Effects of public policies in the prevention of cardiovascular diseases: a systematic review of global literature.

OBJECTIVES: Given the growing interest worldwide in applying public policies to improve human health, we undertook a systematic review of studies investigating whether public policies targeting unhealthy products could reduce cardiovascular diseases. STUDY DESIGN: This study was a systematic review of the literature. METHODS: We searched research studies published in 2000-2020 from major databases, including MEDLINE and Embase. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and narratively synthesized the studies based on vote counting and direction of the intervention effect. RESULTS: Ninety-eight studies, mostly from high-income countries, met the inclusion criteria. Most studies were on public policies targeting sugar-sweetened beverages and tobacco, followed by alcohol, sugar, salt, and junk foods. Overall, many reported that several fiscal, regulatory, and educational policies generated beneficial effects of reducing the diseases. Those studies that reported no or limited effects highlighted several sociodemographic and health risk characteristics and design and implementation aspects of the policy interventions as factors limiting the policy effects; most of these are modifiable with appropriate policy interventions. For instance, low magnitude of tax, substitution with other unhealthy products, firms' competitive response strategies, pre-existence of smoking bans, incremental enactment of smoking regulations, degree of enforcement, and various sociocultural factors minimized the effects of the policies. CONCLUSION: The literature supports a growing consensus on the beneficial effects of public policy for improving human health. The design and implementation of public policies must address various impeding factors and incorporate appropriate remedial measures. Further research is needed from low- and middle-income countries and on whether and how multiple policy instruments work in tandem.

A lesson from history? Worsening mortality and the rise of the Nazi Party in 1930s Germany.

OBJECTIVES: The aim of the study was to test the hypothesis that worsening mortality rates in the early 1930s were associated with increasing votes for the Nazi Party. STUDY DESIGN: The study consist of panel data with fixed effects. METHODS: We used district- and city-level regression models of Nazi vote shares on changes in all-cause mortality rates in 866 districts and 214 cities during federal elections from 1930 to 1933, adjusting for election and district/city-level fixed effects and sociodemographic factors. As a falsification test, we used a subset of deaths less susceptible to sociopolitical factors. RESULTS: Historical downward trends in mortality rates reversed in the early 1930s in Germany. At the district/city level, these increases were positively associated with a rising Nazi vote share. Each increase of 10 deaths per 1000 population was associated with a 6.51-percentage-point increase in Nazi vote share (95% confidence interval = 1.17-11.8). The strongest associations were with deaths due to infectious and communicable diseases, suicides, and alcohol-related deaths. Worsening mortality had no association with votes for the Communist Party or for other contemporary political parties. Greater welfare payments were associated with smaller increases in both mortality and Nazi vote share, and adjusting for welfare generosity mitigated the association by approximately one-third. CONCLUSIONS: Worsening mortality rates were positively associated with the rise of the Nazi Party in 1930s Germany. Social security mitigated the association between mortality and Nazi vote share. Our findings add to the growing evidence that population health declines can be a 'canary in the coal mine' for the health of democracies.

Globalization and health policy space: Introducing the WTOhealth dataset of trade challenges to national health regulations at World Trade Organization, 1995-2016.

Do international trade rules and agreements constrain health policy space? A multitude of global actors and institutions with different interests and power can shape national health policy, and trade rules provide one means through which to exert pressure on governments. Yet, the full scope of political pressure on health policy within the global trade regime is insufficiently understood, as previous research largely focussed on challenges to food, alcohol, and tobacco regulations and used small-N case studies. This potentially overlooks other domains of influence and we lack an understanding of quantitative trends and patterns therein. In this article we introduce a novel dataset, WTOhealth, comprising all challenges to national health regulations at the WTO Technical Barriers to Trade (TBT) Committee between 1995 and 2016. The dataset is based on 1496 pages of minutes from 71 TBT meetings. We describe how we developed this dataset and present an exploratory analysis of key patterns within the data. Our analysis shows that WTO members raised 250 trade challenges to health regulations between 1995 and 2016. 83.6% of challenges to low- or lower-middle income country (LMIC) members were raised by high-income countries (HICs). Many challenges centred on food (16.4% challenges), alcohol (10.4%), and tobacco (4.2%) policies, but a substantial proportion concerned other products, including toxic chemicals (9.1%), pharmaceuticals and medical devices (8.1%), machinery (7.8%), and motor vehicles (7.3%). This includes measures targeting medical device safety, increased access to pharmaceuticals, and reduced exposure to toxins harmful to both health and the environment. We further examine these challenges, finding that HIC members made claims with contentious scientific support. In short, diverse health regulations may be changed or delayed following contentious challenges at the TBT Committee. There is a need for further research investigating the nature and influence of WTO challenges to diverse health regulations.

Does retirement trigger depressive symptoms? A systematic review and meta-analysis.

AIMS: Retirement is a major life transition that may improve or worsen mental health, including depression. Existing studies provide contradictory results. We conducted a systematic review with meta-analysis to quantitatively pool available evidence on the association of retirement and depressive symptoms. METHODS: We applied PRISMA guidelines to conduct a systematic review and meta-analysis to retrieve, quantitatively pool and critically evaluate the association between retirement and both incident and prevalent depression and to understand better the potential role of individual and contextual-level determinants. Relevant original studies were identified by searching PubMed, Embase, PsycINFO and the Cochrane Library, through 4 March 2021. Subgroup and sensitivity meta-analyses were conducted by gender, study design (longitudinal v. cross-sectional studies), study quality score (QS) and considering studies using validated scales to diagnose depression. Heterogeneity between studies was evaluated with I2 statistics. RESULTS: Forty-one original studies met our a priori defined inclusion criteria. Meta-analysis on more than half a million subjects (n = 557 111) from 60 datasets suggested a protective effect of retirement on the risk of depression [effect size (ES) = 0.83, 95% confidence interval (CI) = 0.74-0.93], although with high statistical heterogeneity between risk estimates (χ2 = 895.19, df = 59, I2 = 93.41%, p-value < 0.0001). Funnel plot asymmetry and trim and fill method suggested a minor potential publication bias. Results were consistent, confirm their robustness and suggest stronger protective effects when progressively restricting the included studies based on quality criteria: (i) studies with the highest QS [55 datasets, 407 086 subjects, ES = 0.81, 95% CI = 0.71-0.91], (ii) studies with a high QS and using validated assessment tools to diagnose depression (44 datasets, 239 453 subjects, ES = 0.76, 95% CI = 0.65-0.88) and (iii) studies of high quality, using a validated tool and with a longitudinal design (24 datasets, 162 004 subjects, ES = 0.76, 95% CI = 0.64-0.90). We observed a progressive reduction in funnel plot asymmetry. About gender, no statistically significant difference was found (females ES = 0.79, 95% CI = 0.61-1.02 v. men ES = 0.87, 95% CI = 0.68-1.11). CONCLUSIONS: Pooled data suggested that retirement reduces by nearly 20% the risk of depression; such estimates got stronger when limiting the analysis to longitudinal and high-quality studies, even if results are affected by high heterogeneity.As retirement seems to have an independent and protective effect on mental health and depressive symptoms, greater flexibility in retirement timing should be granted to older workers to reduce their mental burden and avoid the development of severe depression. Retirement may also be identified as a target moment for preventive interventions, particularly primary and secondary prevention, to promote health and wellbeing in older ages, boosting the observed impact.

Self-reported access to health care, communicable diseases, violence and perception of legal status among online transgender identifying sex workers in the UK.

OBJECTIVES: Transgender-identifying sex workers (TGISWs) are among the most vulnerable groups but are rarely the focus of health research. Here we evaluated perceived barriers to healthcare access, risky sexual behaviours and exposure to violence in the United Kingdom (UK), based on a survey of all workers on BirchPlace, the main transgender sex commerce website in the UK. STUDY DESIGN: The study design used in the study is an opt-in text-message 12-item questionnaire. METHODS: Telephone contacts were harvested from BirchPlace's website (n = 592 unique and active numbers). The questionnaire was distributed with Qualtrics software, resulting in 53 responses. RESULTS: Our survey revealed significant reported barriers to healthcare access, exposure to risky sexual behaviours and to physical violence. Many transgender sex workers reportedly did not receive a sexual screening, and 28% engaged in condomless penetrative sex within the preceding six months, and 68% engaged in condomless oral sex. 17% responded that they felt unable to access health care they believed medically necessary. Half of the participants suggested their quality of life would be improved by law reform. CONCLUSIONS: TGISWs report experiencing a high level of risky sexual behaviour, physical violence and inadequate healthcare access. Despite a National Health System, additional outreach may be needed to ensure access to services by this population.

Population uptake and effectiveness of test-and-treat antiretroviral therapy guidelines for preventing the global spread of HIV: an ecological cross-national analysis.

OBJECTIVES: Although the benefits of adopting test-and-treat antiretroviral therapy (ART) guidelines that recommend initiation of ART regardless of CD4 cell counts have been demonstrated at the individual level, there is uncertainty about how this translates to the population level. Here, we explored whether adopting ART guidelines recommending earlier treatment initiation improves population ART access and viral suppression and reduces overall disease transmission. METHODS: Data on ART initiation guidelines and treatment coverage, viral suppression, and HIV incidence from 37 European and Central Asian countries were collected from the European Centre for Disease Prevention and Control and the Global HIV Policy Watch and HIV 90-90-90 Watch databases. We used multivariate linear regression models to quantify the association of ART initiation guidelines with population ART access, viral suppression, and HIV incidence, adjusting for potential confounding factors. RESULTS: Test-and-treat policies were associated with 15.2 percentage points (pp) [95% confidence interval (CI) 0.8-29.6 pp; P = 0.039] greater treatment coverage (proportion of HIV-positive people on ART) compared with countries with ART initiation at CD4 cell counts ≤ 350 cells/µL. The presence of test-and-treat policies was associated with 15.8 pp (95% CI 2.4-29.1 pp; P = 0.023) higher viral suppression rates (people on ART virally suppressed) compared with countries with treatment initiation at CD4 counts ≤ 350 cells/µL. ART initiation at CD4 counts ≤ 500 cells/µL did not significantly improve ART coverage compared to initiation at CD4 counts ≤ 350 cells/µL but achieved similar degrees of viral suppression as test-and-treat. CONCLUSIONS: Test-and-treat was found to be associated with substantial improvements in population-level access to ART and viral suppression, further strengthening evidence that rapid initiation of treatment will help curb the spread of HIV.

Amenable mortality in the EU-has the crisis changed its course?

Background: Did the global financial crisis and its aftermath impact upon the performance of health systems in Europe? We investigated trends in amenable and other mortality in the EU since 2000 across 28 EU countries. Methods: We use WHO detailed mortality files from 28 EU countries to calculate age-standardized deaths rates from amenable and other causes. We then use joinpoint regression to analyse trends in mortality before and after the onset of the economic crisis in Europe in 2008. Results: Amenable and other mortality have declined in the EU since 2000, albeit faster for amenable mortality. We observed increases in amenable mortality following the global financial crisis for females in Estonia [from -4.53 annual percentage change (APC) in 2005-12 to 0.03 APC in 2012-14] and Slovenia (from -4.22 APC in 2000-13 to 0.73 in 2013-15) as well as males and females in Greece(males: from -2.93 APC in 2000-10 to 0.01 APC in 2010-13; females: from -3.48 APC in 2000-10 to 0.06 APC in 2010-13). Other mortality continued to decline for these populations. Increases in deaths from infectious diseases before and after the crisis played a substantial part in reversals in Estonia, Slovenia and Greece. Conclusion: There is evidence that amenable mortality rose in Greece and, among females in Estonia and Slovenia. However, in most countries, trends in amenable mortality rates appeared to be unaffected by the crisis.

Gender violence, poverty and HIV infection risk among persons engaged in the sex industry: cross-national analysis of the political economy of sex markets in 30 European and Central Asian countries.

OBJECTIVES: Persons engaged in the sex industry are at greater risk of HIV and other sexually transmitted infections than the general population. One major factor is exposure to higher levels of risky sexual activity. Expanding condom use is a critical prevention strategy, but this requires negotiation with those buying sex, which takes place in the context of cultural and economic constraints. Impoverished individuals who fear violence are more likely to forego condoms. METHODS: Here we tested the hypotheses that poverty and fear of violence are two structural drivers of HIV infection risk in the sex industry. Using data from the European Centre for Disease Prevention and Control and the World Bank for 30 countries, we evaluated poverty, measured using the average income per day per person in the bottom 40% of the income distribution, and gender violence, measured using homicide rates in women and the proportion of women exposed to violence in the last 12 months and/or since age 16 years. RESULTS: We found that HIV prevalence among those in the sex industry was higher in countries where there were greater female homicide rates (ß = 0.86; P = 0.018) and there was some evidence that self-reported exposure to violence was also associated with higher HIV prevalence (ß = 1.37; P = 0.043). Conversely, HIV prevalence was lower in countries where average incomes among the poorest were greater (ß = -1.05; P = 0.046). CONCLUSIONS: Our results are consistent with the theory that reducing poverty and exposure to violence may help reduce HIV infection risk among persons engaged in the sex industry.

Tracking search engine queries for suicide in the United Kingdom, 2004-2013.

OBJECTIVES: First, to determine if a cyclical trend is observed for search activity of suicide and three common suicide risk factors in the United Kingdom: depression, unemployment, and marital strain. Second, to test the validity of suicide search data as a potential marker of suicide risk by evaluating whether web searches for suicide associate with suicide rates among those of different ages and genders in the United Kingdom. STUDY DESIGN: Cross-sectional. METHODS: Search engine data was obtained from Google Trends, a publicly available repository of information of trends and patterns of user searches on Google. The following phrases were entered into Google Trends to analyse relative search volume for suicide, depression, job loss, and divorce, respectively: 'suicide'; 'depression + depressed + hopeless'; 'unemployed + lost job'; 'divorce'. Spearman's rank correlation coefficient was employed to test bivariate associations between suicide search activity and official suicide rates from the Office of National Statistics (ONS). RESULTS: Cyclical trends were observed in search activity for suicide and depression-related search activity, with peaks in autumn and winter months, and a trough in summer months. A positive, non-significant association was found between suicide-related search activity and suicide rates in the general working-age population (15-64 years) (ρ = 0.164; P = 0.652). This association is stronger in younger age groups, particularly for those 25-34 years of age (ρ = 0.848; P = 0.002). CONCLUSIONS: We give credence to a link between search activity for suicide and suicide rates in the United Kingdom from 2004 to 2013 for high risk sub-populations (i.e. male youth and young professionals). There remains a need for further research on how Google Trends can be used in other areas of disease surveillance and for work to provide greater geographical precision, as well as research on ways of mitigating the risk of internet use leading to suicide ideation in youth.

'First, do no harm': are disability assessments associated with adverse trends in mental health? A longitudinal ecological study.

BACKGROUND: In England between 2010 and 2013, just over one million recipients of the main out-of-work disability benefit had their eligibility reassessed using a new functional checklist-the Work Capability Assessment. Doctors and disability rights organisations have raised concerns that this has had an adverse effect on the mental health of claimants, but there are no population level studies exploring the health effects of this or similar policies. METHOD: We used multivariable regression to investigate whether variation in the trend in reassessments in each of 149 local authorities in England was associated with differences in local trends in suicides, self-reported mental health problems and antidepressant prescribing rates, while adjusting for baseline conditions and trends in other factors known to influence mental ill-health. RESULTS: Each additional 10,000 people reassessed in each area was associated with an additional 6 suicides (95% CI 2 to 9), 2700 cases of reported mental health problems (95% CI 548 to 4840), and the prescribing of an additional 7020 antidepressant items (95% CI 3930 to 10100). The reassessment process was associated with the greatest increases in these adverse mental health outcomes in the most deprived areas of the country, widening health inequalities. CONCLUSIONS: The programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. This policy may have had serious adverse consequences for mental health in England, which could outweigh any benefits that arise from moving people off disability benefits.

Fit-for-work or fit-for-unemployment? Does the reassessment of disability benefit claimants using a tougher work capability assessment help people into work?

BACKGROUND: Many governments have introduced tougher eligibility assessments for out-of-work disability benefits, to reduce rising benefit caseloads. The UK government initiated a programme in 2010 to reassess all existing disability benefit claimants using a new functional checklist. We investigated whether this policy led to more people out-of-work with long-standing health problems entering employment. METHOD: We use longitudinal data from the Labour Force Survey linked to data indicating the proportion of the population experiencing a reassessment in each of 149 upper tier local authorities in England between 2010 and 2013. Regression models were used to investigate whether the proportion of the population undergoing reassessment in each area was independently associated with the chances that people out-of-work with a long-standing health problem entered employment and transitions between inactivity and unemployment. We analysed whether any effects differed between people whose main health problem was mental rather than physical. RESULTS: There was no significant association between the reassessment process and the chances that people out-of-work with a long-standing illness entered employment. The process was significantly associated with an increase in the chances that people with mental illnesses moved from inactivity into unemployment (HR=1.22, 95% CI 1.03 to 1.45). CONCLUSIONS: The reassessment policy appears to have shifted people with mental health problems from inactivity into unemployment, but there was no evidence that it had increased their chances of employment. There is an urgent need for services that can support the increasing number of people with mental health problems on unemployment benefits.