Does persistent precarious employment affect health outcomes among working age adults? A systematic review and meta-analysis.

OBJECTIVE: To evaluate the impact of persistent precarious employment (lasting 12+ months) on the health of working age adults, compared with more stable employment. Persistent precarity reflects a shift towards less secure forms of employment and may be particularly important for health. METHODS: Nine databases were systematically searched to identify quantitative studies that assessed the relationship between persistent precarious employment and health outcomes. Risk of bias (RoB) was assessed using an adaptation of the Effective Public Health Practice Project tool. Narrative synthesis and random effects meta-analysis were conducted. Certainty of evidence was assessed using the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: Of 12 940 records screened, 50 studies met the inclusion criteria and 29 were included in meta-analyses. RoB was generally high (n=18). The most reported outcome domain was mental health; with evidence also reported relating to general health, physical health,and health behaviours. Of GRADE assessed outcomes, persistent precarious employment was associated with increased risk of poor self-rated health (OR 1.53, 95% CI 1.09 to 2.14, I2=80%) and mental health symptoms (OR 1.44, 95% CI 1.23 to 1.70, I2=65%). The association with all-cause mortality was imprecisely estimated (OR 1.10, 5% CI 0.91 to 1.33, I2=73%). There was very low GRADE certainty across all outcomes. CONCLUSIONS: Persistent precarious employment is associated with poorer health, particularly for outcomes with short time lags, though associations are small and causality is highly uncertain. Further research using more robust methods is needed but given potential health harms of persistent precarious employment, exploration of precautionary labour regulations and employment policies is warranted.

Which is most important for mental health: Money, poverty, or paid work? A fixed-effects analysis of the UK Household Longitudinal Study.

BACKGROUND: The relative importance of income, poverty and unemployment status for mental health is unclear, and understanding this has implications for income and welfare policy design. We aimed to assess the association between changes in these exposures and mental health. METHODS: We measured effects of three transition exposures between waves of the UK Household Longitudinal Study from 2010/11-2019/20 (n=38,697, obs=173,859): income decreases/increases, moving in/out of poverty, and job losses/gains. The outcome was General Health Questionnaire (GHQ), which measures likelihood of common mental disorder (CMD) as a continuous (GHQ-36) and binary measure (score ≥4 = case). We used fixed-effects linear and linear probability models to adjust for time invariant and time-varying confounders. To investigate effect modification, we stratified analyses by age, sex and highest education. RESULTS: A 10% income decrease/increase was associated with a 0.02% increase (95% CI 0.00, 0.04) and 0.01% reduction (95% CI -0.03, 0.02) in likelihood of CMD respectively. Effect sizes were larger for moving into poverty (+1.8% [0.2, 3.5]), out of poverty (-1.8%, [-3.2, -0.3]), job loss (+15.8%, [13.6, 18.0]) and job gain (-11.4%, [-14.4, -8.4]). The effect of new poverty was greater for women (+2.3% [0.8, 3.9] versus +1.2% [-1.1, 3.5] for men) but the opposite was true for job loss (+17.8% [14.4, 21.2] for men versus +13.5% [9.8, 17.2] for women). There were no clear differences by age, but those with least education experienced the largest effects from poverty transitions, especially moving out of poverty (-2.9%, [-5.7, -0.0]). CONCLUSIONS: Moving into unemployment was most strongly associated with CMD, with poverty also important but income effects generally much smaller. Men appear most sensitive to employment transitions, but poverty may have larger impacts on women and those with least education. As the COVID-19 pandemic recedes, minimising unemployment as well as poverty is crucial for population mental health.

The contribution of changes to tax and social security to stalled life expectancy trends in Scotland: a modelling study.

BACKGROUND: Life expectancy (LE) improvements have stalled, and UK tax and welfare 'reforms' have been proposed as a cause. We estimated the effects of tax and welfare reforms from 2010/2011 to 2021/2022 on LE and inequalities in LE in Scotland. METHODS: We applied a published estimate of the cumulative income impact of the reforms to the households within Scottish Index of Multiple Deprivation (SIMD) quintiles. We estimated the impact on LE by applying a rate ratio for the impact of income on mortality rates (by age group, sex and SIMD quintile) and calculating the difference between inflation-only changes in benefits and the reforms. RESULTS: We estimated that changes to household income resulting from the reforms would result in an additional 1041 (+3.7%) female deaths and 1013 (+3.8%) male deaths. These deaths represent an estimated reduction of female LE from 81.6 years to 81.2 years (-20 weeks), and male LE from 77.6 years to 77.2 years (-23 weeks). Cuts to benefits and tax credits were modelled to have the most detrimental impact on LE, and these were estimated to be most severe in the most deprived areas. The modelled impact on inequalities in LE was widening of the gap between the most and least deprived 20% of areas by a further 21 weeks for females and 23 weeks for males. INTERPRETATION: This study provides further evidence that austerity, in the form of cuts to social security benefits, is likely to be an important cause of stalled LE across the UK.

The effect of income-based policies on mortality inequalities in Scotland: a modelling study.

BACKGROUND: The unequal distribution of income is a fundamental determinant of health inequalities. Decision making around economic policies could be enhanced by showing their potential health effects. We used scenario modelling to assess the effects of 12 income-based policies on years of life lost (YLL) and inequalities in YLL in Scotland for the 2017-21 period. METHODS: In this modelling study, we used EUROMOD version H1.0+, a tax-benefit microsimulation model, to estimate the effects of hypothetical fiscal policies on household income for Scottish households in the 2014/15 Family Resources Survey (n=2871). The effects were modelled excluding housing costs. Income change from baseline was estimated for each quintile of the 2016 Scottish Index of Multiple Deprivation (SIMD) after weighting to account for differential non-response to the Family Resources Survey, and incomes were equivalised according to the Organisation for Economic Co-operation and Development's modified equivalence scale. A regression analysis of cross-sectional data was used to estimate the relationship between income change and all-cause mortality, followed up by a sensitivity analysis to account for uncertainties around the assumptions on effect size. Informing Interventions to reduce health Inequalities (Triple I), a health inequalities scenario modelling tool, was used to estimate policy effects on YLL and government spending after five years of theoretical implementation. The Triple I model used population estimates for 2016 stratified by sex, 5-year age group, and SIMD quintile, which were obtained from the National Records of Scotland. Preliminary estimates of relative policy costs were calculated from the EUROMOD-derived combined effects of each policy on tax bills, National Insurance contributions, and benefits receipts for Scottish households. FINDINGS: Taxation-based policies did not substantially affect household incomes, whereas benefits-based policies had large effects across the quintiles. The best policy for improving health and narrowing health inequalities was a 50% increase to means-tested benefits (approximately 105 177 [4·7%] YLL fewer than the baseline of 2·2 million, and a 7·9% reduction in relative index of inequality). Effects on YLL and health inequalities were inversely correlated in response to changes in taxation policy. Citizen's Basic Income (CBI) schemes also substantially narrowed inequalities (3·7% relative index of inequality for basic scheme, 5·9% for CBI with additional payments for individuals with disability), and modestly reduced YLL (0·7% for the basic scheme and 1·4% with additional payments). The estimated government spending associated with a policy was proportional to its effect on YLL, but less closely related to its effect on inequalities in YLL. INTERPRETATION: Policies that affect incomes could potentially have marked effects on health and health inequalities in Scotland. Our projections suggest that the most effective policies for reducing health inequalities appeared to be those that disproportionately increased incomes in the most deprived areas. Although modelling was subject to various assumptions, the approach can be useful to inform decisions around addressing the upstream determinants of health inequalities. FUNDING: None.

Do patients who die from an alcohol-related condition 'drift' into areas of greater deprivation? Alcohol-related mortality and health selection theory in Scotland.

BACKGROUND: Health selection has been proposed to explain the patterning of alcohol-related mortality by area deprivation. This study investigated whether persons who die from alcohol-related conditions are more likely to experience social drift than those who die from other causes. METHODS: Deaths recorded in Scotland (2013, >21 years) were coded as 'alcohol-related' or 'other' and by deprivation decile of residence at death. Acute hospital admissions data from 1996 to 2012 were used to provide premortality deprivation data. χ² tests estimated the difference between observed and expected alcohol-related deaths by first Scottish Index of Multiple Deprivation (SIMD) decile and type of death. Logistic regression models were fitted using type of death as the outcome of interest and change in SIMD decile as the exposure of interest. RESULTS: Of 47 012 deaths, 1458 were alcohol-related. Upward and downward mobility was observed for both types of death. An estimated 31 more deaths than expected were classified 'alcohol-related' among cases whose deprivation score decreased, while 204 more deaths than expected were classified 'alcohol-related' among cases whose initial deprivation ranking was in the four most deprived deciles. Becoming more deprived and first deprivation category were both associated with increased odds of type of death being alcohol-related after adjusting for confounders. CONCLUSION: This study suggests that health selection appears to contribute less to the deprivation gradient in alcohol-related mortality in Scotland than an individual's initial area deprivation category.

Knowledge and attitudes to reporting adverse drug reactions.

The reporting of adverse drug reactions (ADRs) by health professionals forms an important component of ongoing surveillance of post-marketing drug safety. The extension of responsibility for all health professionals to report ADRs has coincided with national immunization programmes, such as the national childhood immunization, human papillomavirus (HPV), and seasonal and H1N1 influenza programmes. The study objective was to evaluate knowledge of, and attitudes to, reporting ADRs among the professional groups most likely to see suspected reactions to vaccines. This included nursing professionals, whose views have not been included in previous studies. A survey of 91 practice nurses, health visitors, school nurses and GPs working in Ayrshire and Arran during June, July and August 2007 was undertaken. The respondents' knowledge of ADR reporting varied considerably. Although the majority of respondents recognized that it is the responsibility of health professionals to report suspected ADRs, there were lower levels of knowledge about the purpose of the Yellow Card system specifically; less than 50% of the respondents reported good knowledge about the system. The study suggests implications for practice with regard to the implementation of large-scale immunization programmes and potential solutions to under-reporting among these professional groups.