The Association Between Unemployment and Mortality: A Cohort Study of Workplace Downsizing and Closure

Workplace downsizing and closure have been considered natural experiments that strengthen causal inference when assessing the association between unemployment and health. Selection into unemployment plays a lesser role among those exposed to severe workplace downsizing. This study compared mortality for individuals unemployed from stable, downsized, and closed workplaces with a reference group unexposed to unemployment. We examined nationally representative register data of residents of Finland aged 25-63 years in 1990-2009 (n = 275,738). Compared with the control group, the hazard ratio for substance use-related mortality among men unemployed from stable workplaces was 2.43 (95% confidence interval (CI): 2.22, 2.67), from downsized workplaces 1.85 (CI: 1.65, 2.08), and from closed workplaces 2.16 (CI: 1.84, 2.53). Among women, the corresponding estimates were 3.01 (CI: 2.42, 3.74), 2.39 (CI: 1.75, 3.27), and 1.47 (CI: 1.09, 1.99). Unemployment from stable workplaces was associated with mortality from psychiatric and self-harm-related conditions. However, mortality due to ischemic heart disease and other somatic diseases decreased for those unemployed following closure. The results indicate that selection mechanisms partially explain the excess mortality among the unemployed. However, substance-use outcomes among men and women, and fatal accidents and violence among men, might be causally associated with unemployment.

Trauma and violent offending among adolescents: a birth cohort study

BACKGROUND

Earlier studies, based on data collected among juvenile court clients or prisoners, suggest that there is an association between trauma and adolescent-onset offending. However, there is a lack of large-scale data on juvenile violence and clinical mental health observations with unselected participants, and a risk-factor-oriented research combining multiple variables affecting violent behaviour.

METHODS

We analyse the effect of trauma on violent offending using longitudinal register-linkage population data. The study is based on administrative data on all Finnish children born between 1986 and 2000, linked with their biological and adoptive parents (N=913 675). The data include annually updated demographic and socioeconomic information from Statistics Finland, hospital discharge and specialised outpatient service records as well as the data from all suspected criminal offences known to the police (1996-2017). We measured trauma diagnosis at age 12-14 and followed participants for subsequent violent criminality from age 15 to 17.

RESULTS

The population average estimates, taking into account observed substance abuse and other mental health diagnoses, shows that trauma-related disorders (adjustment problems, post-traumatic stress disorder and acute stress disorder) were associated with violent offending. The same was true in sibling fixed effect models, which take into account genetic and environmental confounding shared by siblings.

DISCUSSION

These results suggest that severe stress related to traumatic or strong negative life changes in adolescence is a risk factor for violent behaviour.

Childhood adversity and depressive symptoms among middle-aged and older Chinese: results from China health and retirement longitudinal study

Objectives: A number of studies have established the link between childhood adversity (CA) and depression across the life span. This association can be culturally specific, and it remains unclear whether and how different aspects of CA affect depressive symptoms in later life in non-Western societies.Method: Data were from the China Health and Retirement Longitudinal Study in 2011, 2013, 2014 (Life Event History survey) and 2015 (N = 13,710). Depressive symptoms were measured repeatedly in 2011, 2013, and 2015 using the ten-item Centre for Epidemiologic Studies Depression Scale (CES-D-10). CA was assessed in 2014 by parental physical abuse, maternal emotional neglect, early parental death, parental mental health problems, poor quality of parental relationship, and childhood socioeconomic disadvantage. Multilevel linear models were used to analyse the data.Results: Parental physical abuse was associated with 0.51 (95% confidence interval [CI]: 0.28, 0.74) and 0.59 (95% CI: 0.31, 0.88) higher CES-D-10 scores compared to those without such abuse experience for men and women, respectively. Emotional neglect predicted 0.30 (95% CI: 0.07, 0.51) and 0.33 (95% CI: 0.08, 0.58) higher CES-D-10 scores for men and women. Elevated CES-D-10 scores were also found among men and women whose parents had poor mental health and poor relationship, and those who experienced food inadequacy (men: 0.78, 95% CI: 0.54, 1.01; women: 1.15, 95% CI: 0.90, 1.41). Early parental death nevertheless was not associated with CES-D-10 scores.Conclusion: CA exerts long-term detrimental effects on mental health in mid- and late-life among Chinese adults. The findings are consistent with those from Western societies, except for early parental death.

Rethinking morbidity compression

Studies of morbidity compression routinely report the average number of years spent in an unhealthy state but do not report variation in age at morbidity onset. Variation was highlighted by Fries (1980) as crucial for identifying disease postponement. Using incidence of first hospitalization after age 60, as one working example, we estimate variation in morbidity onset over a 27-year period in Denmark. Annual estimates of first hospitalization and the population at risk for 1987 to 2014 were identified using population-based registers. Sex-specific life tables were constructed, and the average age, the threshold age, and the coefficient of variation in age at first hospitalization were calculated. On average, first admissions lasting two or more days shifted towards older ages between 1987 and 2014. The average age at hospitalization increased from 67.8 years (95% CI 67.7-67.9) to 69.5 years (95% CI 69.4-69.6) in men, and 69.1 (95% CI 69.1-69.2) to 70.5 years (95% CI 70.4-70.6) in women. Variation in age at first admission increased slightly as the coefficient of variation increased from 9.1 (95% CI 9.0-9.1) to 9.9% (95% CI 9.8-10.0) among men, and from 10.3% (95% CI 10.2-10.4) to 10.6% (95% CI 10.5-10.6) among women. Our results suggest populations are ageing with better health today than in the past, but experience increasing diversity in healthy ageing. Pensions, social care, and health services will have to adapt to increasingly heterogeneous ageing populations, a phenomenon that average measures of morbidity do not capture.

Time patterns of external and alcohol-related mortality after marital and non-marital separation: the contribution of psychiatric morbidity

BACKGROUND

External and alcohol-related mortality is elevated postseparation, but the role of poor mental health in explaining this excess is unclear. We assess postseparation excess mortality by union type and over time since separation and examine how psychiatric morbidity present already before separation, during the separation process and after separation attenuates this excess.

METHODS

Using individual-level register data from 1995 to 2012, we followed 311 751 Finns in long-term unions. Psychiatric morbidity was identified from dates of prescription medication purchases and hospital admissions, separations from dates of moving out of joint households and mortality from the Death Register. Cox regression was used to analyse postseparation mortality controlling for psychiatric morbidity before, during and after separation.

RESULTS

External and alcohol-related excess mortality is most pronounced immediately after separation, particularly among men, and is much larger following marital than non-marital separation. After sociodemographic factors are adjusted for, further adjustment for psychiatric morbidity attenuates the excess by about 25%. Psychiatric morbidity poorly explains alcohol-related postseparation excess mortality, but for suicide mortality, adjustment for psychiatric morbidity reduces the excess by about 40% among men and 50% among women. Among women, this is largely due to psychiatric morbidity present already before separation, whereas among men the attenuation is also due to psychiatric morbidity during the separation process and after it.

CONCLUSION

Separation may exacerbate the problems of people already in poor mental health, and relationship dynamics should thus be considered during treatment. Particularly among men separation is a risk factor for suicide even without pre-existing mental health problems.

Men's age at first birth and alcohol-related morbidity and mortality among siblings

BACKGROUND

Men's age at first birth may negatively or positively affect alcohol-related morbidity and mortality, although little evidence is available.

METHODS

We used register data of over 22,000 brothers to analyze the associations between age at first birth and alcohol-related morbidity and mortality from the age of 35 until the age of 60 or 72. We employed conventional Cox models and inter-sibling models, which allowed adjustment for unobserved social and genetic characteristics shared by brothers.

RESULTS

The findings show that men's age at first birth was inversely associated with alcohol-related morbidity and mortality, independent of unobserved characteristics shared by brothers and of observed demographic confounders. Men who had their first child late at 35-45 years experienced lower alcohol-related morbidity and mortality (hazard ratio (HR) = 0.57, 95 % confidence interval (CI) = 0.43, 0.75) than men who had their first child at 25-29. Men who had their first child before age 20 had the highest morbidity and mortality among all fathers (HR = 1.36, 95 % CI = 1.09, 1.69), followed by men who had their child at 20-24 (HR = 1.12, 95 % CI = 1.00, 1.25).

CONCLUSIONS

The results imply that the inverse association between men's age at first birth and alcohol-related morbidity and mortality is not driven by familial characteristics.

A closer look at labour market status and crime among a general population sample of young men and women

Those in the most criminally active age groups are facing particular difficulties in entering the labour market and accumulating stable work experiences. This study uses a large representative sample of Finnish adolescents to examine how different labour market statuses are associated with crime. Both for men and women, within-individual variation in employment is inversely linked to all crime measures considered, albeit to a different extent. In addition, qualitatively different categories of non-employment (e.g., non-participation without legitimate reason, studying, being on parental leave) are distinctly associated with crime. The findings underscore the importance of a detailed conceptualization of labour market status in research that aligns with the changed nature of employment and approximates the actual labour market experiences of young adults.

Midlife socioeconomic position and old-age dementia mortality: a large prospective register-based study from Finland

OBJECTIVES

To assess the association between multiple indicators of socioeconomic position and dementia-related death, and to estimate the contribution of dementia to socioeconomic differences in overall mortality at older ages.

DESIGN

Prospective population-based register study.

SETTING

Finland.

PARTICIPANTS

11% random sample of the population aged 70-87 years resident in Finland at the end of year 2000 (n=54 964).

MAIN OUTCOME MEASURE

Incidence rates, Kaplan-Meier survival probabilities and Cox regression HRs of dementia mortality in 2001-2016 by midlife education, occupational social class and household income measured at ages 53-57 years.

RESULTS

During the 528 387 person-years at risk, 11 395 individuals died from dementia (215.7 per 10 000 person-years). Lower midlife education, occupational social class and household income were associated with higher dementia mortality, and the differences persisted to the oldest old ages. Compared with mortality from all other causes, however, the socioeconomic differences emerged later. Dementia accounted for 28% of the difference between low and high education groups in overall mortality at age 70+ years, and for 21% of the difference between lowest and highest household income quintiles. All indicators of socioeconomic position were independently associated with dementia mortality, low household income being the strongest independent predictor (HR=1.24, 95% CI 1.16 to 1.32), followed by basic education (HR=1.14, 1.06 to 1.23). Manual occupational social class was related to a 6% higher hazard (HR=1.06, 1.01 to 1.11) compared with non-manual social class. Adjustment for midlife economic activity, baseline marital status and chronic health conditions attenuated the excess hazard of low midlife household income, although significant effects remained.

CONCLUSION

Several indicators of socioeconomic position predict dementia mortality independently and socioeconomic inequalities persist into the oldest old ages. The results demonstrate that dementia is among the most important contributors to socioeconomic inequalities in overall mortality at older ages.

Maternal age and risk of low birth weight and premature birth in children conceived through medically assisted reproduction. Evidence from Finnish population registers

STUDY QUESTION

Does the risk of low birth weight and premature birth increase with age among mothers who conceive through medically assisted reproduction (MAR)?

SUMMARY ANSWER

Among MAR mothers, the risk of poorer birth outcomes does not increase with maternal age at birth except at very advanced maternal ages (40+).

WHAT IS KNOWN ALREADY

The use of MAR treatments has been increasing over the last few decades and is especially diffused among women who conceive at older ages. Although advanced maternal age is a well-known risk factor for adverse birth outcomes in natural pregnancies, only a few studies have directly analysed the maternal age gradient in birth outcomes for MAR mothers.

STUDY DESIGN, SIZE, DURATION

The base dataset was a 20% random sample of households with at least one child aged 0-14 at the end of 2000, drawn from the Finnish population register and other administrative registers. This study included children who were born in 1995-2000, because the information on whether a child was conceived through MAR or naturally was available only from 1995 onwards.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The outcome measures were whether the child had low birth weight (LBW, <2500 g at birth) and whether the child was delivered preterm (<37 weeks of gestation). Conceptions through MAR were identified by examining data on purchases of prescription medication from the National Prescription Register. Linear probability models were used to analyse and compare the maternal age gradients in birth outcomes of mothers who conceived through MAR or naturally before and after adjustment for maternal characteristics (i.e. whether the mother suffered from acute/chronic conditions before the pregnancy, household income and whether the mother smoked during pregnancy).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 56 026 children, 2624 of whom were conceived through MAR treatments, were included in the study. Among the mothers who used MAR to conceive, maternal age was not associated with an increased risk of LBW (the overall prevalence was 12.6%) at ages 25-39. For example, compared to the risk of LBW at ages 30-34, the risk was 0.22 percentage points lower (95% CI: -3.2, 2.8) at ages 25-29 and was 1.34 percentage points lower (95% CI: -4.5, 1.0) at ages 35-39. The risk of LBW was increased only at maternal ages ≥40 (six percentage points, 95% CI: 0.2, 12). Adjustment for maternal characteristics only marginally attenuated these associations. In contrast, among the mothers who conceived naturally, the results showed a clear age gradient. For example, compared to the risk of LBW (the overall prevalence was 3.3%) at maternal ages 30-34, the risk was 1.1 percentage points higher (95% CI: 0.6, 1.6) at ages 35-39 and was 1.5 percentage points higher (95% CI: 0.5, 2.6) at ages ≥40. The results were similar for preterm births.

LIMITATIONS, REASON FOR CAUTION

A limited number of confounders were included in the study because of the administrative nature of the data used. Our ability to reliably distinguish mothers based on MAR treatment type was also limited.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to analyse the maternal age gradient in the risk of adverse birth outcomes among children conceived through MAR using data from a nationally representative sample and controlling for important maternal health and socio-economic characteristics. This topic is of considerable importance in light of the widespread and increasing use of MAR treatments.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this project was provided by the European Research Council (grant no. 803959 MARTE to Alice Goisis and grant no. 336475 COSTPOST to Mikko Myrskylä). E.S. reports personal fees from Theramex, personal fees from Merck Serono, personal fees from Health Reimbursement Arrangement, non-financial support from Merck Serono and grants from Ferring, grants from Theramex, outside the submitted work. The remaining authors have no competing interests.

TRIAL REGISTRTION NUMBER

N/A.

Social services Interventions and the Mental Health and Mortality of care leavers: a population based data linkage study in Northern Ireland and Finland

BackgroundResearch has highlighted the poor mental health of looked after children compared to those never in care. However, little is known on what becomes of these children and their mental health trajectories after they leave the care of social services. In addition, previous studies are limited in their ability to differentiate between type of social care intervention received; kinship care, foster care or residential care. AimTo utilise nationwide social services data from two countries (Northern Ireland (NI) and Finland), with similar populations but different intervention policies, linked to a range of demographic and health datasets to examine the mental health outcomes of young adults in the years following leaving care. MethodsData from both countries on children born 1991-2000 were linked to social services data, hospital admissions, prescribed medication data and death records. Mental health outcomes were defined after the age of 18years (when statutory care provision ends) examined by care intervention and included admissions to psychiatric hospital, for self-harm and death by suicide. ResultsThe gender split in care in Finland is reflective of the population but more males are in care in NI. Initial results from Finnish data suggest those exposed to care in childhood have an increased risk of self-harm, psychiatric hospital admission and suicide after the age of 18years compared to those never in care. After adjusting for gender, age of entry to care and deprivation at birth those exposed to any care intervention had 3 times the risk of suicide (HR=3.06, 95% CI 1.18,7.98). Risk increased with duration in care but was equivalent across care intervention types. Analysis on the NI data is underway. ConclusionFull results will be available December 2019 and will explore which care pathways are most associated with poor mental health outcomes informing discussion around intervention opportunities and policy.

Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Validating record-linkage based methodology for addressing health survey non-participation

Background

As a consequence of declining levels of participation in health surveys, the results purported to be population-representative may be biased. Traditional adjustments for non-participation, such as weighting, can fail to correct for such biases. We aim to validate our developed methodology, which simulates non-participants, and compare results from the inferred sample to the ’gold standard’ sample of participants and true non-participants, and participants alone.

Methods

Participants and non-participants of the Finnish Health 2000 survey, and a contemporaneous population sample are available, with alcohol-related hospitalisations and deaths (“harms”, individually record-linked for all Health 2000 invitees). Synthetic observations on non-participants were simulated through comparison of participants and population sample. Alcohol consumption of true and inferred non-participants were multiply imputed based on harms and education as well as age and sex, assuming data are Missing At Random (MAR). Results are compared via the relative differences (RD) between the inferred sample and 1) gold standard sample, and 2) participants alone.

Results

Average weekly estimates for men are 129g in the inferred sample, and 130g in the gold standard (RD -1.2%, 95%CI -2.0, -0.4%), and 35g for women in both samples (RD -0.8%; -1.9, 0.3%). Estimates for men with secondary levels of education had the greatest RD (-1.9%; -3.3, -0.5%). Comparisons between the participants and the inferred sample revealed few differences.

Conclusions

All RD between the inferred and gold standard samples lie within our ±5% acceptability limits, in support of the use of our methodology for adjusting for non-participation in health surveys. However, under MAR, there are no significant differences between the results generated from the inferred sample and the participants alone. Further work exploring Missing Not At Random scenarios is required to ensure utility for reliable population health monitoring.

Key messages

Survey weights alone cannot adjust for non-representativeness, but we have shown that data linkage can be used to match the characteristics and outcomes of the selected sample. Non-participation in health surveys may be adjusted for using our methodology, with further exploration into alternative missing data scenarios required.

Experience of maternal and paternal adversities in childhood as determinants of self-harm in adolescence and young adulthood

INTRODUCTION

Previous studies suggest that childhood experience of parental adversities increases the risk of subsequent offspring self-harm, but studies on distinct paternal and maternal characteristics are few and it remains unclear how these interact with childhood social position. The study aims to assess whether paternal and maternal adversities have different associations with offspring self-harm in adolescence and young adulthood. Interaction by offspring gender and childhood income are investigated, as well as cumulative effects of multiple adversities.

METHODS

The study uses administrative register data on a 20% random sample of Finnish households with children aged 0-14 years in 2000. We follow children born in 1986-1998 (n=155 855) from their 13th birthday until 2011. Parental substance abuse, psychiatric disorders, criminality and hospitalisations due to interpersonal violence or self-harm are used to predict offspring self-harm with Cox proportional hazards models.

RESULTS

The results show a clear increase in the risk of self-harm among those exposed to maternal or paternal adversities with HRs between 1.5 and 5.4 among boys and 1.7 and 3.9 among girls. The excess risks hold for every measure of maternal and paternal adversities after adjusting for childhood income and parental education. Evidence was found suggesting that low income, accumulation of adversity and female gender may exacerbate the consequences of adversities.

CONCLUSIONS

Our findings suggest that both parents' adversities increase the risk of self-harm and that multiple experiences of parental adversities in childhood are especially harmful, regardless of parent gender. Higher levels of childhood income can protect from the negative consequences of adverse experiences.

Progress in reducing inequalities in cardiovascular disease mortality in Europe

OBJECTIVE

To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

METHODS

In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

RESULTS

Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

CONCLUSIONS

Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

Mortality inequalities by occupational class among men in Japan, South Korea and eight European countries: a national register-based study, 1990-2015

BACKGROUND

We compared mortality inequalities by occupational class in Japan and South Korea with those in European countries, in order to determine whether patterns are similar.

METHODS

National register-based data from Japan, South Korea and eight European countries (Finland, Denmark, England/Wales, France, Switzerland, Italy (Turin), Estonia, Lithuania) covering the period between 1990 and 2015 were collected and harmonised. We calculated age-standardised all-cause and cause-specific mortality among men aged 35-64 by occupational class and measured the magnitude of inequality with rate differences, rate ratios and the average inter-group difference.

RESULTS

Clear gradients in mortality were found in all European countries throughout the study period: manual workers had 1.6-2.5 times higher mortality than upper non-manual workers. However, in the most recent time-period, upper non-manual workers had higher mortality than manual workers in Japan and South Korea. This pattern emerged as a result of a rise in mortality among the upper non-manual group in Japan during the late 1990s, and in South Korea during the late 2000s, due to rising mortality from cancer and external causes (including suicide), in addition to strong mortality declines among lower non-manual and manual workers.

CONCLUSION

Patterns of mortality by occupational class are remarkably different between European countries and Japan and South Korea. The recently observed patterns in the latter two countries may be related to a larger impact on the higher occupational classes of the economic crisis of the late 1990s and the late 2000s, respectively, and show that a high socioeconomic position does not guarantee better health.

A gold mine, but still no Klondike: Nordic register data in health inequalities research

Aims: Future research on health inequality relies on data that cover life-course exposure, different birth cohorts and variation in policy contexts. Nordic register data have long been celebrated as a 'gold mine' for research, and fulfil many of these criteria. However, access to and use of such data are hampered by a number of hurdles and bottlenecks. We present and discuss the experiences of an ongoing Nordic consortium from the process of acquiring register data on socio-economic conditions and health in Denmark, Finland, Norway and Sweden. Methods: We compare experiences of data-acquisition processes from a researcher's perspective in the four countries and discuss the comparability of register data and the modes of collaboration available to researchers, given the prevailing ethical and legal restrictions. Results: The application processes we experienced were time-consuming, and decision structures were often fragmented. We found substantial variation between the countries in terms of processing times, costs and the administrative burden of the researcher. Concerned agencies differed in policy and practice which influenced both how and when data were delivered. These discrepancies present a challenge to comparative research. Conclusions: We conclude that there are few signs of harmonisation, as called for by previous policy documents and research papers. Ethical vetting needs to be centralised both within and between countries in order to improve data access. Institutional factors that seem to facilitate access to register data at the national level include single storage environments for health and social data, simplified ethical vetting and user guidance.

The relationship between living arrangements and higher use of hospital care at middle and older ages: to what extent do observed and unobserved individual characteristics explain this association?

BACKGROUND

Previous research has shown that certain living arrangements, such as living alone, are associated with worse health at older ages. We assessed the association between living arrangements and hospital care use among middle-aged and older adults, and investigated to what extent observed and unobserved individual characteristics explain this association.

METHODS

Longitudinal Finnish registry data for men and women aged 50-89 years were used for the period 1987-2007. The relationship between living arrangements (based on whether an individual lived with a partner, other adults or alone, and whether they lived with minor/adult children) and heavy hospital care use (i.e., having been in hospital for 8 or more days in a year) was studied. First, we applied logistic regression models and linear probability models controlling for observed time-invariant factors (socioeconomic status measured by education, labour force status, and household income; and marital status), and then individual linear probability models with fixed-effects to further account for unobserved time-invariant individual characteristics in the measurement period. Analyses were done separately for 10 year age-groups.

RESULTS

In the logistic regression models, men and women who lived alone had higher crude odds of heavy hospital care use than those living only with their partner. These odds ratios were highest for men and women in the youngest age category (50-59 years, 1.72 and 1.36 respectively) and decreased with age. Adjusting for observed time-invariant socioeconomic status attenuated these odds by 14-40%, but adjusting for marital status did not affect the results. Lower odds were observed among adults aged 50-59 years who lived with their partner and (minor or adult) children. But odds were higher for individuals aged 60-79 years who co-resided with their adult children, regardless of whether they lived with a partner. Adjusting for observed time-invariant factors generally did not change these results. After further adjusting for unobserved time-invariant individual characteristics in the individual fixed-effects models, most of these associations largely attenuated or disappeared, particularly for ages 80-89 years.

CONCLUSIONS

The association between living arrangements and higher use of hospital care at middle and older ages is largely explained by socioeconomic disadvantage and unobserved time-invariant individual characteristics.

Age at Immigration, Generational Status, and Death Among Children of Immigrant Mothers: A Longitudinal Analysis of Siblings

Studies have documented that age at immigration and generational status are important predictors of socioeconomic outcomes among children of immigrants. Whether these characteristics are related to long-term risk of death is unknown. Leveraging variation within sibships, we evaluated the association of age at immigration and generational status (i.e., first or second generation) with death among children of immigrant mothers to Sweden. Data included 272,429 individuals (126,701 sibships) aged 15 or more years from the total Swedish population followed between 1990 and 2009. Population-average and sibling fixed-effect regressions were estimated, with the latter controlling for unobserved factors shared by siblings. The foreign-born children of immigrants experienced a 17% higher risk of death than the Swedish-born children of immigrants. This excess risk was evident for external and nonexternal causes of death. In general, a graded association was not detected between age at immigration and death among the foreign-born individuals; however, those arriving during primary school ages appeared especially vulnerable. This study provides robust evidence that among children of immigrants, being foreign born was associated with a long-term death penalty compared with being born in the host country.

Life course socioeconomic position and incidence of mid-late life depression in China and England: a comparative analysis of CHARLS and ELSA

BACKGROUND

Despite the growing prevalence of depression in the Chinese elderly, there is conflicting evidence of life course socioeconomic position (SEP) and depression onset in China, and whether this association is akin to that observed in Western societies. We compared incident risk of mid-late life depression by childhood and adulthood SEP in China and England, a country where mental health inequality is firmly established.

METHODS

Depression-free participants from the China Health and Retirement Longitudinal Study (N=8508) and the English Longitudinal Study of Ageing (N=6184) were studied over 4 years. Depressive symptoms were classified as incident cases using the Center for Epidemiologic Studies Depression Scale criteria. Associations between SEP (education, wealth, residence ownership and childhood/adolescent deprivation) and depression symptom onset were assessed using Cox proportional hazards models. In China, we also investigated children's government employment status as a SEP marker.

RESULTS

Higher education and wealth predicted lower incidence of depression in both countries. The association with non-ownership of residence appeared stronger in England (HR 1.61, 95% CI 1.41 to 1.86) than in China (HR 1.11, 95% CI 0.95 to 1.29), while that with childhood/adolescent deprivation was stronger in China (HR 1.43, 95% CI 1.29 - 1.60) than in England (HR 1.33, 95% CI 0.92 to 1.92). Chinese adults whose children were employed in high-status government jobs, had lower rates of depression onset.

CONCLUSIONS

Consistent findings from China and England demonstrate that SEP is a pervasive determinant of mid-late life depression in very diverse social contexts. Together with conventional measures of SEP, the SEP of children also affects the mental health of older Chinese.

The contribution of smoking-related deaths to the gender gap in life expectancy in Sweden between 1997 and 2016

Aims: In recent decades, smoking-related mortality has declined among men and increased among women in Sweden. We estimate the contribution of smoking-related deaths to the narrowing of the gender gap in life expectancy in Sweden between 1997 and 2016. Methods: We extracted population data on deaths and population under risk on the entire Swedish population aged 25 years and over for the period 1997-2016. Smoking-related mortality was assessed using an indirect method based on lung cancer mortality. We then estimated the contribution of smoking to the gender gap in life expectancy by comparing the observed life expectancies to life expectancies excluding smoking-related deaths. Results: The gender gap in life expectancy was 5.0 years in 1997 and 3.4 years in 2016. The gender gap narrowed by 1.6 years, of which 0.6 years were attributable to smoking-related deaths. Conclusions: The combination of decreasing smoking-related mortality among men and increasing smoking-related mortality among women in Sweden accounted for almost 40% of the narrowing of the gender gap in life expectancy during the period 1997-2016.

Income trajectories prior to alcohol-attributable death in Finland and Sweden

BACKGROUND AND AIMS

Mortality from alcohol-attributable causes is patterned by income. We study the income trajectories 17-19 years prior to death in order to determine: (1) whether income levels and trajectories differ between those who die of alcohol-attributable causes, survivors with similar socio-demographic characteristics, all survivors and those dying of other causes; (2) whether the income trajectories of these groups differ by education; and (3) whether there are differences in income trajectories between Finland and Sweden-two countries with differing levels of alcohol-attributable mortality but similar welfare-provision systems.

DESIGN

Retrospective cohort study using individual-level longitudinal register data including information on income, cause of death and socio-economic status.

SETTING

Finland and Sweden.

PARTICIPANTS

The subjects comprised an 11% sample of the Finnish population in 2006-07 and the total population of Sweden aged 45-64 years in 2007-08.

MEASUREMENTS

Median household income trajectories by educational group were calculated by cause of death and population alive during the respective years. Additionally, propensity score matching was used to match the surviving population to those dying from alcohol-attributable causes with regard to socio-demographic characteristics.

FINDINGS

The median income 17-19 years prior to death from alcohol-attributable causes was 92% (Finland) and 91% (Sweden) of survivor income: 1 year prior to death, the respective figures were 47% and 57%. The trajectories differed substantially. Those dying of alcohol-attributable causes had lower and decreasing incomes for substantially longer periods than survivors and people dying from other causes. These differences were more modest among the highly educated individuals. The baseline socio-demographic characteristics of those dying of alcohol causes did not explain the different trajectories.

CONCLUSIONS

In Finland and Sweden, income appears to decline substantially before alcohol-attributable death. Highly educated individuals may be able to buffer the negative effects of extensive alcohol use on their income level. Income trajectories are similar in Finland and Sweden, despite marked differences in the level of alcohol-attributable mortality.

Rural-urban disparities in age trajectories of depression caseness in later life: The China Health and Retirement Longitudinal Study

BACKGROUND

No consensus has been reached on whether depression decreases or increases with age in later life. Majority of the evidence comes from Western societies, while little is known about this relationship and its rural-urban disparities in the Chinese context.

METHODS

Three waves of data from 15,501 Chinese adults aged 45-85 years from the China Health and Retirement Longitudinal Study, Chinese sister study of Health and Retirement Study, were used. Depression caseness was identified using the 10-item Center for Epidemiologic Studies Depression Scale (score ≥12). Urbanisation levels were determined by combining rural-urban residence and rural-urban Hukou (a household registration system). Odds ratios and predicted probabilities of depression caseness were estimated using generalised linear mixed models.

RESULTS

For both men and women and across all ages, the crude predicted probability of depression caseness was the highest in the rural group, followed by the semi-urban group, and the lowest in the urban group. The probability was stable over age among urban men (around 0.05), but it increased at an accelerated rate with age among semi-urban men (0.25 at age 85, 95% confidence interval [CI]: 0.13-0.44) and rural men (0.29 at age 85, 95% CI: 0.22-0.39). Among women the age pattern was similar between the urbanisation groups: the probability increased with age, reached a peak at ages 75-80 (urban women: 0.16, 95% CI: 0.13-0.20; semi-urban women: 0.28, 95% CI: 0.20-0.39; rural women: 0.41, 95% CI: 0.36-0.46), and decreased slightly afterwards. These differences were significantly attenuated when socio-demographic characteristics and physical disability, but not when behaviour-related factors, were controlled for.

CONCLUSION

The age trajectories of later-life depression caseness varied by gender and urbanisation levels, and were not U-shaped as in many Western societies. The increasing depression caseness with age and the large rural disadvantage were substantially driven by socio-demographic characteristics and physical disability.

Validation of non-participation bias methodology based on record-linked Finnish register-based health survey data: a protocol paper

INTRODUCTION

Decreasing participation levels in health surveys pose a threat to the validity of estimates intended to be representative of their target population. If participants and non-participants differ systematically, the results may be biased. The application of traditional non-response adjustment methods, such as weighting, can fail to correct for such biases, as estimates are typically based on the sociodemographic information available. Therefore, a dedicated methodology to infer on non-participants offers advancement by employing survey data linked to administrative health records, with reference to data on the general population. We aim to validate such a methodology in a register-based setting, where individual-level data on participants and non-participants are available, taking alcohol consumption estimation as the exemplar focus.

METHODS AND ANALYSIS

We made use of the selected sample of the Health 2000 survey conducted in Finland and a separate register-based sample of the contemporaneous population, with follow-up until 2012. Finland has nationally representative administrative and health registers available for individual-level record linkage to the Health 2000 survey participants and invited non-participants, and the population sample. By comparing the population sample and the participants, synthetic observations representing the non-participants may be generated, as per the developed methodology. We can compare the distribution of the synthetic non-participants with the true distribution from the register data. Multiple imputation was then used to estimate alcohol consumption based on both the actual and synthetic data for non-participants, and the estimates can be compared to evaluate the methodology's performance.

ETHICS AND DISSEMINATION

Ethical approval and access to the Health 2000 survey data and data from administrative and health registers have been given by the Health 2000 Scientific Advisory Board, Statistics Finland and the National Institute for Health and Welfare. The outputs will include two publications in public health and statistical methodology journals and conference presentations.