained in selected food items between 2011 and 2012. Both studies used an interrupted time series design. Neither included study had a parallel control group from another geographic area. The included studies investigated an unbalanced panel of approximately 2000 households in Denmark and the sales data from a specific Danish supermarket chain (1293 stores). Therefore, the included studies did not address individual participants, and no restriction regarding age, sex, and socioeconomic characteristics were defined. We judged the overall risk of bias of the two included studies as unclear. For the outcome total consumption of fat, a reduction of 41.8 grams per week per person in a household (P < 0.001) was estimated. For the consumption of saturated fat, one study reported a reduction of 4.2% from minced beef sales, a reduction of 5.8% from cream sales, and an increase of 0.5% to sour cream sales (no measures of statistical precision were reported for these estimates). These estimates are based on a restricted number of food types and derived from sales data; they do not measure individual intake. Moreover, these estimates do not account for other relevant sources of fat intake (e.g. packaged or processed food) or other food outlets (e.g. restaurants or cafeterias); hence, we judged the evidence on the effect of taxation on total fat consumption or saturated fat consumption to be very uncertain. We did not identify evidence on the effect of the intervention on energy intake or the incidence or prevalence of overweight or obesity. AUTHORS' CONCLUSIONS: Given the very low quality of the evidence currently available, we are unable to reliably establish whether a tax on total fat or saturated fat is effective or ineffective in reducing consumption of total fat or saturated fat. There is currently no evidence on the effect of a tax on total fat or saturated fat on total energy intake or energy intake through saturated fat or total fat, or preventing the incidence or reducing the prevalence of overweight or obesity.

Taxation of unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes.

BACKGROUND: Global prevalence of overweight and obesity are alarming. For tackling this public health problem, preventive public health and policy actions are urgently needed. Some countries implemented food taxes in the past and some were subsequently abolished. Some countries, such as Norway, Hungary, Denmark, Bermuda, Dominica, St. Vincent and the Grenadines, and the Navajo Nation (USA), specifically implemented taxes on unprocessed sugar and sugar-added foods. These taxes on unprocessed sugar and sugar-added foods are fiscal policy interventions, implemented to decrease their consumption and in turn reduce adverse health-related, economic and social effects associated with these food products. OBJECTIVES: To assess the effects of taxation of unprocessed sugar or sugar-added foods in the general population on the consumption of unprocessed sugar or sugar-added foods, the prevalence and incidence of overweight and obesity, and the prevalence and incidence of other diet-related health outcomes. SEARCH METHODS: We searched CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Embase and 15 other databases and trials registers on 12 September 2019. We handsearched the reference list of all records of included studies, searched websites of international organisations and institutions, and contacted review advisory group members to identify planned, ongoing or unpublished studies. SELECTION CRITERIA: We included studies with the following populations: children (0 to 17 years) and adults (18 years or older) from any country and setting. Exclusion applied to studies with specific subgroups, such as people with any disease who were overweight or obese as a side-effect of the disease. The review included studies with taxes on or artificial increases of selling prices for unprocessed sugar or food products that contain added sugar (e.g. sweets, ice cream, confectionery, and bakery products), or both, as intervention, regardless of the taxation level or price increase. In line with Cochrane Effective Practice and Organisation of Care (EPOC) criteria, we included randomised controlled trials (RCTs), cluster-randomised controlled trials (cRCTs), non-randomised controlled trials (nRCTs), controlled before-after (CBA) studies, and interrupted time series (ITS) studies. We included controlled studies with more than one intervention or control site and ITS studies with a clearly defined intervention time and at least three data points before and three after the intervention. Our primary outcomes were consumption of unprocessed sugar or sugar-added foods, energy intake, overweight, and obesity. Our secondary outcomes were substitution and diet, expenditure, demand, and other health outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all eligible records for inclusion, assessed the risk of bias, and performed data extraction.Two review authors independently assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We retrieved a total of 24,454 records. After deduplicating records, 18,767 records remained for title and abstract screening. Of 11 potentially relevant studies, we included one ITS study with 40,210 household-level observations from the Hungarian Household Budget and Living Conditions Survey. The baseline ranged from January 2008 to August 2011, the intervention was implemented on September 2011, and follow-up was until December 2012 (16 months). The intervention was a tax - the so-called 'Hungarian public health product tax' - on sugar-added foods, including selected foods exceeding a specific sugar threshold value. The intervention includes co-interventions: the taxation of sugar-sweetened beverages (SSBs) and of foods high in salt or caffeine. The study provides evidence on the effect of taxing foods exceeding a specific sugar threshold value on the consumption of sugar-added foods. After implementation of the Hungarian public health product tax, the mean consumption of taxed sugar-added foods (measured in units of kg) decreased by 4.0% (standardised mean difference (SMD) -0.040, 95% confidence interval (CI) -0.07 to -0.01; very low-certainty evidence). The study was at low risk of bias in terms of performance bias, detection bias and reporting bias, with the shape of effect pre-specified and the intervention unlikely to have any effect on data collection. The study was at unclear risk of attrition bias and at high risk in terms of other bias and the independence of the intervention. We rated the certainty of the evidence as very low for the primary and secondary outcomes. The Hungarian public health product tax included a tax on sugar-added foods but did not include a tax on unprocessed sugar. We did not find eligible studies reporting on the taxation of unprocessed sugar. No studies reported on the primary outcomes of consumption of unprocessed sugar, energy intake, overweight, and obesity. No studies reported on the secondary outcomes of substitution and diet, demand, and other health outcomes. No studies reported on differential effects across population subgroups. We could not perform meta-analyses or pool study results. AUTHORS' CONCLUSIONS: There was very limited evidence and the certainty of the evidence was very low. Despite the reported reduction in consumption of taxed sugar-added foods, we are uncertain whether taxing unprocessed sugar or sugar-added foods has an effect on reducing their consumption and preventing obesity or other adverse health outcomes. Further robustly conducted studies are required to draw concrete conclusions on the effectiveness of taxing unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes.

The cumulative effect of living with disability on mental health in working-age adults: an analysis using marginal structural models.

PURPOSE: Previous studies have shown that acquiring a disability is associated with a reduction in mental health, but they have not considered the cumulative impact of having a disability on mental health. We used acquisition of a non-psychological disability to estimate the association of each additional year lived with disability on mental health (measured using the Mental Component Summary score of the Short Form Health Survey). METHODS: We used the first 13 waves of data (years 2001-2013) from the Household, Income and Labour Dynamics in Australia Survey. The sample included 4113 working-age (18-65 years) adults who were disability-free at waves 1 and 2. We fitted marginal structural models with inverse probability weights to estimate the association of each additional year of living with disability on mental health, employing multiple imputation to handle the missing data. RESULTS: Of the 4113 participants, 7.7 percent acquired a disability. On average, each additional year lived with disability was associated with a decrease in the mean Mental Component Summary score (ß = - 0.42; 95% CI - 0.71, - 0.14). CONCLUSIONS: This study provides evidence that each additional year lived with non-psychological disability is associated with a decline in mental health among working-age Australians.

Exercise programmes to prevent falls among older adults: modelling health gain, cost-utility and equity impacts.

BACKGROUND: Some falls prevention interventions for the older population appear cost-effective, but there is uncertainty about others. Therefore, we aimed to model three types of exercise programme each running for 25 years among 65+ year olds: (i) a peer-led group-based one; (ii) a home-based one and (iii) a commercial one. METHODS: An established Markov model for studying falls prevention in New Zealand (NZ) was adapted to estimate incremental cost-effectiveness ratios (ICERs) in cost per quality-adjusted life-years (QALYs) gained. Detailed NZ experimental, epidemiological and cost data were used for the base year 2011. A health system perspective was taken and a discount rate of 3% applied. Intervention effectiveness estimates came from a Cochrane Review. RESULTS: The intervention generating the greatest health gain and costing the least was the home-based exercise programme intervention. Lifetime health gains were estimated at 47 100 QALYs (95%uncertainty interval (UI) 22 300 to 74 400). Cost-effectiveness was high (ICER: US$4640 per QALY gained; (95% UI US$996 to 10 500)), and probably more so than a home safety assessment and modification intervention using the same basic model (ICER: US$6060). The peer-led group-based exercise programme was estimated to generate 42 000 QALYs with an ICER of US$9490. The commercially provided group programme was more expensive and less cost-effective (ICER: US$34 500). Further analyses by sex, age group and ethnicity (Indigenous Maori and non-Maori) for the peer-led group-intervention showed similar health gains and cost-effectiveness. CONCLUSIONS: Implementing any of these three types of exercise programme for falls prevention in older people could produce considerable health gain, but with the home-based version being likely to be the most cost-effective.

Combining fixed effects and instrumental variable approaches for estimating the effect of psychosocial job quality on mental health: evidence from 13 waves of a nationally representative cohort study.

Background: Previous studies suggest that poor psychosocial job quality is a risk factor for mental health problems, but they use conventional regression analytic methods that cannot rule out reverse causation, unmeasured time-invariant confounding and reporting bias. Methods: This study combines two quasi-experimental approaches to improve causal inference by better accounting for these biases: (i) linear fixed effects regression analysis and (ii) linear instrumental variable analysis. We extract 13 annual waves of national cohort data including 13 260 working-age (18-64 years) employees. The exposure variable is self-reported level of psychosocial job quality. The instruments used are two common workplace entitlements. The outcome variable is the Mental Health Inventory (MHI-5). We adjust for measured time-varying confounders. Results: In the fixed effects regression analysis adjusted for time-varying confounders, a 1-point increase in psychosocial job quality is associated with a 1.28-point improvement in mental health on the MHI-5 scale (95% CI: 1.17, 1.40; P < 0.001). When the fixed effects was combined with the instrumental variable analysis, a 1-point increase psychosocial job quality is related to 1.62-point improvement on the MHI-5 scale (95% CI: -0.24, 3.48; P = 0.088). Conclusions: Our quasi-experimental results provide evidence to confirm job stressors as risk factors for mental ill health using methods that improve causal inference.

Transgender Health: New Zealand's Innovative Statistical Standard for Gender Identity.

The implementation of the New Zealand government's recently developed statistical standard for gender identity has led to, and will stimulate further, collection of gender identity data in administrative records, population surveys, and perhaps the census. This will provide important information about the demographics, health service use, and health outcomes of transgender populations to allow evidence-based policy development and service planning. However, the standard does not promote the two-question method, risking misclassification and undercounts; does promote the use of the ambiguous response category "gender diverse" in standard questions; and is not intersex inclusive. Nevertheless, the statistical standard provides a first model for other countries and international organizations, including United Nations agencies, interested in policy tools for improving transgender people's health.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries.

BACKGROUND: Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age or HIV infection) are a type of social protection intervention that addresses a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided so long as the recipient engages in prescribed behaviours such as using a health service or attending school) is unknown. OBJECTIVES: To assess the effects of UCTs for improving health services use and health outcomes in vulnerable children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure and to compare to effects of UCTs versus CCTs. SEARCH METHODS: We searched 17 electronic academic databases, including the Cochrane Public Health Group Specialised Register, the Cochrane Database of Systematic Reviews (the Cochrane Library 2017, Issue 5), MEDLINE and Embase, in May 2017. We also searched six electronic grey literature databases and websites of key organisations, handsearched key journals and included records, and sought expert advice. SELECTION CRITERIA: We included both parallel group and cluster-randomised controlled trials (RCTs), quasi-RCTs, cohort and controlled before-and-after (CBAs) studies, and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (18 years or older) in LMICs. Comparison groups received either no UCT or a smaller UCT. Our primary outcomes were any health services use or health outcome. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened potentially relevant records for inclusion criteria, extracted data and assessed the risk of bias. We tried to obtain missing data from study authors if feasible. For cluster-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method with random effects. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS: We included 21 studies (16 cluster-RCTs, 4 CBAs and 1 cohort study) involving 1,092,877 participants (36,068 children and 1,056,809 adults) and 31,865 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative synthesis. The 17 types of UCTs we identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 53.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT, and three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection and/or performance bias). Most studies were funded by national governments and/or international organisations.Throughout the review, we use the words 'probably' to indicate moderate-quality evidence, 'may/maybe' for low-quality evidence, and 'uncertain' for very low-quality evidence. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09, P = 0.07, 5 cluster-RCTs, N = 4972, I² = 2%, low-quality evidence). At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (odds ratio (OR) 0.73, 95% CI 0.57 to 0.93, 5 cluster-RCTs, N = 8446, I² = 57%, moderate-quality evidence). Evidence from five cluster-RCTs on food security was too inconsistent to be combined in a meta-analysis, but it suggested that at 13 to 24 months' follow-up, UCTs could increase the likelihood of having been food secure over the previous month (low-quality evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01, 4 cluster-RCTs, N = 9347, I² = 79%, low-quality evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. No evidence was available on the effect of a UCT on the likelihood of having died. UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.03 to 1.09, 6 cluster-RCTs, N = 4800, I² = 0%, moderate-quality evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, extreme poverty, participation in child labour, adult employment or parenting quality. Evidence from six cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 24 months into the intervention (low-quality evidence). The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services, the likelihood of having had any illness or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three. AUTHORS' CONCLUSIONS: This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), one social determinant of health (i.e. the likelihood of attending school), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Invited Commentary: Using Financial Credits as Instrumental Variables for Estimating the Causal Relationship Between Income and Health.

Social epidemiologists are interested in determining the causal relationship between income and health. Natural experiments in which individuals or groups receive income randomly or quasi-randomly from financial credits (e.g., tax credits or cash transfers) are increasingly being analyzed using instrumental variable analysis. For example, in this issue of the Journal, Hamad and Rehkopf (Am J Epidemiol. 2016;183(9):775-784) used an in-work tax credit called the Earned Income Tax Credit as an instrument to estimate the association between income and child development. However, under certain conditions, the use of financial credits as instruments could violate 2 key instrumental variable analytic assumptions. First, some financial credits may directly influence health, for example, through increasing a psychological sense of welfare security. Second, financial credits and health may have several unmeasured common causes, such as politics, other social policies, and the motivation to maximize the credit. If epidemiologists pursue such instrumental variable analyses, using the amount of an unconditional, universal credit that an individual or group has received as the instrument may produce the most conceptually convincing and generalizable evidence. However, other natural income experiments (e.g., lottery winnings) and other methods that allow better adjustment for confounding might be more promising approaches for estimating the causal relationship between income and health.

Using Marginal Structural Modeling to Estimate the Cumulative Impact of an Unconditional Tax Credit on Self-Rated Health.

In previous studies, researchers estimated short-term relationships between financial credits and health outcomes using conventional regression analyses, but they did not account for time-varying confounders affected by prior treatment (CAPTs) or the credits' cumulative impacts over time. In this study, we examined the association between total number of years of receiving New Zealand's Family Tax Credit (FTC) and self-rated health (SRH) in 6,900 working-age parents using 7 waves of New Zealand longitudinal data (2002-2009). We conducted conventional linear regression analyses, both unadjusted and adjusted for time-invariant and time-varying confounders measured at baseline, and fitted marginal structural models (MSMs) that more fully adjusted for confounders, including CAPTs. Of all participants, 5.1%-6.8% received the FTC for 1-3 years and 1.8%-3.6% for 4-7 years. In unadjusted and adjusted conventional regression analyses, each additional year of receiving the FTC was associated with 0.033 (95% confidence interval (CI): -0.047, -0.019) and 0.026 (95% CI: -0.041, -0.010) units worse SRH (on a 5-unit scale). In the MSMs, the average causal treatment effect also reflected a small decrease in SRH (unstabilized weights: ß = -0.039 unit, 95% CI: -0.058, -0.020; stabilized weights: ß = -0.031 unit, 95% CI: -0.050, -0.007). Cumulatively receiving the FTC marginally reduced SRH. Conventional regression analyses and MSMs produced similar estimates, suggesting little bias from CAPTs.

Home safety assessment and modification to reduce injurious falls in community-dwelling older adults: cost-utility and equity analysis.

BACKGROUND: This study aimed to improve on previous modelling work to determine the health gain, cost-utility and health equity impacts from home safety assessment and modification (HSAM) for reducing injurious falls in older people. METHODS: The model was a Markov macrosimulation one that estimated quality-adjusted life-years (QALYs) gained. The setting was a country with detailed epidemiological and cost data (New Zealand (NZ)) for 2011. A health system perspective was taken and a discount rate of 3% was used (for both health gain and costs). Intervention effectiveness estimates came from a Cochrane systematic review and NZ-specific intervention costs were from a randomised controlled trial. RESULTS: In the 65 years and above age group, the HSAM programme cost a total of US$98 million (95% uncertainty interval (UI) US$65 to US$139 million) to implement nationally and the accrued net health system costs were US$74 million (95% UI: cost saving to US$132 million). Health gains were 34 000 QALYs (95% UI: 5000 to 65 000). The incremental cost-effectiveness ratio (ICER) was US$6000 (95% UI: cost saving to US$13 000), suggesting that HSAM is highly cost-effective. Targeting HSAM only to older people with previous injurious falls and to older people aged 75 years and above were also cost-effective (ICERs=US$1000 and US$11 000, respectively). There was no evidence for differential cost-effectiveness by gender or by ethnicity (Indigenous New Zealanders: Maori vs non-Maori). CONCLUSIONS: As per other studies, this modelling study indicates that the provision of an HSAM intervention produces considerable health gain and is highly cost-effective among older people. Targeting this intervention to older people with previous injurious falls is a promising initial approach before any scale up. TRIAL REGISTRATION NUMBER: ACTRN12609000779279.

Climate change, cash transfers and health.

The forecast consequences of climate change on human health are profound, especially in low- and middle-income countries and among the most disadvantaged populations. Innovative policy tools are needed to address the adverse health effects of climate change. Cash transfers are established policy tools for protecting population health before, during and after climate-related disasters. For example, the Ethiopian Productive Safety Net Programme provides cash transfers to reduce food insecurity resulting from droughts. We propose extending cash transfer interventions to more proactive measures to improve health in the context of climate change. We identify promising cash transfer schemes that could be used to prevent the adverse health consequences of climatic hazards. Cash transfers for using emission-free, active modes of transport - e.g. cash for cycling to work - could prevent future adverse health consequences by contributing to climate change mitigation and, at the same time, improving current population health. Another example is cash transfers provided to communities that decide to move to areas in which their lives and health are not threatened by climatic disasters. More research on such interventions is needed to ensure that they are effective, ethical, equitable and cost-effective.

Les conséquences attendues du changement climatique sur la santé humaine sont importantes, en particulier dans les pays à revenu faible et intermédiaire et pour les populations les plus défavorisées. Des moyens d'intervention innovants sont nécessaires pour lutter contre les effets néfastes du changement climatique sur la santé. Les transferts d'argent sont des moyens d'intervention éprouvés pour protéger la santé de la population avant, pendant et après les catastrophes climatiques. Le Programme de création de dispositifs de sécurité productifs de l'Éthiopie, par exemple, prévoit des transferts d'argent pour réduire l'insécurité alimentaire découlant des périodes de sécheresse. Nous proposons d'inclure les opérations de transfert d'argent dans des actions plus préventives en vue d'améliorer la santé dans le contexte du changement climatique. Nous avons identifié différents systèmes de transfert d'argent prometteurs qui pourraient être utilisés pour éviter les conséquences néfastes des risques liés au climat sur la santé. Les transferts d'argent visant l'utilisation de moyens de transport actifs et sans émissions ­ pour se rendre au travail à vélo par ex. ­ pourraient prévenir les futures conséquences néfastes sur la santé en contribuant à l'atténuation du changement climatique et en améliorant ainsi l'état actuel de la santé de la population. Un autre exemple concerne les transferts d'argent accordés aux communautés qui décident de s'établir dans des régions où leur vie et leur santé ne sont pas menacées par des catastrophes climatiques. Davantage de recherches sur ces opérations sont nécessaires pour prouver leur efficacité, leur caractère éthique et équitable ainsi que leur rentabilité.

Las consecuencias previstas del cambio climático en la salud humana son severas, especialmente en los países de ingresos bajos y medios y entre los grupos más desfavorecidos. Se necesitan instrumentos normativos innovadoras para afrontar los efectos adversos sobre la salud que el cambio climático produce. Las transferencias de efectivo son instrumentos normativos establecidos para proteger la salud de la población antes, durante y después de los desastres relacionados con el clima. Por ejemplo, el Programa "Red de Seguridad Productiva" de Etiopía proporciona transferencias de efectivo para reducir la inseguridad alimentaria derivada de las sequías. Nosotros proponemos extender las intervenciones de transferencias de efectivo a medidas más proactivas para mejorar la salud en el contexto del cambio climático. Identificamos planes prometedores de transferencia de efectivo que podrían utilizarse para prevenir las consecuencias adversas sobre la salud provocadas por los riesgos climáticos. Las transferencias de efectivo para usar modos de transporte activos y libres de emisiones (por ejemplo, dinero para ir al trabajo en bicicleta) podrían prevenir futuras consecuencias adversas sobre la salud, contribuyendo a la mitigación del cambio climático y, al mismo tiempo, mejorando la salud actual de la población. Otro ejemplo son las transferencias de efectivo realizadas a comunidades que deciden trasladarse a zonas dónde sus vidas y su salud no estén amenazadas por los desastres climáticos. Es necesario llevar a cabo más investigaciones en estas intervenciones para garantizar que sean efectivas, éticas, equitativas y costoefectivas.

The case for the World Health Organization's Commission on Social Determinants of Health to address gender identity.

We analyzed the case of the World Health Organization's Commission on Social Determinants of Health, which did not address gender identity in their final report. We argue that gender identity is increasingly being recognized as an important social determinant of health (SDH) that results in health inequities. We identify right to health mechanisms, such as established human rights instruments, as suitable policy tools for addressing gender identity as an SDH to improve health equity. We urge the World Health Organization to add gender identity as an SDH in its conceptual framework for action on the SDHs and to develop and implement specific recommendations for addressing gender identity as an SDH.

Unconditional cash transfers for assistance in humanitarian disasters: effect on use of health services and health outcomes in low- and middle-income countries.

BACKGROUND: Unconditional cash transfers (UCTs) are a common social protection intervention that increases income, a key social determinant of health, in disaster contexts in low- and middle-income countries (LMICs). OBJECTIVES: To assess the effects of UCTs in improving health services use, health outcomes, social determinants of health, health care expenditure, and local markets and infrastructure in LMICs. We also compared the relative effectiveness of UCTs delivered in-hand with in-kind transfers, conditional cash transfers, and UCTs paid through other mechanisms. SEARCH METHODS: We searched 17 academic databases, including the Cochrane Public Health Group Specialised Register, the Cochrane Database of Systematic Reviews (The Cochrane Library 2014, Issue 7), MEDLINE, and EMBASE between May and July 2014 for any records published up until 4 May 2014. We also searched grey literature databases, organisational websites, reference lists of included records, and academic journals, as well as seeking expert advice. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials (RCTs), as well as cohort, interrupted time series, and controlled before-and-after studies (CBAs) on UCTs in LMICs. Primary outcomes were the use of health services and health outcomes. DATA COLLECTION AND ANALYSIS: Two authors independently screened all potentially relevant records for inclusion criteria, extracted the data, and assessed the included studies' risk of bias. We requested missing information from the study authors. MAIN RESULTS: Three studies (one cluster-RCT and two CBAs) comprising a total of 13,885 participants (9640 children and 4245 adults) as well as 1200 households in two LMICs (Nicaragua and Niger) met the inclusion criteria. They examined five UCTs between USD 145 and USD 250 (or more, depending on household characteristics) that were provided by governmental, non-governmental or research organisations during experiments or pilot programmes in response to droughts. Two studies examined the effectiveness of UCTs, and one study examined the relative effectiveness of in-hand UCTs compared with in-kind transfers and UCTs paid via mobile phone. Due to the methodologic limitations of the retrieved records, which carried a high risk of bias and very serious indirectness, we considered the body of evidence to be of very low overall quality and thus very uncertain across all outcomes.Depending on the specific health services use and health outcomes examined, the included studies either reported no evidence that UCTs had impacted the outcome, or they reported that UCTs improved the outcome. No single outcome was reported by more than one study. There was a very small increase in the proportion of children who received vitamin or iron supplements (mean difference (MD) 0.10 standard deviations (SDs), 95% confidence interval (CI) 0.06 to 0.14) and on the child's home environment, as well as clinically meaningful, very large reductions in the chance of child death (hazard ratio (HR) 0.26, 95% CI 0.10 to 0.66) and the incidence of severe acute malnutrition (HR 0.44, 95% CI 0.24 to 0.80). There was also a moderate reduction in the number of days children spent sick in bed (MD - 0.36 SDs, 95% CI - 0.62 to - 0.10). There was no evidence for any effect on the proportion of children receiving deworming drugs, height for age among children, adults' level of depression, or the quality of parenting behaviour. No adverse effects were identified. The included comparisons did not examine several important outcomes, including food security and equity impacts.With regard to the relative effectiveness of UCTs compared with a food transfer providing a relatively high total caloric value, there was no evidence that a UCT had any effect on the chance of child death (HR 2.27, 95% CI 0.69 to 7.44) or severe acute malnutrition (HR 1.15, 95% CI 0.67 to 1.99). A UCT paid in-hand led to a clinically meaningful, moderate increase in the household dietary diversity score, compared with the same UCT paid via mobile phone (difference-in-differences estimator 0.43 scores, 95% CI 0.06 to 0.80), but there was no evidence for an effect on social determinants of health, health service expenditure, or local markets and infrastructure. AUTHORS' CONCLUSIONS: Additional high-quality evidence (especially RCTs of humanitarian disaster contexts other than droughts) is required to reach clear conclusions regarding the effectiveness and relative effectiveness of UCTs for improving health services use and health outcomes in humanitarian disasters in LMICs.

In-work tax credits for families and their impact on health status in adults.

BACKGROUND: By improving two social determinants of health (poverty and unemployment) in low- and middle-income families on or at risk of welfare, in-work tax credit for families (IWTC) interventions could impact health status and outcomes in adults. OBJECTIVES: To assess the effects of IWTCs on health outcomes in working-age adults (18 to 64 years). SEARCH METHODS: We searched 16 electronic academic databases, including the Cochrane Public Health Group Specialised Register, Cochrane Database of Systematic Reviews (The Cochrane Library 2012, Issue 7), MEDLINE and EMBASE, as well as six grey literature databases between July and September 2012 for records published between January 1980 and July 2012. We also searched key organisational websites, handsearched reference lists of included records and relevant journals, and contacted academic experts. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials and cohort, controlled before-and-after (CBA) and interrupted time series (ITS) studies of IWTCs in working-age adults. Included primary outcomes were: self rated general health; mental health/psychological distress; mental illness; overweight/obesity; alcohol use and tobacco use. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias in included studies. We contacted study authors to obtain missing information. MAIN RESULTS: Five studies (one CBA and four ITS) comprising a total of 5,677,383 participants (all women) fulfilled the inclusion criteria and were synthesised narratively. The in-work tax credit intervention assessed in all included studies is the permanent Earned Income Tax Credit in the United States, established in 1975. This intervention distributed nearly USD 62 billion to over 27 million individuals in 2011, and its administration costs were less than one per cent of its total costs. All included studies carried a high risk of bias (especially from confounding and insufficient control for underlying time trends). Due to the small number of (observational) studies and their high risk of bias, we judged this body of evidence to have very low overall quality.One study found that IWTC had no detectable effect on self rated general health and mental health/psychological distress five years after its implementation (i.e. a considerable change in the generosity of the permanent IWTC) and on overweight/obesity eight years after implementation. One study found no effect of IWTC on tobacco use five years after implementation, one a moderate reduction in tobacco use one year after implementation (odds ratio 0.95, 95% confidence interval (CI) 0.94 to 0.96), and one differential effects, with no effect in African-Americans and a large reduction in European-Americans two years after implementation (risk difference -11.1%, 95% CI -20.9% to -1.3%). No evidence was available for the effect of IWTC on mental illness and alcohol use. No adverse effects of IWTC were identified.One study also found no detectable effect of IWTC on the number of bad physical health days and of risky biomarkers for inflammation, cardiovascular disease and metabolic conditions eight years after implementation. One study found that IWTC had a large, positive effect on income from wages or salaries one year after implementation. Two studies found no effect on employment two and five years after implementation, whereas two found a moderate increase five and eight years after implementation and one a large increase in employment due to IWTC one year after implementation.No differences in outcomes between groups with different educational status were found for self rated health and mental health/psychological distress. In one study European-American women with lower levels of education were more likely to reduce tobacco use, while tobacco use did not change among African-American women with lower levels of education. However, no differences in tobacco use by educational status were observed in a second study. Two studies found that the intervention may have reduced inequity with respect to employment, where women with less education were more likely to move into employment (although one did not establish whether this difference was statistically significant), while two studies found no such difference and no studies found differences by ethnic group on employment rates. AUTHORS' CONCLUSIONS: In summary, the small and methodologically limited existing body of evidence with a high risk of bias provides no evidence for an effect of in-work tax credit for families interventions on health status (except for mixed evidence for tobacco smoking) in adults.

Global, regional and national burdens of non-melanoma skin cancer attributable to occupational exposure to solar ultraviolet radiation for 183 countries, 2000-2019: A systematic analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: A World Health Organization (WHO) and International Labour Organization (ILO) systematic review reported sufficient evidence for higher risk of non-melanoma skin cancer (NMSC) amongst people occupationally exposed to solar ultraviolet radiation (UVR). This article presents WHO/ILO Joint Estimates of global, regional, national and subnational occupational exposures to UVR for 195 countries/areas and the global, regional and national attributable burdens of NMSC for 183 countries, by sex and age group, for the years 2000, 2010 and 2019. METHODS: We calculated population-attributable fractions (PAFs) from estimates of the population occupationally exposed to UVR and the risk ratio for NMSC from the WHO/ILO systematic review. Occupational exposure to UVR was modelled via proxy of occupation with outdoor work, using 166 million observations from 763 cross-sectional surveys for 96 countries/areas. Attributable NMSC burden was estimated by applying the PAFs to WHO's estimates of the total NMSC burden. Measures of inequality were calculated. RESULTS: Globally in 2019, 1.6 billion workers (95 % uncertainty range [UR] 1.6-1.6) were occupationally exposed to UVR, or 28.4 % (UR 27.9-28.8) of the working-age population. The PAFs were 29.0 % (UR 24.7-35.0) for NMSC deaths and 30.4 % (UR 29.0-31.7) for disability-adjusted life years (DALYs). Attributable NMSC burdens were 18,960 deaths (UR 18,180-19,740) and 0.5 million DALYs (UR 0.4-0.5). Men and older age groups carried larger burden. Over 2000-2019, attributable deaths and DALYs almost doubled. CONCLUSIONS: WHO and the ILO estimate that occupational exposure to UVR is common and causes substantial, inequitable and growing attributable burden of NMSC. Governments must protect outdoor workers from hazardous exposure to UVR and attributable NMSC burden and inequalities.