The health consequences of informal employment among female workers and their children: a systematic review.

BACKGROUND: Informal employment is unprotected and unregistered and it is often characterized by precarious working arrangements. Although being a global phenomenon and the most common type of employment worldwide, scholarly attention to its health effects has only recently accelerated. While there is still some debate, informal employment is generally understood to be detrimental to workers' health. However, because women are more vulnerable to informality than men, attention is required to the health consequences of female workers specifically. We conducted a systematic review with the objective to examine the global evidence on the consequences of informal employment, compared to formal employment, on the health of female workers and their children. METHODS: We searched peer-reviewed literature in Embase, Medline, PsychInfo, Scopus and Web of Science up until November 11, 2022. No restrictions were applied in terms of year, language or country. Individual-level quantitative studies that compared women of reproductive age in informal and formal employment, or their children (≤ 5 years), were eligible for inclusion. If studies reported outcomes per subgroup level, these were included. Study quality was assessed using the Joanna Briggs Institute checklist and a narrative synthesis of the results were conducted. RESULTS: 13 articles were included in the review, looking at breastfeeding outcomes (n = 4), child nutritional status and low birthweight (n = 4), antenatal health (n = 3), and general health outcomes for women (n = 2). The overall evidence from the included studies was that compared to formal employment, there was an association between informal employment and worse health outcomes, especially on child nutritional status and antenatal health. The evidence for breastfeeding outcomes was mixed and showed that informal employment may be both protective and damaging to health. CONCLUSION: This review showed that informal employment is a potential risk factor for health among female workers and their children. Further research on the pathways between informal employment and health is needed to strengthen the understanding of the health consequences of informal employment.

Have COVID-19 Stimulus Packages Mitigated the Negative Health Impacts of Pandemic-Related Job Losses? A Systematic Review of Global Evidence from the First Year of the Pandemic.

Social protection can buffer the negative impacts of unemployment on health. Have stimulus packages introduced during the COVID-19 pandemic mitigated potential harms to health from unemployment? We performed a systematic review of the health effects of job loss during the first year of the pandemic. We searched three electronic databases and identified 49 studies for inclusion. Three United States-based studies found that stimulus programs mitigated the impact of job loss on food security and mental health. Furloughs additionally appeared to reduce negative impacts when they were paid. However, despite the implementation of large-scale stimulus packages to reduce economic harms, we observed a clear pattern that job losses were nevertheless significantly associated with negative impacts, particularly on mental health, quality of life, and food security. We also observe suggestive evidence that COVID-related job loss was associated with child maltreatment, worsening dental health, and poor chronic disease outcomes. Overall, although we did find evidence that income-support policies appeared to help protect people from the negative health consequences of pandemic-related job loss, they were not sufficient to fully offset the threats to health. Future research should ascertain how to ensure adequate access to and generosity of social protection programs during epidemics and economic downturns.

SARS-CoV-2 Gastrointestinal Shedding in Hospitalized Children.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a respiratory virus that can cause gastrointestinal (GI) symptoms, with studies demonstrating detection of stool viral RNA weeks after respiratory tract clearance. It is unknown if children who test negative for SARS-CoV-2 on a nasopharyngeal (NP) swab may be shedding the virus in their stool. OBJECTIVE: To measure the prevalence of SARS-CoV-2 stool shedding in children with positive and negative SARS-CoV-2 NP polymerase chain reactions (PCR) tests, and to determine clinical factors associated with GI shedding. METHODS: In this cross-sectional study, we enrolled hospitalized patients 0 to 21 years old with a positive or a negative SARS-CoV-2 NP PCR test who had respiratory and/or GI symptoms. Participants were surveyed, and stool samples were sent for viral PCR testing. Fisher's exact test was used to evaluate bivariate associations of stool PCR test positivity with categorical variables. RESULTS: Sixty-seven patients were consented; 34 patients did not provide stool samples so 33 patients were included: 17 NP-positive and 16 NP-negative for SARS-CoV-2. Eight of the 17 NP-positive patients had a positive stool PCR test for SARS-CoV-2, while none of the 16 SARS-CoV-2 NP-negative patients had a positive result (P < .01). For the 17 SARS-CoV-2 NP-positive patients, GI symptoms were associated with a positive stool PCR test (P = .05) for SARS-CoV-2, but this association was not found for all 33 patients (P = .11). No associations were found with patients in an immunocompromised state or those with a comorbid condition, fever and/or chills, respiratory symptoms, headache and/or myalgias, or anosmia and/or ageusia. CONCLUSIONS: SARS-CoV-2 GI shedding is common and associated with GI symptoms in NP-positive children, with 47% having positive stool PCRs for SARS-CoV-2. GI shedding was not demonstrated in SARS-CoV-2 NP-negative children.

Effectiveness of a Simulation Curriculum on Clinical Application: A Randomized Educational Trial.

INTRODUCTION: The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules. METHODS: This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury. RESULTS: Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters. CONCLUSIONS: Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.

The Gender Pain Gap: gender inequalities in pain across 19 European countries.

AIMS: Chronic pain is increasingly considered to be an international public health issue, yet gender differences in chronic pain in Europe are under-examined. This work aimed to examine gender inequalities in pain across Europe. METHODS: Data for 27,552 men and women aged 25-74 years in 19 European countries were taken from the social determinants of health module of the European Social Survey (2014). Inequalities in reporting pain were measured by means of adjusted rate differences (ARD) and relative adjusted rate risks (ARR). RESULTS: At the pooled pan-European level, a greater proportion of women (62.3%) reported pain than men (55.5%) (ARD 5.5% (95% confidence intervals (CI) 4.1, 6.9), ARR 1.10 (95% CI 1.08, 1.13)). These inequalities were greatest for back/neck pain (ARD 5.8% (95% CI 4.4, 7.1), ARR 1.15 (95% CI 1.12, 1.19)), but were also significant for hand/arm pain (ARD 4.6% (95% CI 3.5, 5.7), ARR 1.24 (95% CI 1.17, 1.30)) and foot/leg pain (ARD 2.6% (95% CI 1.5, 3.8), ARR 1.12 (95% CI 1.07, 1.18)). There was considerable cross-national variation in gender pain inequalities across European countries. CONCLUSIONS: Significant gender pain inequalities exist across Europe whereby women experience more pain than men. The extent of the gender pain gap varies by country. The gender pain gap is a public health concern and should be considered in future prevention and management strategies.

Precarious employment and health in the context of COVID-19: a rapid scoping umbrella review.

BACKGROUND: There are widespread concerns that workers in precarious employment have suffered the most in the COVID-19 pandemic and merit special attention. The aim of this rapid scoping umbrella review was to examine what evidence exists about how COVID-19 has affected the health of this highly vulnerable group, and what gaps remain to be investigated. METHODS: Five databases were searched for systematic or scoping reviews from January 2020 to May 2021. The quality of the included reviews was determined using A MeaSurement Tool to Assess systematic Reviews. RESULTS: We identified 6 reviews that reported 30 unique relevant primary studies. The included studies indicate that essential (non-health) workers are at greater risk of COVID-19 infection and case fatality than others in their surrounding community. The occupational risk of exposure to COVID-19 also seems to be greater among more precarious categories of workers, including younger workers and workers in low-income and low-skilled occupations. Further, hazardous working conditions faced by many essential workers appear to have amplified the pandemic, as several occupational sites became 'super-spreaders', due to an inability to socially distance at work and high contact rates among workers. Finally, employment and financial insecurity generated by the pandemic appears to be associated with negative mental health outcomes. The quality of the included reviews however, and their primary studies, were generally weak and many gaps remain in the evidence base. CONCLUSIONS: Our study highlights that COVID-19 is creating new health risks for precarious workers as well as exacerbating the pre-existing health risks of precarious employment.

Glossary on free trade agreements and health part 2: new trade rules and new urgencies in the context of COVID-19.

Part 1 of this glossary provided a brief background on the rise of regional/bilateral free trade agreements (FTAs) and described the health implications of new trade obligations that figure prominently in current and recent trade negotiations, focusing on those provisions that build on previous agreements of the World Trade Organization (WTO). This approach continues into part 2 of the glossary, which also considers components of FTAs that have no precedent within WTO treaties. Following a broader discussion of how the current political context and the COVID-19 pandemic shape the contemporary trade environment, part 2 considers the main areas of trade and health policy incoherence as well as recommendations to address them.

Glossary on free trade agreements and health part 1: the shift from multilateralism and the rise of 'WTO-Plus' provisions.

The global trading system has undergone a shift away from multilateral trade negotiations to a 'spaghetti-bowl' of regional and bilateral free trade agreements (FTAs). In this two-part glossary, we discuss why this shift has occurred, focusing on how it poses new challenges for public health. Specifically, we introduce key terms that shape this new trading environment and explain them through a public health lens. Part 1 of this glossary focuses on provisions in FTAs that build on previous agreements of the World Trade Organization (WTO). These provisions are commonly designated as 'WTO-Plus'. This approach continues into part 2 of the glossary, which also considers components of FTAs that have no precedent within WTO treaties. Following a broader discussion of how the current political context and the COVID-19 pandemic shape the contemporary trade environment, part 2 considers the main areas of trade and health policy incoherence as well as recommendations to address them.

The contribution of employment and working conditions to occupational inequalities in non-communicable diseases in Europe.

BACKGROUND: Social inequalities in non-communicable diseases (NCDs) are evident across all European regions. Employment and working conditions are important determinants of NCDs, however, few comparative studies have examined how these conditions contribute to health inequalities. This study therefore examines the association of non-standard employment and poor working conditions with occupational inequalities in multiple NCDs and whether there are differences by gender and across European regions. METHODS: We used cross-sectional data from 20 European countries for women and men aged 25-75 (n = 19 876), from round 7 of the European Social Survey. Data were analyzed for self-rated health (SRH) and 9 NCDs: heart/circulatory problems, high blood pressure, arm/hand pain, breathing problems, diabetes, severe headaches, cancer, obesity and depression. We used logistic regression models, stratified by gender, and adjusted rate ratios to examine whether occupational inequalities in NCDs were reduced after adjusting for non-standard employment and poor working conditions, across European regions. RESULTS: After adjustment, occupational inequalities were significantly reduced across all regions of Europe. Reductions were particularly large among the lowest occupational group and for poor-SRH, depression and obesity. For these conditions, reductions were in the range of 60-99%. CONCLUSIONS: Employment and working conditions are important determinants of occupational inequalities in NCDs. Labour market regulations should therefore be considered in the formulation of NCD prevention strategies.

USMCA 2.0: a few improvements but far from a 'healthy' trade treaty.

The USMCA (NAFTA 2.0), although signed over a year ago, went through several months of renegotiation of certain of its new rules that the Democrat-controlled US Congress wanted altered or strengthened. In December a 'Protocol of Amendment' was agreed upon and signed by the three Parties (the USA, Mexico, and Canada). A number of tough, new measures governing pharmaceuticals were revised or deleted, making it potentially easier for generic competition and lower drug costs in all three countries. Rules on protection of labour rights were also strengthened, lowering the threshold at which a complaint of unfair labour practices could be initiated. Procedures for investigating such a complaint or resolving a formal dispute were also improved. Similar procedural improvements were made on measures affecting environmental protection. These Protocol agreements are more health-positive than health-negative, and in the case of pharmaceuticals are of significant impact. Overall, however, these amendments are simply a political fine-tuning of the agreement. Concerns raised in our earlier health impact assessment of the USMCA, notably how the agreement's regulatory reforms reduce public health policy flexibilities, remain. The agreement continues to subordinate known or potential health costs of many of its measures to dubious claims of aggregate economic gains. Moreover, these gains, if materialized, are likely to accrue to those atop the income/wealth hierarchies in all three nations.

The use of complementary and alternative medicine (CAM) in Europe.

BACKGROUND: While the use of complementary and alternative medicine (CAM) has become increasingly popular in western societies, we do not understand why CAM use is more frequent in some countries than in others. The aim of this article is to examine the determinants of CAM use at the individual and country-level. METHODS: Logistic multilevel regressions were applied analyzing data from 33,371 respondents in 21 European countries (including Israel) from the seventh round of the European Social Survey. We examined CAM in terms of overall use and also dichotomized treatments into physical and consumable subgroups. RESULTS: At the individual level, we found CAM use to be associated with a range of socioeconomic, demographic and health indicators. At the country level, we found that countries' health expenditures were positively related to the prevalence of overall and physical CAM treatments. CONCLUSIONS: A common predictor for CAM use, both at the individual (in terms of education and financial strain) and country-level (in terms of health expenditures per capita), is greater resources.

Relieving the tension between national health equity strategies and global health equity.

Globally, numerous national strategies have taken aim at reducing health inequities. An ever-present tension characterizing these strategies, however, is their lack of attention to the global political economy. This commentary argues that national policies which target only domestic factors (without engaging with the global political economy) will be limited, both, in their ability to address national levels of health equity and the larger global health inequity problem. Meaningful proposals to reduce health inequities have been made that take into account a global political economy perspective. National health equity strategies could provide the lacking momentum to advance such proposals, but will require united and sustained advocacy by global health and health equity scholars. Ultimately, relieving the tension between national health equity commitments and global health equity concerns could be one of the new approaches needed to improve health equity worldwide.

Correction to: USMCA (NAFTA 2.0): tightening the constraints on the right to regulate for public health.

Following publication of the original article [1], the authors flagged an error concerning two missing article references, which were unfortunately not provided prior to publication of the article.

The European epidemic: Pain prevalence and socioeconomic inequalities in pain across 19 European countries.

BACKGROUND: Using data from the European Social Survey (ESS) 2014, this study presents an update of pain prevalence amongst men and women across Europe and undertakes the first analysis of socioeconomic inequalities in pain. METHODS: Data from the ESS 2014 survey were analysed for three pain variables: back/neck pain (n = 11,032), hand/arm pain (n = 5,954) and foot/leg pain (n = 6,314). Education was used as the indicator of socioeconomic status (SES). Age-adjusted risk differences and age-adjusted risk ratios were calculated from predicted probabilities generated by means of binary logistic regression. These analyses compared the lower education group with the higher education group (the socioeconomic gap), and the medium education group with the higher education group (the gradient). RESULTS: High prevalence rates were reported for all three types of pain across European countries. At a pan-European level, back/neck pain was the most prevalent with 40% of survey participants experiencing pain; then hand/arm pain at 22%, and then foot/leg pain at 21%. There was considerable cross-national variation in pain across European counties, as well as significant socioeconomic inequalities in the prevalence of pain-with social gradients or socioeconomic gaps evident for both men and women; socioeconomic inequalities were most pronounced for hand/arm pain, and least pronounced for back/neck pain. The magnitudes of the socioeconomic pain inequalities differed between countries, but were generally higher for women. CONCLUSIONS: Future strategies to reduce the burden of pain should acknowledge and consider the associated socioeconomic inequalities of pain to ensure the "pain gap" does not widen. SIGNIFICANCE: This is a pan European study that has explored socioeconomic inequalities in pain. Across Europe, pain is more prevalent in people of lower socioeconomic position; these pain inequalities were most significant for hand/arm pain, and least significant for back/neck pain.

USMCA (NAFTA 2.0): tightening the constraints on the right to regulate for public health.

BACKGROUND: In late 2018 the United States, Canada, and Mexico signed a new trade agreement (most commonly referred to by its US-centric acronym, the United States-Mexico-Canada Agreement, or USMCA) to replace the 1994 North American Free Trade Agreement (NAFTA). The new agreement is the first major trade treaty negotiated under the shadow of the Trump Administration's unilateral imposition of tariffs to pressure other countries to accept provisions more favourable to protectionist US economic interests. Although not yet ratified, the agreement is widely seen as indicative of how the US will engage in future international trade negotiations. METHODS: Drawing from methods used in earlier health impact assessments of the Trans-Pacific Partnership agreement, we undertook a detailed analysis of USMCA chapters that have direct or indirect implications for health. We began with an initial reading of the entire agreement, followed by multiple line-by-line readings of key chapters. Secondary sources and inter-rater (comparative) analyses by the four authors were used to ensure rigour in our assessments. RESULTS: The USMCA expands intellectual property rights and regulatory constraints that will lead to increased drug costs, particularly in Canada and Mexico. It opens up markets in both Canada and Mexico for US food exports without reducing the subsidies the US provides to its own producers, and introduces a number of new regulatory reforms that weaken public health oversight of food safety. It reduces regulatory policy space through new provisions on 'technical barriers to trade' and requirements for greater regulatory coherence and harmonization across the three countries. It puts some limitations on contentious investor-state dispute provisions between the US and Mexico, provisions often used to challenge or chill health and environmental measures, and eliminates them completely in disputes between the US and Canada; but it allows for new 'legacy claims' for 3 years after the agreement enters into force. Its labour and environmental chapters contain a few improvements but overall do little to ensure either workers' rights or environmental protection. CONCLUSION: Rather than enhancing public health protection the USMCA places new, extended, and enforceable obligations on public regulators that increase the power (voice) of corporate (investor) interests during the development of new regulations. It is not a health-enhancing template for future trade agreements that governments should emulate.

Health in crises. Migration, austerity and inequalities in Greece and Europe: introduction to the supplement.

This introduction summarizes and discusses the main findings of the supplement 'Health in crises. Migration, austerity and inequalities in Greece and Europe' to the European Journal of Public Health. The supplement applies data from the ESS (2014) health module in combination with the MIGHEAL study, which is a new source of data on the Greek population specially designed to examine health inequalities among and between migrants and natives. This has enabled the authors of the nine articles that constitute this supplement to address several pressing issues about the distribution of health and its determinants in Greece and other European countries. The main finding of the present supplement is the exceptionally high rates of reported depressive symptoms across the whole population residing in Greece and particularly among women. Levels of unmet need for healthcare were also found to be alarmingly high in Greece compared with other European countries, suggesting that the crisis and subsequent austerity policies may have impacted the provision of healthcare services and access to healthcare for broad sections of the population, whether native or migrant.

Health inequalities among migrant and native-born populations in Greece in times of crisis: the MIGHEAL study.

This article presents the MIGHEAL study, which was developed in parallel with the European Social Survey (ESS) Round 7 (2014). Conducted in Greece in 2016 by the National Centre for Social Research, the study was specifically designed to further our understanding of how health varies by social status, focusing particularly on migrant status. In the current article, we report results on health status (non-communicable diseases, self-reported health and depressive symptoms) and health determinants (risky health behaviours, social determinants and access to health care) in Greece, among migrants and native-born. Estimates for the Greek overall population are compared with the European ones (using the ESS 2014 data) and discussed with reference to the ongoing economic and social crisis in Greece. The study provides evidence of social inequalities in health, complementing the pan-European documentation, and supports prior research, which has identified negative health consequences of the crisis.