Child labor and health: a systematic literature review of the impacts of child labor on child’s health in low- and middle-income countries

Child labor and health: a systematic literature review of the impacts of child labor on child’s... Abstract Objective To summarize current evidence on the impacts of child labor on physical and mental health. Methods We searched PubMed and ScienceDirect for studies that included participants aged 18 years or less, conducted in low- and middle-income countries (LMICs), and reported quantitative data. Two independent reviewers conducted data extraction and assessment of study quality. Results A total of 25 studies were identified, the majority of which were cross-sectional. Child labor was found to be associated with a number of adverse health outcomes, including but not limited to poor growth, malnutrition, higher incidence of infectious and system-specific diseases, behavioral and emotional disorders, and decreased coping efficacy. Quality of included studies was rated as fair to good. Conclusion and recommendations Child labor remains a major public health concern in LMICs, being associated with adverse physical and mental health outcomes. Current efforts against child labor need to be revisited, at least in LMICs. Further studies following a longitudinal design, and using common methods to assess the health impact of child labor in different country contexts would inform policy making. children, health impact assessment, occupational diseases Introduction For decades, child labor has been an important global issue associated with inadequate educational opportunities, poverty and gender inequality.1 Not all types of work carried out by children are considered child labor. Engagement of children or adolescents in work with no influence on their health and schooling is usually regarded positive. The International Labor Organization (ILO) describes child labor as ‘work that deprives children of their childhood, potential and dignity, and that is harmful to physical and mental development’.2 This definition includes types of work that are mentally, physically, socially or morally harmful to children; or disrupts schooling. The topic gained scientific attention with the industrial revolution. Research conducted in the UK, because of adverse outcomes in children, resulted in acts for child labor in 18 02.3 Many countries followed the UK, in recognition of the associated health risks. The ILO took its first stance in 1973 by setting the minimum age for work.4 Nevertheless, the ILO and other international organizations that target the issue failed to achieve goals. Child labor was part of the Millennium Development Goals, adopted by 191 nations in 20 005 to be achieved by 2015. Subsequently, child labor was included in the Sustainable Development Goals,6 which explicitly calls for eradication of child labor by 2030. Despite the reported decline in child labor from 1995 to 2000, it remains a major concern. In 2016, it was estimated that ~150 million children under the age of 14 are engaged in labor worldwide, with most of them working under circumstances that denies them a playful childhood and jeopardize their health.7 Most working children are 11–14 years, but around 60 million are 5–11 years old.7 There are no exact numbers of the distribution of child labor globally; however, available statistics show that 96% of child workers are in Africa, Asia and Latin America.1 Research into the impacts of child labor suggests several associations between child labor and adverse health outcomes. Parker1 reported that child labor is associated with certain exposures like silica in industries, and HIV infection in prostitution. Additionally, as child labor is associated with maternal illiteracy and poverty, children who work are more susceptible to malnutrition,1 which predisposes them to various diseases. A meta-analysis on the topic was published in 20 07.8 However, authors reported only an association of child labor with higher mortality and morbidity than in the general population, without reporting individual outcome specific effects.8 Another meta-analysis investigated the effects of adverse childhood experiences (ACEs), including child labor, on health. They reported that ACEs are risk factors for many adverse health outcomes.9 To our knowledge, this is the first systematic review that attempts to summarize current evidence on the impacts of child labor on both physical and mental health, based on specific outcomes. We review the most recent evidence on the health impacts of child labor in low- and middle-income countries (LMICs) according to the World Bank classification. We provide an informative summary of current studies of the impacts of child labor, and reflect upon the progress of anti-child labor policies and laws. Methodology Search strategy We searched PubMed and ScienceDirect databases. Search was restricted to publications from year 1997 onwards. Only studies written in English were considered. Our search algorithm was [(‘child labor’ OR ‘child labor’ OR ‘working children’ OR ‘occupational health’ OR ‘Adolescent work’ OR ‘working adolescents’) AND (Health OR medical)]. The first third of the algorithm was assigned to titles/abstracts to ensure relevance of the studies retrieved, while the rest of the terms were not. On PubMed, we added […AND (poverty OR ‘low income’ OR ‘developing countries’)] to increase the specificity of results; otherwise, the search results were ~60 times more, with the majority of studies being irrelevant. Study selection Studies that met the following criteria were considered eligible: sample age 18 years or less; study was conducted in LMICs; and quantitative data was reported. Two authors reviewed the titles obtained, a.o. to exclude studies related to ‘medical child labor’ as in childbirth. Abstracts of papers retained were reviewed, and subsequently full studies were assessed for inclusion criteria. Two authors assessed the quality of studies using Downs and Black tool for quality assessment.10 The tool includes 27 items, yet not all items fit every study. In such cases, we used only relevant items. Total score was the number of items positively evaluated. Studies were ranked accordingly (poor, fair, good) (Table 1). Table 1 Characteristics of studies included Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  *The quality is based on the percentage of Downs and Black10 tool, < 50% = poor, 50–75% = fair, > 75% = good. **BMI, body mass index. ***HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus. Table 1 Characteristics of studies included Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  *The quality is based on the percentage of Downs and Black10 tool, < 50% = poor, 50–75% = fair, > 75% = good. **BMI, body mass index. ***HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus. Data extraction and management Two authors extracted the data using a standardized data extraction form. It included focus of study (i.e. physical and/or mental health), exposure (type of child labor), country of study, age group, gender, study design, reported measures (independent variables) and outcome measures (Table 1). The extraction form was piloted to ensure standardization of data collection. A third author then reviewed extracted data. Disagreements were solved by discussion. Results Search results A flow diagram (Fig. 1) shows the studies selection process. We retrieved 1050 studies on PubMed and 833 studies on Science Direct, with no duplicates in the search results. We also retrieved 23 studies through screening of the references, following the screening by title of retrieved studies. By reviewing title and abstract, 1879 studies were excluded. After full assessment of the remaining studies, 25 were included. Figure 1 View largeDownload slide Study selection process. Figure 1 View largeDownload slide Study selection process. Characteristics of included studies Among the included studies ten documented only prevalence estimates of physical diseases, six documented mental and psychosocial health including abuse, and nine reported the prevalence of both mental and physical health impacts (Table 1). In total, 24 studies were conducted in one country; one study included data from the Living Standard Measurement Study of 83 LMIC.8 In total, 12 studies compared outcomes between working children and a control group (Table 1). Concerning physical health, many studies reported the prevalence of general symptoms (fever, cough and stunting) or diseases (malnutrition, anemia and infectious diseases). Alternatively, some studies documented prevalence of illnesses or symptoms hypothesized to be associated with child labor (Table 1). The majority of studies focusing on physical health conducted clinical examination or collected blood samples. Concerning mental and psychosocial health, the outcomes documented included abuse with its different forms, coping efficacy, emotional disturbances, mood and anxiety disorders. The outcomes were measured based on self-reporting and using validated measures, for example, the Strengths and Difficulties Questionnaire (SDQ), in local languages. The majority of studies were ranked as of ‘good quality’, with seven ranked ‘fair’ and one ranked ‘poor’ (Table 1). The majority of them also had mixed-gender samples, with only one study restricted to females.24 In addition, valid measures were used in most studies (Table 1). Most studies did not examine the differences between genders. Child labor and physical health Fifteen studies examined physical health effects of child labor, including nutritional status, physical growth, work-related illnesses/symptoms, musculoskeletal pain, HIV infection, systematic symptoms, infectious diseases, tuberculosis and eyestrain. Eight studies measured physical health effects through clinical examination or blood samples, in addition to self-reported questionnaires. All studies in which a comparison group was used reported higher prevalence of physical diseases in the working children group. Two studies were concerned with physical growth and development. A study conducted in Pakistan,11 reported that child labor is associated with wasting, stunting and chronic malnutrition. A similar study conducted in India compared physical growth and genital development between working and non-working children and reported that child labor is associated with lower BMI, shorter stature and delayed genital development in working boys, while no significant differences were found among females.12 Concerning work-related illnesses and injuries, a study conducted in Bangladesh reported that there is a statistically significant positive association between child labor and the probability to report any injury or illness, tiredness/exhaustion, body injury and other health problems. Number of hours worked and the probability of reporting injury and illness were positively correlated. Younger children were more likely to suffer from backaches and other health problems (infection, burns and lung diseases), while probability of reporting tiredness/exhaustion was greater in the oldest age group. Furthermore, the frequency of reporting any injury or illness increases with the number of hours worked, with significant variation across employment sectors.13 A study in Iran reported that industrial workrooms were the most common place for injury (58.2%). Falling from heights or in horizontal surface was the most common mechanism of injury (44%). None of the patients was using a preventive device at the time of injury. Cuts (49.6%) were the most commonly reported injuries.14 Other studies that investigated the prevalence of general symptoms in working children in Pakistan, Egypt, Lebanon, Jordan and Indonesia reported that child labor is negatively associated with health.15–19 Watery eyes, chronic cough and diarrhea were common findings, in addition to history of a major injury (permanent loss of an organ, hearing loss, bone fractures, permanent disability).20 One study, conducted in India reported that working children suffered from anemia, gastrointestinal tract infections, vitamin deficiencies, respiratory tract infections, skin diseases and high prevalence of malnutrition.21 Another study—of poor quality—in India reported that child labor was associated with higher incidence of infectious diseases compared to non-working children.22 Only a few studies focused on specific diseases. A study in Brazil compared the prevalence of musculoskeletal pain between working and non-working children. Authors reported that the prevalence of pain in the neck, knee, wrist or hands, and upper back exceeded 15%. Workers in manufacturing had a significantly increased risk for musculoskeletal pain and back pain, while child workers in domestic services had 17% more musculoskeletal pain and 23% more back pain than non-workers. Awkward posture and heavy physical work were associated with musculoskeletal pain, while monotonous work, awkward posture and noise were associated with back pain.23 A study in Nicaragua, which focused on children working in agriculture, reported that child labor in agriculture poses a serious threat to children’s health; specifically, acute pesticides poisoning.24 A study conducted in India reported that the prevalence of eyestrain in child laborers was 25.9%, which was significantly more than the 12.4% prevalence in a comparison group. Prevalence was higher in boys and those who work more than 4 h daily.25 Another study conducted in India documented that the difference between working and non-working children in the same area in respiratory morbidities (TB, hilar gland enlargement/calcification) was statistically significant.26 A study in Iran explored the prevalence of viral infections (HIV, HCV and HBV) in working children.27 The study reported that the prevalence among working street children was much higher than in general population. The 4.5% of children were HIV positive, 1.7% were hepatitis B positive and 2.6% hepatitis C positive. The likelihood of being HIV positive among working children of Tehran was increased by factors like having experience in trading sex, having parents who used drugs or parents infected with HCV. Lastly, one study was a meta-analysis conducted on data of working children in 83 LMIC documented that child labor is significantly and positively related to adolescent mortality, to a population’s nutrition level, and to the presence of infectious diseases.8 Child labor and mental health Overall, all studies included, except one,28 reported that child labor is associated with higher prevalence of mental and/or behavioral disorders. In addition, all studies concluded that child labor is associated with one or more forms of abuse. A study conducted in Jordan reported a significant difference in the level of coping efficacy and psychosocial health between working non-schooled children, working school children and non-working school children. Non-working school children had a better performance on the SDQ scale. Coping efficacy of working non-schooled children was lower than that of the other groups.29 A study conducted in Pakistan reported that the prevalence of behavioral problems among working children was 9.8%. Peer problems were most prevalent, followed by problems of conduct.30 A study from Ethiopia31 reported that emotional and behavioral disorders are more common among working children. However, another study in Ethiopia28 reported a lower prevalence of mental/behavioral disorders in child laborers compared to non-working children. The stark difference between these two studies could be due to the explanation provided by Alem et al., i.e. that their findings could have been tampered by selection bias or healthy worker effect. A study concerned with child abuse in Bangladesh reported that the prevalence of abuse and child exploitation was widespread. Boys were more exposed. Physical assault was higher towards younger children while other types were higher towards older ones.32 A similar study conducted in Turkey documented that 62.5% of the child laborers were subjected to abuse at their workplaces; 21.8% physical, 53.6% emotional and 25.2% sexual, 100% were subjected to physical neglect and 28.7% were subjected to emotional neglect.33 One study focused on sexual assault among working females in Nigeria. They reported that the sexual assault rate was 77.7%. In 38.6% of assault cases, the assailant was a customer. Girls who were younger than 12 years, had no formal education, worked for more than 8 h/day, or had two or more jobs were more likely to experience sexual assault.34 Discussion Main findings of this study Through a comprehensive systematic review, we conclude that child labor continues to be a major public health challenge. Child labor continues to be negatively associated with the physical and psychological health of children involved. Although no cause–effect relation can be established, as all studies included are cross-sectional, studies documented higher prevalence of different health issues in working children compared to control groups or general population. This reflects a failure of policies not only to eliminate child labor, but also to make it safer. Although there is a decline in the number of working children, the quality of life of those still engaged in child labor seems to remain low. Child labor and physical health Children engaged in labor have poor health status, which could be precipitated or aggravated by labor. Malnutrition and poor growth were reported to be highly prevalent among working children. On top of malnutrition, the nature of labor has its effects on child’s health. Most of the studies adjusted for the daily working hours. Long working hours have been associated with poorer physical outcomes.18, 19, 25, 26, 35 It was also reported that the likelihood of being sexually abused increased with increasing working hours.34 The different types and sectors of labor were found to be associated with different health outcomes as well.13, 18, 24 However, comparing between the different types of labor was not possible due to lack of data. Child labor and mental health The majority of studies concluded that child labor is associated with higher prevalence of mental and behavioral disorders, as shown in the results. School attendance, family income and status, daily working hours and likelihood of abuse, in its different forms, were found to be associated with the mental health outcomes in working children. These findings are consistent with previous studies and research frameworks.36 Child labor subjects children to abuse, whether verbally, physically or sexually which ultimately results in psychological disturbances and behavioral disorders. Moreover, peers and colleagues at work can affect the behavior of children, for example, smoking or drugs. The effects of child labor on psychological health can be long lasting and devastating to the future of children involved. What is already known on this topic Previous reviews have described different adverse health impacts of child labor. However, there were no previous attempts to review the collective health impacts of child labor. Working children are subjected to different risk factors, and the impacts of child labor are usually not limited to one illness. Initial evidence of these impacts was published in the 1920s. Since then, an increasing number of studies have used similar methods to assess the health impacts of child labor. Additionally, most of the studies are confined to a single country. What this study adds To our knowledge, this is the first review that provides a comprehensive summary of both the physical and mental health impacts of child labor. Working children are subjected to higher levels of physical and mental stress compared to non-working children and adults performing the same type of work. Unfortunately, the results show that these children are at risk of developing short and long-term health complications, physically or mentally. Though previous systematic reviews conducted on the topic in 19 971 and 20 078 reported outcomes in different measures, our findings reflect similar severity of the health impacts of child labor. This should be alarming to organizations that set child labor as a target. We have not reviewed the policies targeting child labor here, yet our findings show that regardless of policies in place, further action is needed. Most of the current literature about child labor follow a cross-sectional design, which although can reflect the health status of working children, it cannot establish cause–effect associations. This in turn affects strategies and policies that target child labor. In addition, comparing the impacts of different labor types in different countries will provide useful information on how to proceed. Further research following a common approach in assessing child labor impacts in different countries is needed. Child labor remains a major public health concern in LMICs, being associated with adverse physical and mental health outcomes. Current efforts against child labor need to be revisited, at least in LMICs. Further studies following a longitudinal design, and using common methods to assess the health impact of child labor in different country contexts would inform policy making. Limitations of this study First, we acknowledge that all systematic reviews are subject to publication bias. Moreover, the databases used might introduce bias as most of the studies indexed by them are from industrialized countries. However, these databases were used for their known quality and to allow reproduction of the data. Finally, despite our recognition of the added value of meta-analytic methods, it was not possible to conduct one due to lack of a common definition for child labor, differences in inclusion and exclusion criteria, different measurements and different outcome measures. Nevertheless, to minimize bias, we employed rigorous search methods including an extensive and comprehensive search, and data extraction by two independent reviewers. Compliance with ethical standards The authors declare that they have no conflict of interest. References 1 Parker DL. Child labor. The impact of economic exploitation on the health and welfare of children. Minn Med  1997; 80: 10– 2. Google Scholar PubMed  2 Hilowitz J. Child Labour: A Textbook for University Students . International Labour Office, 2004. 3 Humphries J. Childhood and child labour in the British industrial revolution. Econ Hist Rev  2013; 66( 2): 395– 418. Google Scholar CrossRef Search ADS   4 Dahlén M. The negotiable child: the ILO child labour campaign 1919–1973. Diss. 2007. 5 Sachs JD, McArthur JW. The millennium project: a plan for meeting the millennium development goals. Lancet  2005; 365( 9456): 347– 53. Google Scholar CrossRef Search ADS PubMed  6 Griggs D et al.  . Policy: sustainable development goals for people and planet. Nature  2013; 495( 7441): 305– 7. Google Scholar CrossRef Search ADS PubMed  7 UNICEF. The state of the world’s children 2016: a fair chance for every child. Technical Report, United Nations Children’s Fund (UNICEF) 2016. 8 Roggero P, Mangiaterra V, Bustreo F et al.  . The health impact of child labor in developing countries: evidence from cross-country data. Am J Public Health  2007; 97( 2): 271– 5. Google Scholar CrossRef Search ADS PubMed  9 Hughes K, Bellis MA, Hardcastle KA et al.  . The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health  2017; 2( 8): e356– 66. Google Scholar CrossRef Search ADS PubMed  10 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health  1998; 52( 6): 377– 84. Google Scholar CrossRef Search ADS PubMed  11 Ali M, Shahab S, Ushijima H et al.  . Street children in Pakistan: a situational analysis of social conditions and nutritional status. Soc Sci Med  2004; 59( 8): 1707– 17. Google Scholar CrossRef Search ADS PubMed  12 Ambadekar NN, Wahab SN, Zodpey SP et al.  . Effect of child labour on growth of children. Public Health  1999; 113( 6): 303– 6. Google Scholar CrossRef Search ADS PubMed  13 Ahmed S, Ray R. Health consequences of child labour in Bangladesh. Demogr Res  2014; 30: 111– 50. Google Scholar CrossRef Search ADS   14 Hosseinpour M, Mohammadzadeh M, Atoofi M. Work-related injuries with child labor in Iran. Eur J Pediatr Surg  2014; 24( 01): 117– 20. Google Scholar PubMed  15 Mohammed ES, Ewis AA, Mahfouz EM. Child labor in a rural Egyptian community: an epidemiological study. Int J Public Health  2014; 59( 4): 637– 44. Google Scholar CrossRef Search ADS PubMed  16 Nuwayhid IA, Usta J, Makarem M et al.  . Health of children working in small urban industrial shops. Occup Environ Med  2005; 62( 2): 86– 94. Google Scholar CrossRef Search ADS PubMed  17 Wolff FC. Evidence on the impact of child labor on child health in Indonesia, 1993–2000. Econ Hum Biol  2008; 6( 1): 143– 69. Google Scholar CrossRef Search ADS PubMed  18 Hamdan-Mansour AM, Al-Gamal E, Sultan MK et al.  . Health status of working children in Jordan: comparison between working and nonworking children at schools and industrial sites. Open J Nurs  2013; 3( 01): 55. Google Scholar CrossRef Search ADS   19 Tiwari RR, Saha A. Morbidity profile of child labor at gem polishing units of Jaipur, India. Int J Occup Environ Med  2014; 5( 3): 125– 9. Google Scholar PubMed  20 Khan H, Hameed A, Afridi AK. Study on child labour in automobile workshops of Peshawar, Pakistan, 2007. 21 Banerjee SR, Bharati P, Vasulu TS et al.  . Whole time domestic child labor in metropolitan city of Kolkata, 2008. 22 Daga AS, Working IN. Relative risk and prevalence of illness related to child labor in a rural block. Indian Pediatr  2000; 37( 12): 1359– 60. Google Scholar PubMed  23 Fassa AG, Facchini LA, Dall’Agnol MM et al.  . Child labor and musculoskeletal disorders: the Pelotas (Brazil) epidemiological survey. Public Health Rep  2005; 120( 6): 665– 73. Google Scholar CrossRef Search ADS PubMed  24 Corriols M, Aragón A. Child labor and acute pesticide poisoning in Nicaragua: failure to comply with children’s rights. Int J Occup Environ Health  2010; 16( 2): 175– 82. Google Scholar CrossRef Search ADS   25 Tiwari RR. Eyestrain in working children of footwear making units of Agra, India. Indian Pediatr  2013; 50( 4): 411– 3. Google Scholar CrossRef Search ADS PubMed  26 Tiwari RR, Saha A, Parikh JR. Respiratory morbidities among working children of gem polishing industries, India. Toxicol Ind Health  2009; 25( 1): 81– 4. Google Scholar CrossRef Search ADS PubMed  27 Foroughi M, Moayedi-Nia S, Shoghli A et al.  . Prevalence of HIV, HBV and HCV among street and labour children in Tehran, Iran. Sex Transm Infect  2016; 93( 6): 421– 23. Google Scholar CrossRef Search ADS PubMed  28 Alem AA, Zergaw A, Kebede D et al.  . Child labor and childhood behavioral and mental health problems in Ethiopia. Ethiopian J Health Dev  2006; 20( 2): 119– 26. 29 Al-Gamal E, Hamdan-Mansour AM, Matrouk R et al.  . The psychosocial impact of child labour in Jordan: a national study. Int J Psychol  2013; 48( 6): 1156– 64. Google Scholar CrossRef Search ADS PubMed  30 Bandeali S, Jawad A, Azmatullah A et al.  . Prevalence of behavioural and psychological problems in working children. J Pak Med Assoc  2008; 58( 6): 345. Google Scholar PubMed  31 Fekadu D, Alem A, Hägglöf B. The prevalence of mental health problems in Ethiopian child laborers. J Child Psychol Psychiatry  2006 Sep 1; 47( 9): 954– 9. Google Scholar CrossRef Search ADS PubMed  32 Hadi A. Child abuse among working children in rural Bangladesh: prevalence and determinants. Public Health  2000; 114( 5): 380– 4. Google Scholar PubMed  33 Öncü E, Kurt AÖ, Esenay FI et al.  . Abuse of working children and influencing factors, Turkey. Child Abuse Negl  2013; 37( 5): 283– 91. Google Scholar CrossRef Search ADS PubMed  34 Audu B, Geidam A, Jarma H. Child labor and sexual assault among girls in Maiduguri, Nigeria. Int J Gynecol Obstet  2009 Jan 31; 104( 1): 64– 7. Google Scholar CrossRef Search ADS   35 Gross R, Landfried B, Herman S. Height and weight as a reflection of the nutritional situation of school-aged children working and living in the streets of Jakarta. Soc Sci Med  1996 Aug 1; 43( 4): 453– 8. Google Scholar CrossRef Search ADS PubMed  36 Woodhead M. Psychosocial impacts of child work: a framework for research, monitoring and intervention. Int J Child Rts  2004; 12: 321. Google Scholar CrossRef Search ADS   © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

Child labor and health: a systematic literature review of the impacts of child labor on child’s health in low- and middle-income countries

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health.
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1741-3842
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1741-3850
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10.1093/pubmed/fdy018
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Abstract

Abstract Objective To summarize current evidence on the impacts of child labor on physical and mental health. Methods We searched PubMed and ScienceDirect for studies that included participants aged 18 years or less, conducted in low- and middle-income countries (LMICs), and reported quantitative data. Two independent reviewers conducted data extraction and assessment of study quality. Results A total of 25 studies were identified, the majority of which were cross-sectional. Child labor was found to be associated with a number of adverse health outcomes, including but not limited to poor growth, malnutrition, higher incidence of infectious and system-specific diseases, behavioral and emotional disorders, and decreased coping efficacy. Quality of included studies was rated as fair to good. Conclusion and recommendations Child labor remains a major public health concern in LMICs, being associated with adverse physical and mental health outcomes. Current efforts against child labor need to be revisited, at least in LMICs. Further studies following a longitudinal design, and using common methods to assess the health impact of child labor in different country contexts would inform policy making. children, health impact assessment, occupational diseases Introduction For decades, child labor has been an important global issue associated with inadequate educational opportunities, poverty and gender inequality.1 Not all types of work carried out by children are considered child labor. Engagement of children or adolescents in work with no influence on their health and schooling is usually regarded positive. The International Labor Organization (ILO) describes child labor as ‘work that deprives children of their childhood, potential and dignity, and that is harmful to physical and mental development’.2 This definition includes types of work that are mentally, physically, socially or morally harmful to children; or disrupts schooling. The topic gained scientific attention with the industrial revolution. Research conducted in the UK, because of adverse outcomes in children, resulted in acts for child labor in 18 02.3 Many countries followed the UK, in recognition of the associated health risks. The ILO took its first stance in 1973 by setting the minimum age for work.4 Nevertheless, the ILO and other international organizations that target the issue failed to achieve goals. Child labor was part of the Millennium Development Goals, adopted by 191 nations in 20 005 to be achieved by 2015. Subsequently, child labor was included in the Sustainable Development Goals,6 which explicitly calls for eradication of child labor by 2030. Despite the reported decline in child labor from 1995 to 2000, it remains a major concern. In 2016, it was estimated that ~150 million children under the age of 14 are engaged in labor worldwide, with most of them working under circumstances that denies them a playful childhood and jeopardize their health.7 Most working children are 11–14 years, but around 60 million are 5–11 years old.7 There are no exact numbers of the distribution of child labor globally; however, available statistics show that 96% of child workers are in Africa, Asia and Latin America.1 Research into the impacts of child labor suggests several associations between child labor and adverse health outcomes. Parker1 reported that child labor is associated with certain exposures like silica in industries, and HIV infection in prostitution. Additionally, as child labor is associated with maternal illiteracy and poverty, children who work are more susceptible to malnutrition,1 which predisposes them to various diseases. A meta-analysis on the topic was published in 20 07.8 However, authors reported only an association of child labor with higher mortality and morbidity than in the general population, without reporting individual outcome specific effects.8 Another meta-analysis investigated the effects of adverse childhood experiences (ACEs), including child labor, on health. They reported that ACEs are risk factors for many adverse health outcomes.9 To our knowledge, this is the first systematic review that attempts to summarize current evidence on the impacts of child labor on both physical and mental health, based on specific outcomes. We review the most recent evidence on the health impacts of child labor in low- and middle-income countries (LMICs) according to the World Bank classification. We provide an informative summary of current studies of the impacts of child labor, and reflect upon the progress of anti-child labor policies and laws. Methodology Search strategy We searched PubMed and ScienceDirect databases. Search was restricted to publications from year 1997 onwards. Only studies written in English were considered. Our search algorithm was [(‘child labor’ OR ‘child labor’ OR ‘working children’ OR ‘occupational health’ OR ‘Adolescent work’ OR ‘working adolescents’) AND (Health OR medical)]. The first third of the algorithm was assigned to titles/abstracts to ensure relevance of the studies retrieved, while the rest of the terms were not. On PubMed, we added […AND (poverty OR ‘low income’ OR ‘developing countries’)] to increase the specificity of results; otherwise, the search results were ~60 times more, with the majority of studies being irrelevant. Study selection Studies that met the following criteria were considered eligible: sample age 18 years or less; study was conducted in LMICs; and quantitative data was reported. Two authors reviewed the titles obtained, a.o. to exclude studies related to ‘medical child labor’ as in childbirth. Abstracts of papers retained were reviewed, and subsequently full studies were assessed for inclusion criteria. Two authors assessed the quality of studies using Downs and Black tool for quality assessment.10 The tool includes 27 items, yet not all items fit every study. In such cases, we used only relevant items. Total score was the number of items positively evaluated. Studies were ranked accordingly (poor, fair, good) (Table 1). Table 1 Characteristics of studies included Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  *The quality is based on the percentage of Downs and Black10 tool, < 50% = poor, 50–75% = fair, > 75% = good. **BMI, body mass index. ***HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus. Table 1 Characteristics of studies included Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  Article  Country  Focus  Control group  reported measures  Outcome variables  Quality*  Ahmed and Ray13  Bangladesh  Physical health    Age, gender, school enrollment, working hours, child vaccination, protection at labor, type of job  Work-related injury or illness, symptoms of work-related injury or illness  Good  Al-Gamal et al.29  Jordan  Mental health  –  Age, sex, education, types of child labor, time spent at work, age they started working, the reasons for entering the labor force, parents age, marital status, level of education, employment status, religion, and type of family. SDQ and coping efficacy scale for children  Psychosocial health and coping efficacy  Good  Alem et al.28  Ethiopia  Mental health  Yes  Age, gender, ethnicity, religion, grade attained, self-reporting questionnaire for children, diagnostic interview for children and adolescents  Mental/behavioral disorders  Good  Ali et al.11  Pakistan  Physical and mental health  Yes  Age, gender, ethnicity, education, anthropometric measures, family background, work pattern and earnings  Abuse, stunting, wasting and malnutrition  Good  Ambadekar et al.12  India  Physical growth  –  Age, anthropometric measures  Weight, BMI**, genital development  Good  Audu et al.34  Nigeria  Sexual abuse  Yes  Age, type of work, place of work, educational status, maternal and paternal education, working hours, number of jobs, years of employment  Sexual assault  Good  Bandeali et al.30  Pakistan  Mental health    Demographics, SDQ scale, decision to start working, atmosphere at work place, total monthly salary, household income, number of earning members and family atmosphere  Peer problems, emotional problems, conduct problems, hyperactivity problems, pro-social behavior  Good  Banerjee et al.21  India  Physical and mental health  –  Age, sex, educational status, parental education, type of job, income, physical examination, blood tests including Hb, anthropometric measures  Presence of various diseases (anemia, vitamin deficiencies, infections, systematic diseases), abuse  Fair  Corriols and Aragon24  Nicaragua  Physical health  –    Acute pesticide poisoning  Fair  Daga and Working22  India  Physical health    Father’s education, mother’s education, family income, child’s education, mother’s occupation, father’s occupation  Incidence of infectious diseases  Poor  Fassa et al.23  Brazil  Physical health (musculoskeletal disorders)  Yes  Age, gender, smoking, school attendance, sports activities, use of computer/video games/television, domestic activities, care of other children, and care of sick/elderly family members, work activities and workloads  Musculoskeletal pain/symptoms  Good  Fekadu et al.31  Ethiopia  Mental health  Yes  Sex, age, education, economic status, ethnicity, religion, place of birth, parents’ marital status and occupation, family size and history of migration, types of child labor, time spent at work, age work started, any benefit obtained and how it was spent, rate of changing workplace and the underlying reasons for entering the labor force, and number of people the child supported from the generated income, physical, emotional, and sexual abuse and neglect  Emotional and behavioral disturbances, mood and anxiety disorders  Good  Foroughi et al.27  Iran  Physical health (HIV, HBV, HCV)  Yes  Age, gender, ethnicity, alcohol consumption, smoking, parents’ drug use, sexual abuse, sexual contact, sex trading  HIV, HBV, HCV infection***  Good  Hadi32  Bangladesh  Mental health (abuse)  –  Age, gender, educational status, education and occupation of the father, and the amount of land owned by the family  Physical abuse, sexual abuse, financial exploitation, over burden and forced work  Good  Hamdan-Mansour et al.18  Jordan  Physical and mental health  –  Age, gender, school grade, types of child labor if working, time spent at work, age work started, and the underlying reasons for entering the labor force, medical and surgical history; visits to health clinics, health providers, and hospital emergency, inpatient, and outpatient departments; and general health assessment, psychosocial, substance abuse, and sexual behaviors, anger expression/out, anger in/hostility, anger control/suppression  Physical health (represented in symptoms/illnesses)/psychological health (loneliness, depression, problems with family, law or employer) and risk behaviors (smoking, drugs use)  Good  Hosseinpour et al.14  Iran  Physical health (injuries)  Yes  Age, sex, worker status, anatomic site of injury, place of employment, mechanism of injury  Type of physical injury  Fair  Khan et al.20  Pakistan  Physical health  –  Age, nature of work, clinical examination, monthly wage, exposure to dangerous environment at work and chronic symptoms that children were suffering from, father’s profession, family size and income  History and type of physical injuries, illnesses/symptoms based on the clinical examination and history  Good  Mohammed et al.15  Egypt  Physical and mental health  –  Age, gender, education, mother’s education, father’s education, family size, smoking, drug abuse, clinical examination, anthropometric measures  Health (vitamin deficiencies, anemia, chest symptoms), risk behaviors (smoking, drug abuse), physical injuries  Good  Nuwayhid et al.16  Lebanon  Physical and mental health  Yes  Age, education, father’s occupation/education, mother’s occupation/education, no. of siblings/working siblings, workplace, years of work, salary, work perception, employer relation, physical abuse, verbal abuse, schooling, nutrition (intake of fruit, vegetables, milk, caffeine), social habits (smoking, alcohol intake, dating), acute and chronic health problems, and use of health service, clinical examination, anthropometric measure, blood samples. Children’s Manifest Anxiety Questionnaire, the Hopelessness Scale, and the Self-Esteem Inventory  Social life and habits, nutritional habits, recent complaints (last 2 weeks), chronic illnesses, health during the last year, anxiety, hopelessness, self-esteem  Good  Oncu et al.33  Turkey  Abuse  Yes  Age, gender, working lives, workplace characteristics, family income, family status including number of siblings and parents  Physical, emotional and sexual abuse, as well as physical neglect  Good  Roggero et al.8  Developing countries according to the WB classification  Physical health  –  Gender, adult mortality rate for men, adult mortality rate for women, percentage of the population below the poverty line, percentage of adults infected with HIV/AIDS, percentage of the population undernourished, percentage of children aged 10–14 years who were workers (child labor prevalence)  The mortality rate among boys aged 10–14 years, the mortality rate among girls aged 10–14 years, and the percentage of the population aged 10–14 years undernourished  Good  Tiwari25  India  Physical health  –  Age, gender, employment duration, working hours  Eye strain  Fair  Tiwari and Saha19  India  Physical health  Yes  Age, duration of employment, working hours per day, reasons for working  Systematic symptoms including respiratory, GIT, Musculoskeletal, skin and CNS symptoms, Eye strain and repeated injury  Fair  Tiwari et al.26  India  Physical health (respiratory morbidities)  –  Age, sex, daily working hours, and duration of exposure, X-ray  Respiratory morbidities (TB, Hilar gland enlargement/calcification)  Fair  Wolff17  Indonesia  Physical health      Fever, cough and others  Fair  *The quality is based on the percentage of Downs and Black10 tool, < 50% = poor, 50–75% = fair, > 75% = good. **BMI, body mass index. ***HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus. Data extraction and management Two authors extracted the data using a standardized data extraction form. It included focus of study (i.e. physical and/or mental health), exposure (type of child labor), country of study, age group, gender, study design, reported measures (independent variables) and outcome measures (Table 1). The extraction form was piloted to ensure standardization of data collection. A third author then reviewed extracted data. Disagreements were solved by discussion. Results Search results A flow diagram (Fig. 1) shows the studies selection process. We retrieved 1050 studies on PubMed and 833 studies on Science Direct, with no duplicates in the search results. We also retrieved 23 studies through screening of the references, following the screening by title of retrieved studies. By reviewing title and abstract, 1879 studies were excluded. After full assessment of the remaining studies, 25 were included. Figure 1 View largeDownload slide Study selection process. Figure 1 View largeDownload slide Study selection process. Characteristics of included studies Among the included studies ten documented only prevalence estimates of physical diseases, six documented mental and psychosocial health including abuse, and nine reported the prevalence of both mental and physical health impacts (Table 1). In total, 24 studies were conducted in one country; one study included data from the Living Standard Measurement Study of 83 LMIC.8 In total, 12 studies compared outcomes between working children and a control group (Table 1). Concerning physical health, many studies reported the prevalence of general symptoms (fever, cough and stunting) or diseases (malnutrition, anemia and infectious diseases). Alternatively, some studies documented prevalence of illnesses or symptoms hypothesized to be associated with child labor (Table 1). The majority of studies focusing on physical health conducted clinical examination or collected blood samples. Concerning mental and psychosocial health, the outcomes documented included abuse with its different forms, coping efficacy, emotional disturbances, mood and anxiety disorders. The outcomes were measured based on self-reporting and using validated measures, for example, the Strengths and Difficulties Questionnaire (SDQ), in local languages. The majority of studies were ranked as of ‘good quality’, with seven ranked ‘fair’ and one ranked ‘poor’ (Table 1). The majority of them also had mixed-gender samples, with only one study restricted to females.24 In addition, valid measures were used in most studies (Table 1). Most studies did not examine the differences between genders. Child labor and physical health Fifteen studies examined physical health effects of child labor, including nutritional status, physical growth, work-related illnesses/symptoms, musculoskeletal pain, HIV infection, systematic symptoms, infectious diseases, tuberculosis and eyestrain. Eight studies measured physical health effects through clinical examination or blood samples, in addition to self-reported questionnaires. All studies in which a comparison group was used reported higher prevalence of physical diseases in the working children group. Two studies were concerned with physical growth and development. A study conducted in Pakistan,11 reported that child labor is associated with wasting, stunting and chronic malnutrition. A similar study conducted in India compared physical growth and genital development between working and non-working children and reported that child labor is associated with lower BMI, shorter stature and delayed genital development in working boys, while no significant differences were found among females.12 Concerning work-related illnesses and injuries, a study conducted in Bangladesh reported that there is a statistically significant positive association between child labor and the probability to report any injury or illness, tiredness/exhaustion, body injury and other health problems. Number of hours worked and the probability of reporting injury and illness were positively correlated. Younger children were more likely to suffer from backaches and other health problems (infection, burns and lung diseases), while probability of reporting tiredness/exhaustion was greater in the oldest age group. Furthermore, the frequency of reporting any injury or illness increases with the number of hours worked, with significant variation across employment sectors.13 A study in Iran reported that industrial workrooms were the most common place for injury (58.2%). Falling from heights or in horizontal surface was the most common mechanism of injury (44%). None of the patients was using a preventive device at the time of injury. Cuts (49.6%) were the most commonly reported injuries.14 Other studies that investigated the prevalence of general symptoms in working children in Pakistan, Egypt, Lebanon, Jordan and Indonesia reported that child labor is negatively associated with health.15–19 Watery eyes, chronic cough and diarrhea were common findings, in addition to history of a major injury (permanent loss of an organ, hearing loss, bone fractures, permanent disability).20 One study, conducted in India reported that working children suffered from anemia, gastrointestinal tract infections, vitamin deficiencies, respiratory tract infections, skin diseases and high prevalence of malnutrition.21 Another study—of poor quality—in India reported that child labor was associated with higher incidence of infectious diseases compared to non-working children.22 Only a few studies focused on specific diseases. A study in Brazil compared the prevalence of musculoskeletal pain between working and non-working children. Authors reported that the prevalence of pain in the neck, knee, wrist or hands, and upper back exceeded 15%. Workers in manufacturing had a significantly increased risk for musculoskeletal pain and back pain, while child workers in domestic services had 17% more musculoskeletal pain and 23% more back pain than non-workers. Awkward posture and heavy physical work were associated with musculoskeletal pain, while monotonous work, awkward posture and noise were associated with back pain.23 A study in Nicaragua, which focused on children working in agriculture, reported that child labor in agriculture poses a serious threat to children’s health; specifically, acute pesticides poisoning.24 A study conducted in India reported that the prevalence of eyestrain in child laborers was 25.9%, which was significantly more than the 12.4% prevalence in a comparison group. Prevalence was higher in boys and those who work more than 4 h daily.25 Another study conducted in India documented that the difference between working and non-working children in the same area in respiratory morbidities (TB, hilar gland enlargement/calcification) was statistically significant.26 A study in Iran explored the prevalence of viral infections (HIV, HCV and HBV) in working children.27 The study reported that the prevalence among working street children was much higher than in general population. The 4.5% of children were HIV positive, 1.7% were hepatitis B positive and 2.6% hepatitis C positive. The likelihood of being HIV positive among working children of Tehran was increased by factors like having experience in trading sex, having parents who used drugs or parents infected with HCV. Lastly, one study was a meta-analysis conducted on data of working children in 83 LMIC documented that child labor is significantly and positively related to adolescent mortality, to a population’s nutrition level, and to the presence of infectious diseases.8 Child labor and mental health Overall, all studies included, except one,28 reported that child labor is associated with higher prevalence of mental and/or behavioral disorders. In addition, all studies concluded that child labor is associated with one or more forms of abuse. A study conducted in Jordan reported a significant difference in the level of coping efficacy and psychosocial health between working non-schooled children, working school children and non-working school children. Non-working school children had a better performance on the SDQ scale. Coping efficacy of working non-schooled children was lower than that of the other groups.29 A study conducted in Pakistan reported that the prevalence of behavioral problems among working children was 9.8%. Peer problems were most prevalent, followed by problems of conduct.30 A study from Ethiopia31 reported that emotional and behavioral disorders are more common among working children. However, another study in Ethiopia28 reported a lower prevalence of mental/behavioral disorders in child laborers compared to non-working children. The stark difference between these two studies could be due to the explanation provided by Alem et al., i.e. that their findings could have been tampered by selection bias or healthy worker effect. A study concerned with child abuse in Bangladesh reported that the prevalence of abuse and child exploitation was widespread. Boys were more exposed. Physical assault was higher towards younger children while other types were higher towards older ones.32 A similar study conducted in Turkey documented that 62.5% of the child laborers were subjected to abuse at their workplaces; 21.8% physical, 53.6% emotional and 25.2% sexual, 100% were subjected to physical neglect and 28.7% were subjected to emotional neglect.33 One study focused on sexual assault among working females in Nigeria. They reported that the sexual assault rate was 77.7%. In 38.6% of assault cases, the assailant was a customer. Girls who were younger than 12 years, had no formal education, worked for more than 8 h/day, or had two or more jobs were more likely to experience sexual assault.34 Discussion Main findings of this study Through a comprehensive systematic review, we conclude that child labor continues to be a major public health challenge. Child labor continues to be negatively associated with the physical and psychological health of children involved. Although no cause–effect relation can be established, as all studies included are cross-sectional, studies documented higher prevalence of different health issues in working children compared to control groups or general population. This reflects a failure of policies not only to eliminate child labor, but also to make it safer. Although there is a decline in the number of working children, the quality of life of those still engaged in child labor seems to remain low. Child labor and physical health Children engaged in labor have poor health status, which could be precipitated or aggravated by labor. Malnutrition and poor growth were reported to be highly prevalent among working children. On top of malnutrition, the nature of labor has its effects on child’s health. Most of the studies adjusted for the daily working hours. Long working hours have been associated with poorer physical outcomes.18, 19, 25, 26, 35 It was also reported that the likelihood of being sexually abused increased with increasing working hours.34 The different types and sectors of labor were found to be associated with different health outcomes as well.13, 18, 24 However, comparing between the different types of labor was not possible due to lack of data. Child labor and mental health The majority of studies concluded that child labor is associated with higher prevalence of mental and behavioral disorders, as shown in the results. School attendance, family income and status, daily working hours and likelihood of abuse, in its different forms, were found to be associated with the mental health outcomes in working children. These findings are consistent with previous studies and research frameworks.36 Child labor subjects children to abuse, whether verbally, physically or sexually which ultimately results in psychological disturbances and behavioral disorders. Moreover, peers and colleagues at work can affect the behavior of children, for example, smoking or drugs. The effects of child labor on psychological health can be long lasting and devastating to the future of children involved. What is already known on this topic Previous reviews have described different adverse health impacts of child labor. However, there were no previous attempts to review the collective health impacts of child labor. Working children are subjected to different risk factors, and the impacts of child labor are usually not limited to one illness. Initial evidence of these impacts was published in the 1920s. Since then, an increasing number of studies have used similar methods to assess the health impacts of child labor. Additionally, most of the studies are confined to a single country. What this study adds To our knowledge, this is the first review that provides a comprehensive summary of both the physical and mental health impacts of child labor. Working children are subjected to higher levels of physical and mental stress compared to non-working children and adults performing the same type of work. Unfortunately, the results show that these children are at risk of developing short and long-term health complications, physically or mentally. Though previous systematic reviews conducted on the topic in 19 971 and 20 078 reported outcomes in different measures, our findings reflect similar severity of the health impacts of child labor. This should be alarming to organizations that set child labor as a target. We have not reviewed the policies targeting child labor here, yet our findings show that regardless of policies in place, further action is needed. Most of the current literature about child labor follow a cross-sectional design, which although can reflect the health status of working children, it cannot establish cause–effect associations. This in turn affects strategies and policies that target child labor. In addition, comparing the impacts of different labor types in different countries will provide useful information on how to proceed. Further research following a common approach in assessing child labor impacts in different countries is needed. Child labor remains a major public health concern in LMICs, being associated with adverse physical and mental health outcomes. Current efforts against child labor need to be revisited, at least in LMICs. Further studies following a longitudinal design, and using common methods to assess the health impact of child labor in different country contexts would inform policy making. Limitations of this study First, we acknowledge that all systematic reviews are subject to publication bias. Moreover, the databases used might introduce bias as most of the studies indexed by them are from industrialized countries. However, these databases were used for their known quality and to allow reproduction of the data. Finally, despite our recognition of the added value of meta-analytic methods, it was not possible to conduct one due to lack of a common definition for child labor, differences in inclusion and exclusion criteria, different measurements and different outcome measures. Nevertheless, to minimize bias, we employed rigorous search methods including an extensive and comprehensive search, and data extraction by two independent reviewers. Compliance with ethical standards The authors declare that they have no conflict of interest. References 1 Parker DL. Child labor. The impact of economic exploitation on the health and welfare of children. Minn Med  1997; 80: 10– 2. Google Scholar PubMed  2 Hilowitz J. Child Labour: A Textbook for University Students . International Labour Office, 2004. 3 Humphries J. Childhood and child labour in the British industrial revolution. Econ Hist Rev  2013; 66( 2): 395– 418. Google Scholar CrossRef Search ADS   4 Dahlén M. The negotiable child: the ILO child labour campaign 1919–1973. Diss. 2007. 5 Sachs JD, McArthur JW. The millennium project: a plan for meeting the millennium development goals. Lancet  2005; 365( 9456): 347– 53. Google Scholar CrossRef Search ADS PubMed  6 Griggs D et al.  . Policy: sustainable development goals for people and planet. Nature  2013; 495( 7441): 305– 7. Google Scholar CrossRef Search ADS PubMed  7 UNICEF. The state of the world’s children 2016: a fair chance for every child. Technical Report, United Nations Children’s Fund (UNICEF) 2016. 8 Roggero P, Mangiaterra V, Bustreo F et al.  . The health impact of child labor in developing countries: evidence from cross-country data. Am J Public Health  2007; 97( 2): 271– 5. Google Scholar CrossRef Search ADS PubMed  9 Hughes K, Bellis MA, Hardcastle KA et al.  . The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health  2017; 2( 8): e356– 66. Google Scholar CrossRef Search ADS PubMed  10 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health  1998; 52( 6): 377– 84. Google Scholar CrossRef Search ADS PubMed  11 Ali M, Shahab S, Ushijima H et al.  . Street children in Pakistan: a situational analysis of social conditions and nutritional status. Soc Sci Med  2004; 59( 8): 1707– 17. Google Scholar CrossRef Search ADS PubMed  12 Ambadekar NN, Wahab SN, Zodpey SP et al.  . Effect of child labour on growth of children. Public Health  1999; 113( 6): 303– 6. Google Scholar CrossRef Search ADS PubMed  13 Ahmed S, Ray R. Health consequences of child labour in Bangladesh. Demogr Res  2014; 30: 111– 50. Google Scholar CrossRef Search ADS   14 Hosseinpour M, Mohammadzadeh M, Atoofi M. Work-related injuries with child labor in Iran. Eur J Pediatr Surg  2014; 24( 01): 117– 20. Google Scholar PubMed  15 Mohammed ES, Ewis AA, Mahfouz EM. Child labor in a rural Egyptian community: an epidemiological study. Int J Public Health  2014; 59( 4): 637– 44. Google Scholar CrossRef Search ADS PubMed  16 Nuwayhid IA, Usta J, Makarem M et al.  . Health of children working in small urban industrial shops. Occup Environ Med  2005; 62( 2): 86– 94. Google Scholar CrossRef Search ADS PubMed  17 Wolff FC. Evidence on the impact of child labor on child health in Indonesia, 1993–2000. Econ Hum Biol  2008; 6( 1): 143– 69. Google Scholar CrossRef Search ADS PubMed  18 Hamdan-Mansour AM, Al-Gamal E, Sultan MK et al.  . Health status of working children in Jordan: comparison between working and nonworking children at schools and industrial sites. Open J Nurs  2013; 3( 01): 55. Google Scholar CrossRef Search ADS   19 Tiwari RR, Saha A. Morbidity profile of child labor at gem polishing units of Jaipur, India. Int J Occup Environ Med  2014; 5( 3): 125– 9. Google Scholar PubMed  20 Khan H, Hameed A, Afridi AK. Study on child labour in automobile workshops of Peshawar, Pakistan, 2007. 21 Banerjee SR, Bharati P, Vasulu TS et al.  . Whole time domestic child labor in metropolitan city of Kolkata, 2008. 22 Daga AS, Working IN. Relative risk and prevalence of illness related to child labor in a rural block. Indian Pediatr  2000; 37( 12): 1359– 60. Google Scholar PubMed  23 Fassa AG, Facchini LA, Dall’Agnol MM et al.  . Child labor and musculoskeletal disorders: the Pelotas (Brazil) epidemiological survey. Public Health Rep  2005; 120( 6): 665– 73. Google Scholar CrossRef Search ADS PubMed  24 Corriols M, Aragón A. Child labor and acute pesticide poisoning in Nicaragua: failure to comply with children’s rights. Int J Occup Environ Health  2010; 16( 2): 175– 82. Google Scholar CrossRef Search ADS   25 Tiwari RR. Eyestrain in working children of footwear making units of Agra, India. Indian Pediatr  2013; 50( 4): 411– 3. Google Scholar CrossRef Search ADS PubMed  26 Tiwari RR, Saha A, Parikh JR. Respiratory morbidities among working children of gem polishing industries, India. Toxicol Ind Health  2009; 25( 1): 81– 4. Google Scholar CrossRef Search ADS PubMed  27 Foroughi M, Moayedi-Nia S, Shoghli A et al.  . Prevalence of HIV, HBV and HCV among street and labour children in Tehran, Iran. Sex Transm Infect  2016; 93( 6): 421– 23. Google Scholar CrossRef Search ADS PubMed  28 Alem AA, Zergaw A, Kebede D et al.  . Child labor and childhood behavioral and mental health problems in Ethiopia. Ethiopian J Health Dev  2006; 20( 2): 119– 26. 29 Al-Gamal E, Hamdan-Mansour AM, Matrouk R et al.  . The psychosocial impact of child labour in Jordan: a national study. Int J Psychol  2013; 48( 6): 1156– 64. Google Scholar CrossRef Search ADS PubMed  30 Bandeali S, Jawad A, Azmatullah A et al.  . Prevalence of behavioural and psychological problems in working children. J Pak Med Assoc  2008; 58( 6): 345. Google Scholar PubMed  31 Fekadu D, Alem A, Hägglöf B. The prevalence of mental health problems in Ethiopian child laborers. J Child Psychol Psychiatry  2006 Sep 1; 47( 9): 954– 9. Google Scholar CrossRef Search ADS PubMed  32 Hadi A. Child abuse among working children in rural Bangladesh: prevalence and determinants. Public Health  2000; 114( 5): 380– 4. Google Scholar PubMed  33 Öncü E, Kurt AÖ, Esenay FI et al.  . Abuse of working children and influencing factors, Turkey. Child Abuse Negl  2013; 37( 5): 283– 91. Google Scholar CrossRef Search ADS PubMed  34 Audu B, Geidam A, Jarma H. Child labor and sexual assault among girls in Maiduguri, Nigeria. Int J Gynecol Obstet  2009 Jan 31; 104( 1): 64– 7. Google Scholar CrossRef Search ADS   35 Gross R, Landfried B, Herman S. Height and weight as a reflection of the nutritional situation of school-aged children working and living in the streets of Jakarta. Soc Sci Med  1996 Aug 1; 43( 4): 453– 8. Google Scholar CrossRef Search ADS PubMed  36 Woodhead M. Psychosocial impacts of child work: a framework for research, monitoring and intervention. Int J Child Rts  2004; 12: 321. Google Scholar CrossRef Search ADS   © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

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Journal of Public HealthOxford University Press

Published: Feb 2, 2018

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