Incorporating Economic Policy Into A 'Health-In-All-Policies' Agenda

Economic priorities over population health: A political dilemma in addressing noncommunicable diseases in developing countries

The world is observing a rapid shift in the burden of diseases with predominance of noncommunicable diseases (NCDs). NCDs contribute to 41 million deaths which is equivalent to 74% of all death globally per year. There is ongoing debate on the approaches to reduce public exposure to NCDs' modifiable risk factors which are of economic potential. As the World Health Organization and the World Bank recommend the implementation of taxation to these factors, still questions arise on the effectiveness, sustainability, and practicality of this strategy. With the ongoing transition globally from consumption of natural to processed foods, it is important to counter-check the best interventions on how to protect people from unhealthy eating behaviors. While taxation on unhealthy food and other products like tobacco has been recommended as one among interventional approaches, its effectiveness on sugar sweetened beverages is not reliable compared to approaches that increase self-control. Despite the perceived economic benefits of tobacco and sugar sweetened products, there is detrimental implication in terms of public health. The introduction of taxation which favors public health faces challenges due to conflict of interest from government authorities and other stakeholders. The intertwined relationship between public health and economic development becomes more obvious during implementation of preventive and control measures against modifiable risk factors for NCDs. It is evident that reaching a balanced rational decision on choosing between economic growth and public health is difficult. Countries should enhance both local and international intersectoral and multisectoral approaches in creating integrative policies which include health component in all non-health policies including economic policies so as to harmonize public health and economic growth during this era of extensive globalization.

Early results of a natural experiment evaluating the effects of a local minimum wage policy on the diet-related health of low-wage workers, 2018-2020

OBJECTIVE

The current study presents results of a midpoint analysis of an ongoing natural experiment evaluating the diet-related effects of the Minneapolis Minimum Wage Ordinance, which incrementally increases the minimum wage to $15/h.

DESIGN

A difference-in-difference (DiD) analysis of measures collected among low-wage workers in two U.S. cities (one city with a wage increase policy and one comparison city). Measures included employment-related variables (hourly wage, hours worked and non-employment assessed by survey questions with wages verified by paystubs), BMI measured by study scales and stadiometers and diet-related mediators (food insecurity, Supplemental Nutrition Assistance Program (SNAP) participation and daily servings of fruits and vegetables, whole-grain rich foods and foods high in added sugars measured by survey questions).

SETTING

Minneapolis, Minnesota and Raleigh, North Carolina.

PARTICIPANTS

A cohort of 580 low-wage workers (268 in Minneapolis and 312 in Raleigh) who completed three annual study visits between 2018 and 2020.

RESULTS

In DiD models adjusted for time-varying and non-time-varying confounders, there were no statistically significant differences in variables of interest in Minneapolis compared with Raleigh. Trends across both cities were evident, showing a steady increase in hourly wage, stable BMI, an overall decrease in food insecurity and non-linear trends in employment, hours worked, SNAP participation and dietary outcomes.

CONCLUSION

There was no evidence of a beneficial or adverse effect of the Minimum Wage Ordinance on health-related variables during a period of economic and social change. The COVID-19 pandemic and other contextual factors likely contributed to the observed trends in both cities.

Income Support Policy Packages and Birth Outcomes in U.S. States: An Ecological Analysis

Research suggests that generous social welfare programs play a role in maternal and child health. However, most studies examine a single policy in isolation. Drawing from research documenting low-income families 'packaging' of social policies, we create a novel measure summarizing the value of a collection of income support policies for the working poor. This collection includes: the Supplemental Nutrition Assistance Program (SNAP), the Earned Income Tax Credit (EITC), the minimum wage, and the unemployment insurance (UI) program. Using U.S. state-level administrative data from 1996 to 2014, we estimate fixed effects regression models to examine the relationship between birth outcomes and income support policies (individually and combined). We find that increases in the combined value of the four income supports are significantly associated with reductions in preterm births and low birthweight births, but not infant mortality rates. States with the highest observed levels of combined income support had 14% fewer PTBs and 7% fewer LBWs than states with the lowest levels of income support. Of the four individual income support policies, only unemployment insurance has no significant independent effects. SNAP benefits have the largest and most consistent effects, reducing poor birth outcomes across all three indicators. An annual increase of $1000 in SNAP benefits is associated with a 3% decline in infant deaths, 5% decline in preterm births, and 2% decline in low birthweight births. These results suggest that increasing the generosity of income support policies may be a promising strategy for improving birth outcomes in the United States.

Association of State-Level Tax Policy and Infant Mortality in the United States, 1996-2019

Importance

Infant mortality in the United States is highest among peer nations; it is also inequitable, with the highest rates among Black infants. The association between tax policy and infant mortality is not well understood.

Objective

To examine the association between state-level tax policy and state-level infant mortality in the US.

Design, Setting, and Participants

This state-level, population-based cross-sectional study investigated the association between tax policy and infant mortality in the US from 1996 through 2019. All US infant births and deaths were included, with data obtained from the National Center for Health Statistics. Data were analyzed from November 28, 2021, to July 9, 2022.

Exposures

State-level tax policy was operationalized as tax revenue per capita and tax progressivity. The Suits index was used to measure tax progressivity, with higher progressivity indicating increased tax rates for wealthier individuals.

Main Outcomes and Measures

The association between tax policy and infant mortality rates was analyzed using a multivariable, negative binomial, generalized estimating equations model. Since 6 years of tax progressivity data were available (1995, 2002, 2009, 2012, 2014, and 2018), 300 state-years were included. Adjusted incidence rate ratios (aIRRs) were calculated controlling for year, state-level demographic variables, federal transfer revenue, and other revenue. Secondary analyses were conducted for racial and ethnic subgroups.

Results

There were 148 336 infant deaths in the US from 1996 through 2019, including 27 861 Hispanic infants, 1882 non-Hispanic American Indian or Alaska Native infants, 5792 non-Hispanic Asian or Pacific Islander infants, 41 560 non-Hispanic Black infants, and 68 666 non-Hispanic White infants. The overall infant mortality rate was 6.29 deaths per 1000 live births. Each $1000 increase in tax revenue per capita was associated with a 2.6% decrease in the infant mortality rate (aIRR, 0.97; 95% CI, 0.95-0.99). An increase of 0.10 in the Suits index (ie, increased tax progressivity) was associated with a 4.6% decrease in the infant mortality rate (aIRR, 0.95; 95% CI, 0.91-0.99). Increased tax progressivity was associated with decreased non-Hispanic White infant mortality (aIRR, 0.95; 95% CI, 0.91-0.99), and increased tax revenue was associated with increased non-Hispanic Black infant mortality (aIRR, 1.04; 95% CI, 1.01-1.08).

Conclusions and Relevance

In this cross-sectional study, an increase in tax revenue and the Suits index of tax progressivity were both associated with decreased infant mortality. These associations varied by race and ethnicity. Tax policy is an important, modifiable social determinant of health that may influence state-level infant mortality.

History of Low Hourly Wage and All-Cause Mortality Among Middle-aged Workers

Importance

Earning a low wage is an increasingly recognized public health concern, yet little research exists on the long-term health consequences of sustained low-wage earning.

Objective

To examine the association of sustained low-wage earning and mortality in a sample of workers with hourly wage reported biennially during peak midlife earning years.

Design, Setting, and Participants

This longitudinal study included 4002 US participants, aged 50 years or older, from 2 subcohorts of the Health and Retirement Study (1992-2018) who worked for pay and reported earning hourly wages at 3 or more time points during a 12-year period during their midlife (1992-2004 or 1998-2010). Outcome follow-up occurred from the end of the respective exposure periods until 2018.

Exposures

Low-wage-less than the hourly wage for full-time, full-year work at the federal poverty line-earning history was categorized as never earning a low wage, intermittently earning a low wage, and sustained earning a low wage.

Main Outcomes and Measures

Cox proportional hazards and additive hazards regression models sequentially adjusted for sociodemographics, and economic and health covariates were used to estimate associations between low-wage history and all-cause mortality. We examined interaction with sex or employment stability on multiplicative and additive scales.

Results

Of the 4002 workers (aged 50-57 years at the beginning of exposure period and 61-69 years at the end), 1854 (46.3%) were female; 718 (17.9%) experienced employment instability; 366 (9.1%) had a history of sustained low-wage earning; 1288 (32.2%) had intermittent low-wage earning periods; and 2348 (58.7%) had never earned a low wage. In unadjusted analyses, those who had never earned low wages experienced 199 deaths per 10 000 person-years, those with intermittent low wages, 208 deaths per 10 000 person-years, and those with sustained low wages, 275 deaths per 10 000 person-years. In models adjusted for key sociodemographic variables, sustained low-wage earning was associated with mortality (hazard ratio [HR], 1.35; 95% CI, 1.07-1.71) and excess deaths (66; 95% CI, 6.6-125); these findings were attenuated with additional adjustments for economic and health covariates. Significant excess death and elevated mortality risk were observed for workers with sustained low-wage exposure and employment fluctuations (eg, for sustained low-wage × employment fluctuated, HR, 2.18; 95% CI, 1.35-3.53; for sustained low-wage × stable employment, HR, 1.17; 95% CI, 0.89,-1.54; P for interaction = .003).

Conclusions and Relevance

Sustained low-wage earning may be associated with elevated mortality risk and excess deaths, especially when experienced alongside unstable employment. If causal, our findings suggest that social and economic policies that improve the financial standing of low-wage workers (eg, minimum wage laws) could improve mortality outcomes.

The power of partnerships: state public health department multisector collaborations in major chronic disease programme areas in the United States

BACKGROUND

Multisector collaboration between state public health departments (SHDs) and diverse community partners is increasingly recognized as important for promoting positive public health outcomes, addressing social determinants of health, and reducing health inequalities. This study investigates collaborations between SHDs in the United States and different types of organizations addressing chronic disease in and outside of the health sector.

METHODS

SHD employees were randomly selected from the National Association of Chronic Disease Directors membership list for participation in an online survey. Participants were asked about their primary chronic disease work unit (cancer, obesity, tobacco, diabetes, cardiovascular disease, and others), as well as their work unit collaborations (exchange of information/cooperation in activities) with organizations in health and non-health sectors. As a measure of the different organizations SHDs collaborated with in health and non-health sectors, a collaboration heterogeneity score for each programme area was calculated. One-way analysis of variance (ANOVA) with Tukey's post hoc tests were used to assess differences in collaborator heterogeneity between programme areas.

RESULTS

A total of 574 participants were surveyed. Results indicated that the cancer programme area, along with diabetes and cardiovascular disease, had significantly less collaboration heterogeneity with organizations outside of the health sector compared to the obesity and tobacco programme areas.

CONCLUSIONS

While collaborations with health sector organizations are commonly reported, public health departments can increase collaboration with sectors outside of health to more fully address chronic disease prevention.

The Logic of Policies to Address Income-Related Health Inequity: A Problem-Oriented Approach

Policy Points  Income is a fundamental cause of health across the life course. To address income-related health inequities, we need a set of overlapping and complementary policy approaches rather than focusing on a single policy.  During their lives, individuals inhabit different roles with regard to their ability to earn wages, and at any given time, only about 50% of the US population are expected to earn wages, while the rest (e.g., children, older adults, those who are disabled, unemployed, students, and/or caregivers) are not.  Three key "branch points" for designing policy approaches to address income-related health inequity are (1) should the needed good or service be obtained on the market? (2) do policy beneficiaries currently earn income? and (3) have policy beneficiaries earned income previously? The responses to these questions suggest one of four policy approaches: social services, social enfranchisement, social insurance, or social assistance.

Treatment design, health outcomes, and demographic categories in the literature on minimum wages and health

This literature review analyzes studies from the US, Canada, the UK, and Europe from inception to April 1, 2021 and focuses on treatment designs, health outcomes, demographic categories and data issues. Study designs are classified as treatment-effect-on-the-treated (7 studies), intent-to-treat (37), and what may be called possible-effects-on-anyone (10). Treatment-effects-on-the-treated designs are best for addressing the longstanding question: does income affect health or vice versa? I argue that they are also better for estimating the overall effect of minimum wages on health. Health outcomes are grouped into seven broad categories, such as overall physiological health and behavior, and 33 narrow categories, such as self-rated health and smoking. Demographic categories include gender, race/ethnicity, and age. The preponderance of evidence suggests that studies relying on the treatment-effect-on-the-treated and possible-effects-on-anyone designs find minimum wages improve health; there is no preponderance of evidence for overall health within intent-to-treat designs. With respect to specific health outcomes and demographic categories, there is no preponderance of evidence, except for improving infant and child health. One data issue concerns whether either intent-to-treat or possible-effects-on-everyone studies are reliable given that likely more than 70 % of people in their samples earn substantially above minimum wages thereby favoring the null hypothesis. Treatment-effect-on-the-treated designs are likely the best designs, and findings are largely consistent in showing that minimum wages improve some measures of health, for example, financial anxiety.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

A Mixed-methods Study to Understand Food Environments and Grocery Shopping Patterns of Community Residents in Underserved Neighborhoods in Tampa, Florida

A mixed methods study was conducted to better understand food access, food retail store environment, and perspectives of community residents on their grocery store shopping patterns and access to healthy foods in underserved, predominantly African American neighborhoods. GIS mapping, grocery store observations (n = 4), a food access and grocery store environment survey (n = 126), and focus groups (n = 48) were used. The results indicate that these neighborhoods have a low density of grocery stores, and only two out of four grocery stores meet the standard for a healthy retail store. Barriers to getting healthy foods and solutions to improve food access are discussed.

A Difference-in-Difference Study Evaluating the Effect of Minimum Wage Policy on Body Mass Index and Related Health Behaviors

Minimum wage laws are a promising policy lever to promote health equity, but few rigorous evaluations have tested whether and how minimum wage policy affects health outcomes. This paper describes an ongoing difference-in-difference study evaluating the health effects of the 2017 Minneapolis Minimum Wage Ordinance, which incrementally increases the minimum wage to $15/hr. We present: (1) the conceptual model guiding the study including mediating mechanisms, (2) the study design, and (3) baseline findings from the study, and (4) the analytic plan for the remainder of the study. This prospective study follows a cohort of 974 low-wage workers over four years to compare outcomes among low-wage workers in Minneapolis, Minnesota, and those in a comparison city (Raleigh, North Carolina). Measures include height/weight, employment paystubs, two weeks of food purchase receipts, and a survey capturing data on participant demographics, health behaviors, and household finances. Baseline findings offer a profile of individuals likely to be affected by minimum wage laws. While the study is ongoing, the movement to increase local and state minimum wage is currently high on the policy agenda; evidence is needed to determine what role, if any, such policies play in improving the health of those affected.

Open science initiatives: challenges for public health promotion

While academic open access, open data and open science initiatives have proliferated in recent years, facilitating new research resources for health promotion, open initiatives are not one-size-fits-all. Health research particularly illustrates how open initiatives may serve various interests and ends. Open initiatives not only foster new pathways of research access; they also discipline research in new ways, especially when associated with new regimes of research use and peer review, while participating in innovation ecosystems that often perpetuate existing systemic biases toward commercial biomedicine. Currently, many open initiatives are more oriented toward biomedical research paradigms than paradigms associated with public health promotion, such as social determinants of health research. Moreover, open initiatives too often dovetail with, rather than challenge, neoliberal policy paradigms. Such initiatives are unlikely to transform existing health research landscapes and redress health inequities. In this context, attunement to social determinants of health research and community-based local knowledge is vital to orient open initiatives toward public health promotion and health equity. Such an approach calls for discourses, norms and innovation ecosystems that contest neoliberal policy frameworks and foster upstream interventions to promote health, beyond biomedical paradigms. This analysis highlights challenges and possibilities for leveraging open initiatives on behalf of a wider range of health research stakeholders, while emphasizing public health promotion, health equity and social justice as benchmarks of transformation.

Minimum wages and public health: A literature review

We evaluate evidence for the effectiveness of raising minimum wages on various measures of public health within the US, Canada, the UK, and Europe. We search four scientific websites from the inception of the research through May 20, 2018. We find great variety (20+) in measured outcomes among the 33 studies that pass our initial screening. We establish quality standards in a second screening resulting in 15 studies in which we create outcome-based groups. Outcomes include four broad measures (general overall health, behavior, mental health, and birth weight) and eight narrow measures (self-reported health, "bad" health days, unmet medical need, smoking, problem-drinking, obesity, eating vegetables, and exercise). We establish criteria for "stronger" findings for outcomes and methods. Stronger findings include: $1 increases in minimum wages are associated with 1.4 percentage point (4% evaluated at mean) decreases in smoking prevalence; failure to reject null hypotheses that minimum wages have no effects for most outcomes; and no consistent evidence that minimum wages harm health. One "suggestive" finding is that the best-designed studies have well-defined treatment (or likely affected) and control (unaffected) groups and contain longitudinal data. The major methodological weaknesses afflicting many studies are the lack of focus on persons likely affected by minimum wages and omission of "falsification tests" on persons likely unaffected. An additional weakness is lack of attention to how findings might differ across populations such as teenagers, adults, men, women, continuously employed and unemployed persons. Research into health effects of minimum wages is in its infancy and growing rapidly. We present a list of "better practices" for future research.

Health in All Policies in South Australia-Did It Promote and Enact an Equity Perspective?

Mobilising cross-sectoral action is helpful in addressing the range of social determinants that contribute to health inequities. The South Australian Health in All Policies (SA HiAP) approach was implemented from 2007 to stimulate cross-sector policy activity to address the social determinants of health to improve population wellbeing and reduce health inequities. This paper presents selected findings from a five year multi-methods research study of the SA HiAP approach and draws on data collected during interviews, observation, case studies, and document analysis. The analysis shows that SA HiAP had dual goals of facilitating joined-up government for co-benefits (process focus); and addressing social determinants of health and inequities through cross-sectoral policy activity (outcomes focus). Government agencies readily understood HiAP as providing tools for improving the process of intersectoral policy development, while the more distal outcome-focused intent of improving equity was not well understood and gained less traction. While some early rhetorical support existed for progressing an equity agenda through SA HiAP, subsequent economic pressures resulted in the government narrowing its priorities to economic goals. The paper concludes that SA HiAP’s initial intentions to address equity were only partially enacted and little was done to reduce inequities. Emerging opportunities in SA, and internationally, including the UN Sustainable Development Goals, may revive interest in addressing equity.