Impact of the COVID-19 pandemic on employment and inequalities: a systematic review of international evidence and critical appraisal of statistical methods

AIMS

To assess the impact of the COVID-19 pandemic on individual labour market outcomes and how these vary over time and between different groups of individuals.

METHODS

Searches were conducted using Medline, Scopus and EconLit. Grey literature searches used Google Scholar and Econpapers. Study quality was assessed using the risk of bias in non-randomised studies of exposure tool (ROBINS-E), accompanied by a directed acyclic graph (DAG) to identify relevant mediators, moderators and confounders.

RESULTS

A total of 85 studies (77 peer-reviewed articles, 8 working papers) were included. The ROBINS-E showed that the overall risk of bias varied between studies from low (n = 14), moderate (n = 56) to serious (n = 15). Studies also varied in terms of outcome measures, study designs and the academic disciplines of researchers. Generally, studies using data collected before and during the pandemic showed large negative effects on employment, working hours and income. Studies that assessed moderators (e.g. by industry, occupation, age, gender, race and country of birth) indicated the pandemic has likely worsened pre-existing disparities in health and work. Generally, women, less educated, non-whites and young workers were affected the most, perhaps due to their jobs involving high levels of personal contact (e.g. hospitality, sales and entertainment) and being less amenable to remote working. The DAG highlighted methodological challenges in drawing robust inferences about COVID-19's impact on employment, including the lack of an unexposed control group.

CONCLUSIONS

The COVID-19 health crisis caused unanticipated and unprecedented changes to employment opportunities around the world, with potential long-term health consequences. Further research should investigate the longer-term impact of COVID-19, with greater attention given to low- and middle-income countries. Our study provides guidance on the design and critical appraisal of future studies.

Progression of frailty as measured by a cumulative deficit index: A systematic review

BACKGROUND

Frailty is a risk factor for adverse health outcomes. There is a paucity of literature on frailty progression defined by a cumulative deficit model among community dwelling older people. The objective of this review was to synthesise evidence on these changes in health and mortality among community-dwelling older people.

METHODS

Six databases (Medline, Embase, CINAHL, Cochrane, PsycInfo, Web of Science) and a clinical trials registry were searched in July 2021. The inclusion criteria were studies using a frailty index and providing information on transition between frailty states or to death in community-dwelling older people aged ≥ 50. Exclusion criteria were studies examining specific health conditions, conference abstracts and non-English studies. To standardise the follow-up period and facilitate comparison, we converted the transition probabilities to annual transition rates.

RESULTS

Two reviewers independently screened 5078 studies and 61 studies were included for analysis. Of these, only three used the same frailty state cut-points to facilitate cross-cohort comparison. This review found that frailty tends to increase with time, people who are frail at baseline have greater likelihood to progress in frailty and die, and the main factor that accelerates frailty progression is age. Other risk factors for progression are having chronic disease, smoking, obesity, low-income or/and low-education levels. A frailty index is an accurate predictor of adverse outcomes and death.

DISCUSSION

This systematic review demonstrated that worsening in frailty was a common frailty transition, and older people who are frail at baseline are more likely to die. A frailty index has significant power to predict adverse health outcomes. It is a useful tool for within-cohort comparison but there are challenges comparing different cohorts due to dependence of frailty progression on age and differences in how frailty index is defined and measured.