Background
Methods
Study design
Literature search
Quality assessment
Results
Review articles
Author (Year) | Scope/inclusion criteria (search date range) | Number of studies identified* | Relevant conclusions regarding existing literature |
---|---|---|---|
Breman & Shelton (2007) [17] | Structural adjustment programs (SAPs) and health outcomes; emphasis on empirical analyses (dates not specified) | 76 | - Three main policies of SAPs have been the focus of this literature: reduced government expenditures, liberalized markets, and exchange rate devaluation - “Overwhelming majority” of studies portray the impacts of SAPs on health as negative, but among strictly empirical studies, approximately even split between findings of positive, negative, and neutral impacts |
Young, et al. (2009) [66] | Globalization and co-morbidity between infectious and chronic disease (1950 – end date not specified) | Not specified | - This review technically met our inclusion criteria but the globalization aspect was very minor in the results/discussion |
Loewenson, et al. (2010) [19] | Globalization and nutritional outcomes in sub-Saharan Africa (1990–2009) | 199 | - Limited empirical work in Africa - Need for more research on gender dimensions of globalization and health |
Friel, et al. (2013) [18] | Studies that developed approaches, methods, or indicators to monitor impacts of trade agreements on food environments from an obesity/NCD perspective; examined impacts of trade agreements on food chains and the food environment; or conceptualized links between trade liberalization and food environments (1990 – January 2013) | 9 | - “No studies were identified which used methods or indicators to systematically monitor trade agreements through an obesity/NCD lens” - Proposes potential indicators and food categories for monitoring the impacts of trade agreements on national food systems and food environments |
Baker, et al. (2014) [67] | Trade liberalization, non-communicable diseases, and risk factors in Asia (dates not specified) | Not specified | - Understanding of the mechanisms linking transnational corporations and increased consumption of tobacco, alcohol, and unhealthy foods and beverages “appear to be theoretically and empirically underdeveloped in the public health literature” |
Burns, et al. (2016) [13] | Quantitative studies investigating the relationship between international trade or foreign direct investment, and non-nutritional population health outcomes (until end of 2014) | 16 | - Current evidence on FDI as determinant and consequence of health is unclear; more research needed - Sample stratification may critically affect the estimated relationship between trade and health in international panel studies (e.g., nature of goods imported/exported, industry of international investments, position in global supply chain) - Important to consider mutual association when analyzing trade or FDI and health; adjustments for reverse causality were “typically crude” or absent - Surprisingly limited use of individual-level data |
Barlow, et al. (2017) [22] | Quantitative studies of the health impacts of trade and investment agreements or policy. (1960 – January 2016) | 17 | - “Trade and investment measures varied in specificity” - Studies with stronger methodological designs most often used trade indicators with weak specificity - Mechanisms mediating links were seldom explored - Strong reliance on country-level data precludes exploration of social groups where effects are concentrated |
McNamara (2017) [16] | Studies explicating a clear analytical framework for conceptualizing pathways between trade liberalization and health (until end of 2015) | 43 | - “Many authors include financial flows and foreign investment within conceptualizations of trade liberalization” - “Trade liberalization itself is seldom explicitly defined in frameworks” |
Quantitative studies
Indicator | Number (%) of studies using as explanatory variable |
---|---|
KOF Globalization Index (Swiss Federal Institute of Technology) | 9 (26) |
FDI inflows/GDP (%) | 8 (24) |
Total trade (imports + exports)/GDP (%) | 8 (24) |
Entry into force of a specific agreement or SAP (indicator variable) | 5 (15) |
CSGR Globalisation Index (Univ. of Warwick) | 2 (6) |
Economic Freedom of the World Index (Fraser Institute) | 2 (6) |
Mean applied tariff rate | 2 (6) |
Average imports, weighted by partner countries’ infant mortality rates | 1 (3) |
Black market premium | 1 (3) |
Imported food/total food (%) | 1 (3) |
Index of Economic Freedom (Heritage Foundation/WSJ) | 1 (3) |
Index of service sector liberalization (World Bank) | 1 (3) |
Maastricht Globalisation Index (Univ. of Maastricht) | 1 (3) |
Sachs-Warner Index (indicator variable) | 1 (3) |
Category | Indicator | Number (%) of studies using as outcome variable |
---|---|---|
Health outcomes
| Life expectancy (total and/or by sex) | 14 (41) |
Adult mortality rate (probability of death between ages 15 and 60) | 3 (9) | |
CVD mortality rate | 1 (3) | |
Diabetes prevalence | 1 (3) | |
NCD mortality rate | 1 (3) | |
Proportion of deaths attributable to CVD | 1 (3) | |
Over-nutrition
| Mean BMI (adults, total and/or by sex) | 5 (15) |
Obesity prevalence (total and/or by sex) | 4 (12) | |
Overweight prevalence (total and/or by sex) | 2 (6) | |
Diet
| SSB imports/sales per capita | 3 (9) |
Consumption per capita for selected food groups (e.g., animal proteins, sugars) | 2 (6) | |
Average caloric intake | 1 (3) | |
Consumption of ‘unhealthy’ foods (% of total spending/caloric intake) | 1 (3) | |
Supply of caloric sweeteners per capita | 1 (3) | |
Ultra-processed products sales per capita | 1 (3) | |
Tobacco
| Cigarette consumption per capita | 2 (6) |
Tobacco sales per capita | 1 (3) | |
Alcohol
| Alcohol sales per capita | 1 (3) |
Indicator | Number (%) of studies using as confounding variable |
---|---|
GDP (or GNI) per capita (including squared term or growth rate) | 26 (76) |
Urbanization rate (or urban growth rate) | 10 (29) |
Population (total, density, or growth rate) | 7 (21) |
Educational attainment (years completed, enrollment rate, or literacy rate) | 6 (18) |
Income inequality | 4 (12) |
Female labor force participation rate | 3 (9) |
Health expenditure (% of GDP, total or public) | 3 (9) |
Average caloric intake | 2 (6) |
Consumer price index | 2 (6) |
Dependency ratio | 2 (6) |
FDI (total or % of GDP) | 2 (6) |
Fertility rate | 2 (6) |
Political rights/civil liberties index | 2 (6) |
Polity score | 2 (6) |
Immunization rate (any type) | 2 (6) |
Smoking prevalence | 2 (6) |
No confounders included/tested in models | 7 (21) |
Strengths and weaknesses of study designs
Inventory of data sources
Topic | Measure | International data sources |
---|---|---|
Policy
| Treaty membership | • WTO membership database • UNCTAD International Investment Agreements Navigator |
Depth of commitments in specific agreements | • Design of Trade Agreements (DESTA) project • Mapping BITs | |
Presence and outcome of trade or investment disputes | • WTO Dispute Settlement Gateway • UNCTAD Investment Dispute Settlement Navigator | |
Liberalization
| Product-specific tariff rates | • UNCTAD TRAINS database • WTO Tariff Download Facility |
Non-tariff measures | • UNCTAD TRAINS database • USDA Foreign Agricultural Service reports • UNCTAD International Investment Agreements Navigator | |
Flows
| FDI, by sector & industry | • International Trade Center database • UNCTADstat (by request) |
Product-specific imports & exports | • UN Commodity Trade Statistics (UN Comtrade) • World Bank World Integrated Trade Solution (WITS) • FAO Food and Commodity Balance Sheets • Index Mundi • USDA Foreign Agricultural Service | |
Retail sales | • Euromonitor Global Market Information Database |