Tobacco Use and Uptake of COVID-19 Vaccinations in Finland: A Population-Based Study

INTRODUCTION

People who smoke are at higher risk of Coronavirus Disease-2019 (COVID-19) hospitalizations and deaths and might benefit greatly from high COVID-19 vaccination coverage. Studies on tobacco use and COVID-19 vaccine uptake in the general population are lacking.

AIMS AND METHODS

We conducted a cohort study utilizing linked data from 42 935 participants from two national surveys in Finland (FinSote 2018 and 2020). Exposures were smoking and smokeless tobacco (snus) use. The primary outcome was the uptake of two COVID-19 vaccine doses. Secondary outcomes were the uptake of one COVID-19 vaccine dose; three COVID-19 vaccine doses; time between the first and second dose; and time between the second and third dose. We examined the association between tobacco use and COVID-19 vaccine uptake and between-dose spacing in Finland.

RESULTS

People who smoke had a 7% lower risk of receiving two COVID-19 vaccine doses (95% confidence interval [CI] = 0.91; 0.96) and a 14% lower risk of receiving three doses (95% CI = 0.78; 0.94) compared to never smokers. People who smoked occasionally had a lower risk of receiving three vaccine doses. People who currently used snus had a 28% lower uptake of three doses (95% CI = 0.56; 0.93) compared to never users but we did not find evidence of an association for one or two doses. We did not find evidence of an association between tobacco use and spacing between COVID-19 vaccine doses.

CONCLUSIONS

People who smoke tobacco products daily, occasionally, and use snus had a lower uptake of COVID-19 vaccines. Our findings support a growing body of literature on lower vaccination uptake among people who use tobacco products.

IMPLICATIONS

People who smoke or use snus might be a crucial target group of public health efforts to increase COVID-19 vaccinations and plan future vaccination campaigns.

CLINICAL TRIALS REGISTRATION NUMBER

NCT05479383.

The Association Between Tobacco Use and Risk of COVID-19 Infection and Clinical Outcomes in Sweden: A Population-Based Study

Background: The association between tobacco use and COVID-19 is controversial. During the early course of the pandemic, limited testing prevented studying a wide spectrum of clinical manifestations. Objective: To examine the potential causal association between tobacco use and COVID-19 during the second wave (1 October 2020-30 June 2021) of the pandemic in Stockholm, Sweden. Methods: A population-based cohort study was conducted in the Stockholm region of Sweden, with information on tobacco use collected prior to the pandemic. Adjusted relative risks (RR) of COVID-19 and 95% confidence intervals (CI) were calculated, contrasting current smokers and snus users to non-users of tobacco. Results: Compared with non-users of tobacco, current smokers had a lower risk of COVID-19 (RR 0.78, 95% CI = 0.75-0.81) and of hospitalisation for the disease. Current snus users had a higher risk of COVID-19. Heavy smokers and snus users had longer hospital stays than non-users of tobacco. Conclusion: Tobacco use may have a different impact on the risk of being infected with SARS-CoV-2 and the risk of developing severe clinical manifestations. Further research is needed to determine the underlying mechanisms.

Changes in prevalence and sociodemographic correlates of tobacco and nicotine use in Finland during the COVID-19 pandemic

BACKGROUND

The impact of the coronavirus disease 2019 (COVID-19) pandemic on tobacco and nicotine use remains debated. We examined whether the prevalence of tobacco and nicotine use and nicotine-replacement therapy (NRT) changed during the COVID-19 pandemic and whether changes differed by sociodemographic groups.

METHODS

Repeated cross-sectional study of three national surveys in Finland (2018, 2019 and 2020; n = 58 526 adults aged 20 and over). Outcomes were daily and occasional smoking, smokeless tobacco (snus) use, e-cigarettes use, total tobacco or nicotine use and NRT use. We examined changes for each outcome by sex, age, educational tertiles, marital status, mother tongue and social participation.

RESULTS

Daily smoking decreased among males by 1.15 percentage points (pp) [95% confidence interval (CI) -2.10 to -0.20] between 2018 and 2020 and 0.86 pp among females (95% CI -1.58 to -0.15). Daily snus use remained stable in both sexes. Daily e-cigarette use was below 1% and remained stable. We found weak evidence of a reduction in total tobacco or nicotine use between 2018 and 2020 (males -1.18 pp, 95% CI -2.68 to 0.32 and females -0.8 pp, 95% CI -1.81 to 0.22). NRT use remained stable. Snus and NRT use decreased among 60- to 74-year-olds but remained stable in other age groups. We did not find evidence of interactions by subgroup for other outcomes.

CONCLUSIONS

Daily smoking decreased in Finland between 2018 and 2020, but other forms of tobacco use did not experience a reduction. The COVID-19 pandemic does not seem to have altered the sustained reduction of smoking in Finland, although substantial sociodemographic differences persist.

Does misclassification of former tobacco smokers explain the 'smoker's paradox' in the risk of COVID-19? Insights from the Stockholm Public Health Cohort

BACKGROUND

The association between tobacco smoking and the risk of COVID-19 and its adverse outcomes is controversial, as studies reported contrasting findings. Bias due to misclassification of the exposure in the analyses of current versus non-current smoking could be a possible explanation because former smokers may have higher background risks of the disease due to co-morbidity. The aim of the study was to investigate the extent of this potential bias by separating non-, former, and current smokers when assessing the risk or prognosis of diseases.

METHODS

We analysed data from 43,400 participants in the Stockholm Public Health Cohort, Sweden, with information on smoking obtained prior to the pandemic. We estimated the risk of COVID-19, hospital admissions and death for (a) former and current smokers relative to non-smokers, (b) current smokers relative to non-current smokers, that is, including former smokers; adjusting for potential confounders (aRR).

RESULTS

The aRR of a COVID-19 diagnosis was elevated for former smokers compared with non-smokers (1.07; 95% confidence interval (CI) =1.00-1.15); including hospital admission with any COVID-19 diagnosis (aRR= 1.23; 95% CI = 1.03-1.48); or with COVID-19 as the main diagnosis (aRR=1.23, 95% CI= 1.01-1.49); and death within 30 days with COVID-19 as the main or a contributory cause (aRR=1.40; 95% CI=1.00-1.95). Current smoking was negatively associated with risk of COVID-19 (aRR=0.79; 95% CI=0.68-0.91).

CONCLUSIONS

Separating non-smokers from former smokers when assessing the disease risk or prognosis is essential to avoid bias. However, the negative association between current smoking and the risk of COVID-19 could not be entirely explained by misclassification.

Current tobacco use and SARS-CoV-2 infection in two Norwegian population-based cohorts

BACKGROUND

Clear evidence of an increased risk for SARS-CoV-2 infection among smokers has not been established. We aimed to investigate associations between cigarette smoking or use of snus (snuff) and other nicotine-containing products and a positive SARS-CoV-2 test, taking test behavior into account.

METHODS

Current tobacco use and testing behavior during the pandemic were recorded by adult participants from the Norwegian Mother, Father and Child Cohort Study and The Norwegian Influenza Pregnancy Cohort. SARS-CoV-2 infection status was obtained from The Norwegian Surveillance System for Communicable Diseases (MSIS) in May 2021 (n = 78,860) and antibody measurements (n = 5581). We used logistic regression models stratified by gender and adjusted for age, education, region, number of household members, and work situation.

RESULTS

Snus use was more common among men (26%) than women (9%) and more prevalent than cigarette smoking. We found no clear associations between cigarette smoking or snus and a COVID-19 diagnosis among men. Associations among women were conflicting, indicating that cigarette smoke was negatively associated with a diagnosis (OR 0.51, 95% CI 0.35, 0.75), while no association was found for snus use (OR 1.07, 95% CI 0.86, 1.34). Compared with non-users of tobacco, both cigarette smokers and snus users had increased odds of being tested for SARS-CoV-2.

CONCLUSIONS

Cigarette smoking, but not snus use, was negatively associated with SARS-CoV-2 infection in women. The lack of an association between snus use and SARS-CoV-2 infection in this population with prevalent snus use does not support the hypothesis of a protective effect of nicotine.

Current tobacco use and COVID-19 diagnoses in a cohort of adult clients of public dental clinics in Sweden

Smoking has been linked with both increased and decreased risk of COVID-19, prompting the hypothesis of a protective role of nicotine in the pathogenesis of the disease. Studies of the association between use of smokeless tobacco and COVID-19 would help refining this hypothesis. We analysed data from 424,386 residents in the Stockholm Region, Sweden, with information on smoking and smokeless tobacco (snus) use prior to the pandemic obtained from dental records. Diagnoses of COVID-19 between February and October 2020 were obtained from health-care registers. We estimated the risk of receiving a diagnosis of COVID-19 for current smokers and for current snus users relative to non-users of tobacco, adjusting for potential confounders (aRR). The aRR of COVID -19 was elevated for current snus users (1.09 ;95%CI = 0.99-1.21 among men and 1.15; 95%CI = 1.00-1.33 among women). The risk for women consuming more than 1 can/day was twice as high as among non-users of tobacco. Current smoking was negatively associated with risk of COVID-19 (aRR = 0.68; 95% CI = 0.61-0.75); including hospital admission (aRR = 0.60; 95% CI = 0.47-0.76) and intensive care (aRR = 0.43; 95% CI = 0.21-0.89). The hypothesis of a protective effect of tobacco nicotine on COVID-19 was not supported by the findings. The negative association between smoking and COVID-19 remains unexplained.

Socioeconomic factors and regional differences in mental disorder-based disability pensioning in Finland

Introduction

Prior literature has indicated low socioeconomic status (SES) and regional differences as epidemiological risk factors for disability pension (DP) due to mental disorders.

Objectives

Our studies aimed to examine these associations and differences in greater detail, with separate consideration of the risk factors for mood disorders (F30–39) and non-affective psychotic disorder (F20–29) DP.

Methods

Subjects (N = 36 879) were all those granted DP due to a mental disorder for the first time between 2010 and 2015 in Finland. All the subjects were matched with three controls. Education, income and occupational status were used as measures of SES. Conditional logistic regression models were used to study SES differences. Negative binomial regression analysis was used to study the levels of DP risk in the Finnish hospital districts.

Results

DP recipients had low educational and income levels and often lived alone. The risk of DP was greater in white-collar occupational groups compared with blue-collar workers. Students had the greatest risk of DP for all mental and mood disorders. Significant differences in the regional mental disorder DP risks did not appear to follow the traditional Finnish health differences.

Conclusions

We found evidence of SES factors and regional variation associating with mental disorder-related severe loss of working and studying ability in a disorder-specific way. The increased risk of white-collar worker DP could be related to the psychosocially demanding contemporary working life. Regional variation in DP may at least partly relate to differences in regional mental health service systems.

Disclosure

No significant relationships.

Early childhood family background predicts meal frequency behaviour in children: Five-year follow-up study

AIMS

Childhood nutrition patterns have an important role in later health. We studied the role of family type, other family background factors and their changes over a five-year follow-up with respect to meal frequency among children.

METHODS

Longitudinal data were collected in 2007-2009 and 2013-2014. A nationally representative sample of Finnish children (n = 1822) aged 0.5-5 years at baseline and 5-10 years at follow-up and their families were used. The participation rate was 83% at baseline and 54% at follow-up. Meal frequency was defined as four to six meals per day. The associations of meal frequency with family background factors over a five-year follow-up period were examined by bivariate and multivariate regression analyses.

RESULTS

Eighty-nine per cent of the 5-10-year-old boys and girls had the recommended meal frequency at follow-up. Living in a single-parent family at baseline increased the risk of not eating the recommended number of meals compared with those living in intact families. After adjustments, a mother's low level of education (OR 0.51, CI 0.29-0.93) and a decrease in income sufficiency (OR 0.54, CI 0.35-0.84) during the follow-up period were unfavourably associated with the recommended meal frequency. The difference between children in stable single-parent, reconstituted or joint physical custody families and those living in stable intact families remained significant when controlling for other variables.

CONCLUSIONS

Single-parent families with a low socioeconomic position represent important target groups for interventions designed to promote regular meal frequency.

Selection of equalization scale and its effect on income-health gradient in the EU countries

Background

It has become customary to adjust income across different household types by using an equalization scale. When assessing inequalities in personal health using the equalized income entails, however, a number of assumptions that are rarely discussed in the socioeconomic health inequality studies. Earlier studies show, e.g. that rather small changes in equalization scale can produce different poverty and income inequality estimates. The aim of this study is to analyse the effect of selection of the scale on socioeconomic health inequalities.

Methods

For this we utilize the 2018 data of the Statistics on Income and Living Conditions (EU-SILC) for 32 European countries. Health is measured with a five choice question on self-perceived health to the household reference person. Household income is measured with the total disposable household (previous year) annual income. Two widely used equalization scales (OECD and OCED modified) are used to for calculating incomes per consumption unit, and then ranked into five income quintiles. A multidimensional frequency table is analyzed with nonparametric tests and log-linear modelling.

Results

Preliminary analyses from a smaller group of the countries indicate that the OECD modified scale produces more “flat” income-health gradient than the OECD scale. Also a smaller proportion of those reporting poor health are classified as having low income. The finding accounts probably for the fact that those living in a single household tend to report poorer health and lower personal income compared to respondents living in a bigger household.

Conclusions

Adjusting for income for the household size appears to affect more on larger households - who also report higher perceived health. Due to this effect, selecting an equivalence scale that imposes a bigger weight on additional household members, such as the OECD modified scale, produces less steep income-health gradient.

Key messages

Adjusting income for household size using standard scales affects the steepness of income-health gradient. Even relatively small changes in the modification scale may have large effects on the health gradient.

Contextual and mental health service factors in mental disorder-based disability pensioning in Finland - a regional comparison

Background

We investigated the regional differences in all mental disorder disability pensions (DP) between 2010 and 2015 in Finland, and separately in mood disorders and non-affective psychotic disorder DP. We also studied the contribution of several district-level contextual and mental health service factors to mental disorder DP.

Methods

Subjects were all those granted mental disorder DP for the first time between 2010 and 2015 in Finland (N = 36,879). Associations between the district-level contextual and mental health service factors and regional DP risks collected from the year 2015 were studied with negative binomial regression analysis in the Finnish hospital districts. The population number on the age (18 to 65 years), gender, occupational status and residential hospital district of the Finnish population from 2015 was used as exposure in the model.

Results

Significant differences in the regional mental disorder DP risks between and within hospital districts did not appear to follow the traditional Finnish health differences. A lower risk of DP was associated with contextual indicators of higher regional socioeconomic level. Furthermore, population density as a proxy for access to mental health services indicated a higher regional DP risk for lower density in all mental (IRR 1.10; 95% CI 1.06–1.14) and mood disorder (IRR 1.12; 95% CI 1.08–1.16) DP. Both the highest and the lowest regional numbers of all mental health outpatient visits were associated with a higher DP risk in all mental and mood disorder DP, whereas particularly low regional numbers of inpatient treatment periods and of patients were associated with a lower risk of DP.

Conclusions

In this comprehensive population-level study, we found evidence of significant regional variation in mental disorder DP and related district-level factors. This variation may at least partly relate to differences in regional mental health service systems and treatment practices. Adapting to the needs of the local population appears to be indicated for both regional mental health service systems and treatment practices to achieve optimal performance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07099-4.

Assessing health gradient with different equivalence scales for household income - A sensitivity analysis

Research on health inequalities shows considerable variation in health by socioeconomic position regardless of measurement. Income level is among the most commonly used indicators to measure the social gradient in health. The income gradient in health may, however, vary according to what aspect of health is studied but equally it may depend on how income is measured. The traditional approach of measuring income is to use household income and to modify it with consumption needs and size of the household. Our hypothesis was that the traditional picture of the income-health gradient becomes more nuanced when we use different equalization scales for household incomes than the most often used modified OECD equalization scale. More technically, we expected the steepness of the income-health gradient to change when the equivalence scale for adjusting household size and composition is altered. The data were Finnish cross-sectional 2017 data from EU-SILC (N = 9406). The primary measures were perceived health status and total household disposable annual income by household type. Ordered probit estimation using Stata package was applied to solving the function between health and income controlling for age, age-squared and gender. Respondents' health status associated with their household type similarly to the association between personal income and household type. Those living in a single household tend to report poorer health but also tend to have lower personal income. Our main finding was that the health-income gradient becomes steeper with the larger equivalence scales, i.e., larger scale relativities, which assume bigger consumption needs for additional household members. One should be more aware of the fact that when household consumption is adjusted with conventional equivalence scales, other income-related aspects beyond consumption potential - such as social status, economic security - are also adjusted for.

Cumulative social disadvantage and hospitalisations due to ambulatory care-sensitive conditions in Finland in 2011─2013: a register study

OBJECTIVES

To study the interplay between several indicators of social disadvantage and hospitalisations due to ambulatory care-sensitive conditions (ACSC) in 2011─2013. To evaluate whether the accumulation of preceding social disadvantage in one point of time or prolongation of social disadvantage had an effect on hospitalisations due to ACSCs. Four common indicators of disadvantage are examined: living alone, low level of education, poverty and unemployment.

DESIGN

A population-based register study.

SETTING

Nationwide individual-level register data on hospitalisations due to ACSCs for the years 2011-2013 and preceding data on social and socioeconomic factors for the years 2006─2010.

PARTICIPANTS

Finnish residents aged 45 or older on 1 January 2011.

OUTCOME MEASURE

Hospitalisations due to ACSCs in 2011-2013. The effect of accumulation of preceding disadvantage in one point of time and its prolongation on ACSCs was studied using modified Poisson regression.

RESULTS

People with preceding cumulative social disadvantage were more likely to be hospitalised due to ACSCs. The most hazardous combination was simultaneously living alone, low level of education and poverty among the middle-aged individuals (aged 45-64 years) and the elderly (over 64 years). Risk ratio (RR) of being hospitalised due to ACSC was 3.16 (95% CI 3.03-3.29) among middle-aged men and 3.54 (3.36-3.73) among middle-aged women compared with individuals without any of these risk factors when controlling for age and residential area. For the elderly, the RR was 1.61 (1.57-1.66) among men and 1.69 (1.64-1.74) among women.

CONCLUSIONS

To improve social equity in healthcare, it is important to recognise not only patients with cumulative disadvantage but also-as this study shows-patients with particular combinations of disadvantage who may be more susceptible. The identification of these vulnerable patient groups is also necessary to reduce the use of more expensive treatment in specialised healthcare.

Late start of upper secondary education and health-compromising behaviours among Finnish adolescents-a follow-up study

Background

The Finnish government has emphasized the need to expedite educational transitions. We study if a late start of upper secondary education is related to health-related selection, namely health-compromising behaviours in adolescence.

Methods

A large cohort of adolescents from the seventh (12–13 years) and ninth (15–16 years) grades answered online classroom surveys (total n = 10 873). They were followed to the start of upper secondary education, obtained from the Joint Application Registry. We compared those who continued studies directly from the ninth grade with later starters. We measured late bedtime, breakfast not every school day, tooth brushing less than twice-a-day, monthly alcohol consumption, weekly smoking, daily energy drinks, physical activity <6 days/week and excessive screen time. Multilevel logistic regressions and latent class analyses were conducted.

Results

In gender and school adjusted models in the seventh grade, all behaviours except physical activity predicted the late start. The strongest predictor was smoking, OR = 2.96 (CI = 2.25–3.89). In the ninth grade, smoking, breakfast, tooth brushing and energy drinks, OR = 1.80, (CI = 1.36–2.39, strongest), were predictive. After controlling for sociodemographic background and academic achievement, associations for alcohol and screen time became non-significant in the seventh grade. In the ninth grade, only screen time remained significant, OR = 1.33 (CI = 1.04–1.71). Health-compromising behaviours formed clusters. Belonging to the unhealthy cluster predicted the late start in both grades, in adjusted models only in the seventh grade.

Conclusions

Students with health-compromising behaviours are less likely to start upper secondary education directly after the compulsory education. This may increase the risk for fragmentary educational trajectories and work careers.

Accumulated Disadvantage over the Lower Secondary School Years in Helsinki Metropolitan Area, Finland

Accumulated disadvantage (AD) is conceptualised here as an agglomeration of unfavourable or prejudicial conditions which in adolescence may compromise the progress to further education or future life chances. There are several theories on AD, suggesting, e.g., (1) an increase of AD by age and (2) trajectories (previous disadvantage predicts later disadvantage). Social pathways theory suggests that (3) a third factor (e.g., socioeconomic position, SEP) mediates or moderates the association between early and later disadvantage, while other theories imply (4) polarisation (a strengthening association between AD and SEP by age) or (5) equalisation (a weakening of association between AD and SEP). We apply these theories to longitudinal data of 7th graders (13 years, N = 5742), followed until the end of the 9th grade. Five dimensions of disadvantage were health (poor self-rated health), social behaviour (poor prosocial behaviour), normative (conduct disorders), educational (poor academic achievement), and economic (parental unemployment). The results show that the prevalence of AD increased over the follow-up as most indicators of disadvantage elevated. AD at the 7th grade predicted later AD, as did the SEP of the students. Moderation of AD by SEP was also observed. The study corroborates with hypotheses on increase of AD, trajectory, and social pathways but no signs of polarisation or equalisation were observed.

Bidirectional Relationship of Sleep with Emotional and Behavioral Difficulties: A Five-year Follow-up of Finnish Adolescents

The long-term effects of sleep on adolescent psychosocial well-being are mostly unknown, although insufficient sleep has been associated with emotional and behavioral difficulties in cross-sectional studies. With a five-year follow-up of Finnish adolescents (Time 1: n = 8834; Mean age = 13 years, 51.1% female, Time 2: n = 5315, Mean age = 15 years, 51.6% female, Time 3: n = 3712; Mean age = 17 years; 50.2% female), the purpose of this longitudinal study was to investigate the relations between self-reported sleep duration, sleep problems, and emotional and behavioral difficulties during adolescence. Emotional and behavioral difficulties were assessed using The Strengths and Difficulties Questionnaire (SDQ) measuring emotional symptoms, conduct problems, hyperactivity, peer problems and total difficulties. Sleep duration was calculated by counting the hours between self-reported bedtime and wake-up time. Sleep problems were assessed with a single question about the general sleep problems. According to the cross-lagged models for sleep and emotional and behavioral difficulties, the findings of this study indicate a developmental process during adolescence where, firstly, short sleep duration is a stronger predictor for current and prospective emotional and behavioral difficulties than vice versa. Secondly, increased emotional and behavioral difficulties expose adolescents to current and later sleep problems more strongly than reverse. Thus, the results show that short sleep duration predisposed to emotional and behavioral difficulties across adolescence, which then led to more prospective sleep problems. These findings suggest a developmental process where sleep and emotional and behavioral difficulties are intertwined in shaping adolescents' health.

Health and educational aspirations in adolescence: a longitudinal study in Finland

Background

The health selection hypothesis suggests that poor health leads to low educational attainment during the life course. Adolescence is an important period as poor health might prevent students from making the best educational choices. We test if health in adolescence is associated with educational aspirations and whether these associations persist over and above sociodemographic background and academic achievement.

Methods

Using classroom surveys, a cohort of students (n = 5.614) from the Helsinki Metropolitan Region was followed from the 7th (12–13 years,) up to the 9th grade (15–16 years) when the choice between the academic and the vocational track is made in Finland. Health factors (Strengths and Difficulties Questionnaire (SDQ), self-rated health, daily health complaints, and long-term illness and medicine prescribed) and sociodemographic background were self-reported by the students. Students’ educational aspirations (applying for academic versus vocational track, or both) and their academic achievement were obtained from the Joint Application Registry held by the Finnish National Agency for Education. We conducted multilevel multinomial logistic regression analyses, taking into account that students are clustered within schools.

Results

All studied health factors were associated with adolescents’ educational aspirations. For the SDQ, daily health complaints, and self-rated health these associations persisted over and above sociodemographic background and academic achievement. Students with better health in adolescence were more likely to apply for the academic track, and those who were less healthy were more likely to apply for the vocational track. The health in the group of those students who had applied for both educational tracks was in between. Inconsistent results were observed for long-term illness. We also found robust associations between educational aspirations and worsening health from grade 7 to grade 9.

Conclusions

Our findings show that selection by health factors to different educational trajectories takes place at early teenage much before adolescents choose their educational track, thus supporting the health selection hypothesis in the creation of socioeconomic health inequalities. Our findings also show the importance of adolescence in this process. More studies are needed to reveal which measures would be effective in helping students with poor health to achieve their full educational potential.

Improving child and adolescent public health from a sociological point of view

Changes in social divisions and their intersections are keys to understanding child and adolescent health from a sociological perspective. Furthermore, with European societies facing demographic change, aging of the population will also lead to a change in the societal position of children, young people and their families. This paper will focus on discussing ways to improving child and adolescent public health with special reference to broader societal and demographic changes and their implications to service provision, milieux and (collective) lifestyles of families. Broadly the point of the presentation is that ignoring the larger societal context may amount to prioritizing services, programmes or income transfers contributing to few or no public health effects at all.

Transition into secondary education and health-compromising behaviours: A longitudinal study

Background

We studied the associations of health-compromising behaviours with a transition into secondary education by following a large cohort of Finnish adolescents. Students with a direct (successful) transition into secondary education after the 9th grade (73%) and those with a late transition (7%) were compared.

Methods

We analysed the following health behaviours in the 7th and 9th grades collected in school surveys in the Helsinki Metropolitan Area: late bed time, irregular breakfast pattern, tooth brushing less than twice a day, monthly alcohol consumption, smoking, regular energy drink consumption, physical activity level under recommendations, and excessive screen time, as well as clustering of these behaviours.

Results

In logistics regression models (adjusted for gender, school), in the 7th grade all health-compromising behaviors except physical inactivity were related to the late transition, and in the 9th grade energy drink, smoking, breakfast, tooth brushing and screen time. In multivariate models (controlled for academic achievement, immigrant status, language spoken at home, and parents’ education) only bed time was independently associated in both grades. Bed time, breakfast, tooth brushing, alcohol, smoking, and energy drink formed three behavioral clusters -healthy, mixed, and unhealthy lifestyles. The last two predicted the late start in both grades; in multivariate models unhealthy only. Change in academic achievement over time, but not in lifestyle, predicted the transition.

Conclusions

Students with unhealthy lifestyle are more likely to start secondary education later than those with healthy lifestyle meaning also postponing of their graduation and start of working life.

Key messages

The unhealthy lifestyle of those who start secondary education later than average, may be one of the mechanisms in the origin of socioeconomic health differences in later life. Healthy lifestyle as early as 13 years predicts successful educational paths.

Low schoolwork engagement and schoolwork difficulties predict smoking in adolescence?

Background

Low academic achievement has been associated with smoking but factors behind this association are poorly known. Such factors could include schoolwork disengagement and schoolwork difficulties. To assess the extent to which they contribute to the explanation of how health inequalities emerge, we study in a longitudinal design whether these have an independent effect on smoking or whether their effect is mediated through academic achievement.

Methods

Longitudinal data were collected in the Helsinki metropolitan area, Finland in 2011 and 2014. Participants were seventh-graders (12 - 13 years, N=9497). In the follow-up, 6534 students reported their smoking status in the ninth grade (15 - 16 years). Smoking, schoolwork behavioural engagement, i.e. participation in academic activities, and disengagement, schoolwork difficulties and cognitive competence were self-reported by adolescents. Academic achievement was obtained from the Finnish national application register on upper secondary education. A mediation analysis was executed with bootstrapped confidence intervals.

Results

Higher schoolwork behavioural engagement and cognitive competence in the seventh grade predicted that adolescents were more likely not to smoke in the ninth grade (all P<0.001) while higher schoolwork disengagement and schoolwork difficulties predicted adolescents' smoking (all P<0.001). The effects were mediated through academic achievement.

Conclusions

Students' behavioural disengagement with schoolwork and schoolwork difficulties are risks for smoking initiation. Their effect is mediated through poor school achievement. As smoking often continues in adulthood and poor school performance typically leads to lower education, schoolwork disengagement and difficulties in adolescence constitute potential pathways to inequalities in health.

Trends of socioeconomic equality in mortality amenable to healthcare and health policy in 1992-2013 in Finland: a population-based register study

OBJECTIVE

To study trends in socioeconomic equality in mortality amenable to healthcare and health policy interventions.

DESIGN

A population-based register study.

SETTING

Nationwide data on mortality from the Causes of Death statistics for the years 1992-2013.

PARTICIPANTS

All deaths of Finnish inhabitants aged 25-74.

OUTCOME MEASURES

Yearly age-standardised rates of mortality amenable to healthcare interventions, alcohol-related mortality, ischaemic heart disease mortality and mortality due to all the other causes by income. Concentration index (C) was used to evaluate the magnitude and changes in income group differences.

RESULTS

Significant socioeconomic inequalities favouring the better-off were observed in each mortality category among younger (25-64) and older (65-74) age groups. Inequality was highest in alcohol-related mortality, C was -0.58 (95% CI -0.62 to -0.54) among younger men in 2008 and -0.62 (-0.72 to -0.53) among younger women in 2013. Socioeconomic inequality increased significantly during the study period except for alcohol-related mortality among older women.

CONCLUSIONS

The increase in socioeconomic inequality in mortality amenable to healthcare and health policy interventions between 1992 and 2013 suggests that either the means or the implementation of the health policies have been inadequate.

Well-Being and Academic Achievement: Differences Between Schools From 2002 to 2010 in the Helsinki Metropolitan Area

BACKGROUND

We studied school-level differences in academic achievement and well-being from 2002 to 2010 in the Helsinki Metropolitan Area, as well as the connection between academic achievement, well-being, and socioeconomic composition.

METHODS

The School Health Promotion Study covered 109 schools and 78% of schoolchildren (N = 100,413; aged 14 to 16 years). Depression was measured with the modified Beck Depression Scale and academic achievement with the grade-point average. Trajectory analysis identified groups of schools that were as heterogeneous over time as possible.

RESULTS

Six school trajectories differing in academic achievement and 3 in well-being were observed. Differences between the trajectories persisted over time. Academic achievement and well-being were related: schools on a poor achievement trajectory were more often on a low-well-being trajectory. The poor socioeconomic composition of students was more common in low-academic achievement and well-being trajectories.

CONCLUSIONS

Academic achievement and well-being differed between schools and are closely related to each other and to the school's socioeconomic composition. Differences between the schools did not increase over time. Educational policies aimed at reducing differences should address both academic achievement and well-being.

Indoor air problems and the perceived social climate in schools: A multilevel structural equation analysis

Indoor air problems in schools appear to influence learning outcomes and absence rates. However, previous research has not investigated whether indoor air problems influence the social climate of schools. Therefore, we studied whether indoor air problems observed in schools associate with students' perceptions of the teacher-student relationship and class spirit. The nationwide sample of Finnish schools (N=194 schools/27153 students) was analyzed using multilevel structural equation modeling. Data on the schools' social climate collected from students were merged with independently collected data on observed indoor air problems from school principals. We found that the teacher-student relationship was reported to be worse in schools with observed indoor air problems compared to those without observed indoor air problems. Furthermore, the reported class spirit was worse in schools with observed indoor air problems, but only among students with a high grade point average. Our findings indicate that indoor air problems may affect the student-perceived social climate.

Health as a Predictor of Students' Academic Achievement: A 3-Level Longitudinal Study of Finnish Adolescents

BACKGROUND

Studies have shown a relationship between students' health and their academic achievements, but whether health of classmates and schoolmates impacts individual students' school achievement is less known. We studied these effects on students in lower secondary school in Finland.

METHODS

Students (seventh grade, age 12-13 years, N = 7779, 123 schools, 565 classes) participated in a classroom survey measuring health (externalizing and internalizing problems, daily health complaints, and long-term illness) and academic achievement. Academic achievement when leaving school (15-16 years) was obtained from the Finnish national application register on upper secondary education. Three-level (student, class, and school) multilevel regression analyses were executed.

RESULTS

All health variables predicted academic achievement at leaving school at the student level and externalizing and internalizing problems at the class level; better health predicted better achievement. Students' health at the school level was not related to academic achievement. The effect of class-level health on academic achievement was as strong as the effect of student-level health.

CONCLUSION

Both student and classmates' health at the beginning of lower secondary school contribute to academic achievement when leaving school.

Pathways from problems in adolescent family relationships to midlife mental health via early adulthood disadvantages - a 26-year longitudinal study

Poor childhood family conditions have a long-term effect on adult mental health, but the mechanisms behind this association are unclear. Our aim was to study the pathways from problematic family relationships in adolescence to midlife psychological distress via disadvantages in early adulthood. Participants of a Finnish cohort study at the age of 16 years old in 1983 were followed up at ages 22, 32 and 42 years old (N = 1334). Problems in family relationships were measured with poor relationship with mother and father, lack of parental support in adolescent’s individuation process and poor home atmosphere, and mental health was assessed using Kessler’s Psychological Distress Scale (K10). We analyzed the indirect effects of adolescent family relations on mental health at age 42 years old via various disadvantages (somatic and psychological symptoms, relationship/marital status, low education/unemployment and heavy drinking) at ages 22 and 32 years old. Problematic adolescent family relationships were associated with midlife psychological distress in women (0.19; 95% CI 0.11, 0.26) and men (0.13; 95% CI 0.04, 0.21). However, after adjustment for adolescent psychological symptoms, the association was only significant for women (0.12; 95% CI 0.04, 0.20). Poor family relationships were associated with various disadvantages in early adulthood. The association from poor family relationships (16 years old) to psychological distress (42 years old) was in part mediated via psychological symptoms in women (0.03; 95% CI 0.01, 0.04) and men (0.02; 95% CI 0.00, 0.04) and in women also via heavy drinking in early adulthood (0.02; 95% CI 0.00, 0.03). Adolescent family relationships have a role in determining adult mental health. Targeted support addressing psychological well-being and hazardous drinking for adolescents with problematic family relationships might prevent disadvantages in early adulthood, and further prevent poor midlife mental health.

The associations of indoor environment and psychosocial factors on the subjective evaluation of Indoor Air Quality among lower secondary school students: a multilevel analysis

Subjective evaluation of Indoor Air Quality (subjective IAQ) reflects both building-related and psychosocial factors, but their associations have rarely been studied other than on the individual level in occupational settings and their interactions have not been assessed. Therefore, we studied whether schools' observed indoor air problems and psychosocial factors are associated with subjective IAQ and their potential interactions. The analysis was performed with a nationwide sample (N = 195 schools/26946 students) using multilevel modeling. Two datasets were merged: (i) survey data from students, including information on schools' psychosocial environment and subjective IAQ, and (ii) data from school principals, including information on observed indoor air problems. On the student level, school-related stress, poor teacher-student relationship, and whether the student did not easily receive help from school personnel, were significantly associated with poor subjective IAQ. On the school level, observed indoor air problem (standardized β = -0.43) and poor teacher-student relationship (standardized β = -0.22) were significant predictors of poor subjective IAQ. In addition, school-related stress was associated with poor subjective IAQ, but only in schools without observed indoor air problem (standardized β = -0.44).

The contribution of travel-related urban zones, cycling and pedestrian networks and green space to commuting physical activity among adults - a cross-sectional population-based study using geographical information systems

BACKGROUND

The current political agenda aims to promote active environments and physical activity while commuting to work, but research on it has provided mixed results. This study examines whether the proximity of green space and people's residence in different travel-related urban zones contributes to commuting physical activity.

METHODS

Population-based cross-sectional health examination survey, Health 2011 study, and geographical information system (GIS) data were utilized. The GIS data on green space and travel-related urban zones were linked to the individuals of the Health 2011 study, based on their home geocoordinates. Commuting physical activity was self-reported. Logistic regression models were applied, and age, gender, education, leisure-time and occupational physical activity were adjusted. Analyses were limited to those of working age, living in the core-urban areas of Finland and having completed information on commuting physical activity (n = 2 098).

RESULTS

Home location in a pedestrian zone of a main centre (odds ratio = 1.63; 95 % confidence interval = 1.06-2.51) or a pedestrian zone of a sub-centre (2.03; 1.09-3.80) and higher proportion of cycling and pedestrian networks (3.28; 1.71-6.31) contributed to higher levels of commuting physical activity. The contribution remained after adjusting for all the environmental attributes and individuals. Based on interaction analyses, women living in a public transport zone were almost two times more likely to be physically active while commuting compared to men. A high proportion of recreational green space contributed negatively to the levels of commuting physical activity (0.73; 0.57-0.94) after adjusting for several background factors. Based on interaction analyses, individuals aged from 44 to 54 years and living in sub-centres, men living in pedestrian zones of sub-centres, and those individuals who are physically inactive during leisure-time were less likely to be physically active while commuting.

CONCLUSIONS

Good pedestrian and cycling infrastructure may play an important role in promoting commuting physical activity among the employed population, regardless of educational background, leisure-time and occupational physical activity. Close proximity to green space and a high proportion of green space near the home may not be sufficient to initiate commuting physical activity in Finland, where homes surrounded by green areas are often situated in car-oriented zones far from work places.

Multiple social disadvantage does it have an effect on amenable mortality: a brief report

INTRODUCTION

Most studies on inequalities in health and health-care focus on single indicators of social position, e.g. income or education. Recent research has suggested that multiple social circumstances need to be analysed simultaneously to disentangle their influence on health. In past decades mortality amenable to health-care, i.e. premature mortality that should not occur given timely and effective health-care, has increasingly been used to study the effect of health-care on health outcomes. This study elaborates the effect of social and regional deprivation and unemployment on the association between income and mortality amenable to health-care in Finland.

METHODS

Individual-level data for deaths were gathered by disease category between 1992 and 2008 for the resident Finnish population aged 25 to 59 years. Differences in amenable mortality and changes over time were assessed using individual-level linked register data. We used gender- and age-standardised rates and Poisson regression models to examine the simultaneous effect of these indicators on amenable mortality.

RESULTS

Altogether 22,663 persons aged 25-59 years died from causes amenable to health-care during the study period. An inverse pattern was found in amenable mortality for income. The mortality rate in the lowest income quintile was 98 (93-104) per 100,000 in the period 1991-1996 while in the highest group the figure was 40 (38-42) for the same period. Whereas the level of amenable mortality decreased, mortality differences between income groups steepened and amenable mortality increased in the lowest income group towards the end of the study period. Those in poor labour market position or living alone had significantly larger income differences in amenable mortality. Risk of regional deprivation was not associated with amenable mortality.

CONCLUSIONS

In order to prevent and treat at an early phase conditions that otherwise may lead to premature and unnecessary deaths more attention should be focused on groups with increased social and economic deprivation risk in municipal health centres with the aim at improving access to primary care. Our results also call for joint action by both health-care and social services, since health services alone cannot deal with the risks posed by accumulating social disadvantage.

A 26-year follow-up study of heavy drinking trajectories from adolescence to mid-adulthood and adult disadvantage

AIMS

The aim of the study was to identify heavy drinking trajectories from age 16 to 42 years and to examine their associations with health, social, employment and economic disadvantage in mid-adulthood.

METHODS

Finnish cohort study's participants who were 16 years old in 1983 were followed up at age 22, 32 and 42 (n = 1334). Heavy drinking was assessed at every study phase and based on these measurements trajectories of heavy drinking were identified. The trajectory groups were then examined as predictors of disadvantage at age 42.

RESULTS

Five distinct heavy drinking trajectories were identified: moderate (35%), steady low (22%), decreasing (9%), increasing (11%) and steady high (23%). Frequencies of the trajectory groups differed by gender. Using the moderate trajectory as a reference category, women in the steady high trajectory had an increased risk of experiencing almost all disadvantages at age 42. In men, increasing and steady high groups had an increased risk for experiencing health and economic disadvantage.

CONCLUSION

Steady high female drinkers and steady high and increasing male drinkers had the highest risk for disadvantage in mid-adulthood. By identifying heavy drinking trajectories from adolescence to mid-adulthood we can better predict long-term consequences of heavy alcohol use and plan prevention and intervention programmes.

Associations between sexual abstinence ideals, religiosity, and alcohol abstinence: a longitudinal study of Finnish twins

We analyzed prevalence and stability of attitudes endorsing sexual abstinence ideals from late adolescence into early adulthood and studied associations of these attitudes with religiosity and alcohol abstinence in a sexually liberal Nordic society. Our population-based sample of Finnish twins permitted comparisons of co-twins concordant for religiosity but discordant for drinking to evaluate the association of sexual abstinence ideals with alcohol abstinence, controlling for household environment. From age 17 to 24, endorsement of sexual abstinence as a romantic ideal declined from 25% to 15%. Religiosity and alcohol abstinence correlated, both separately and together, with endorsing sexual abstinence. Abstinence ideals were associated with literal belief in fundamental tenets of the Bible. The association of sexual abstinence ideals with alcohol abstinence was confirmed in within-family comparisons of co-twins discordant for drinking but concordant for religiosity. Alcohol-abstinent twins were significantly more likely than their non-alcohol-abstinent twin siblings to endorse sexual abstinence ideals; that result suggests the association of sexual abstinence ideals with abstaining from alcohol is not explained by unmeasured confounds in familial background and structure. Our longitudinal results and analyses of discordant twins suggest that attitudes toward sexual abstinence ideals are embedded within other conservative attitudes and behaviors.

Individual differences in adolescent religiosity in Finland: familial effects are modified by sex and region of residence

Data from 16-year-old Finnish twin pairs were used to estimate familial effects on religiosity and the modification of those effects by sex and residential region. The sample of 2265 twin boys and 2521 twin girls formed 779 monozygotic and 1614 dizygotic pairs, 785 of the same sex and 829 of opposite sex. We compared religiosity scores of twins living in more rural and traditional northern Finland with those living in the more urban and secular southern region. Girls had higher religiosity scores than did boys, and twins living in northern Finland had higher religiosity scores than those resident in southern Finland. Correlations for monozygotic twins were slightly higher than those for dizygotic twins, and covariance modeling found modest heritability of religiosity [11% (95% CI 0–24) for girls; 22% (95% CI 6–38) for boys], and substantial shared environmental effects [60% (95% CI 49–69) and 45% (95% CI 31–57)] among girls and boys, respectively. The correlation between shared environmental effects in boys and girls was estimated to be 0.84 (95% CI 0.73–0.99). In analyses distinguishing region of residence, girls living in southern Finland were found to have significantly higher unshared environmental effects than girls in northern Finland, while boys living in the urban south appeared to have lower shared environmental effects, and higher additive genetic effects, than boys living in the rural north.

Subjective social status and health in young people

Health inequalities according to objective socioeconomic position (SEP), have been well-documented. Yet, in young people the associations are negligible. Recently, research on the association of subjective social status (SSS), and adult health has begun to accumulate. Studies on young people are rare and describe societies with large income inequalities. Here, we investigated the association between SSS and health, while controlling for own and familial SEP. The study population consisted of 15-year-olds (N = 2369) who have grown up in a context of low social inequalities. Data were derived from surveys carried out in 2004 in 29 secondary schools in Helsinki. The SSS was measured with an indicator specific to and validated for adolescents (a societal ladder). Outcome measures were self-rated health, health complaints, presence of limiting longstanding illness (LLI) and GHQ-12 caseness (indicating psychiatric morbidity). The SSS associated strongly with all health measures. Adjusting for objective socioeconomic measures attenuated the associations; although they all remained statistically significant apart from LLI among girls. The subjective assessment contributes to health inequalities in young people largely independent of objective SEP. Subjective ratings most probably capture aspects of social hierarchy that are more subtle and less well represented than in conventional measures.

Smoking and SF-36 health functioning

OBJECTIVE

To examine the association between smoking and general health as measured by the Short-Form Health Survey (SF-36) questionnaire.

METHODS

Data derived are from three cross-sectional surveys conducted in 2000, 2001 and 2002. Respondents to the postal surveys were middle-aged employees of the City of Helsinki (1799 men and 7171 women, response rate 67%). Smoking status was divided into current heavy and moderate smokers, ex-smokers and never smokers. Health status was measured by the eight SF-36 subscales and the physical and mental component summaries.

RESULTS

On the physical subscales, current smokers reported poorer health than non-smokers on general health and physical functioning in men. On the mental subscales, current smokers had consistently poorer health than non-smokers. However, often only heavy smokers differed from non-smokers. No differences were found between ex-smokers and never smokers on any subscale or the component summaries of the SF-36.

CONCLUSIONS

Differences between smoking categories were found on some physical and all mental subscales of the SF-36. The differences were slightly larger among men. As heavy smokers more often report limitations with daily activities as well as loss of well-being, these impairments potentially provide valuable incentives for non-smoking to be used in health education messages and interventions.

Socioeconomic status and smoking: analysing inequalities with multiple indicators

BACKGROUND AND AIMS

Socioeconomic differences in smoking have been well established. While previous studies have mostly relied on one socioeconomic indicator at a time, this study examined socioeconomic differences in smoking by using several indicators that reflect different dimensions of socioeconomic position.

DATA AND METHODS

Data derive from Helsinki Health Study baseline surveys conducted among the employees of the City of Helsinki in 2000 and 2001. The data include 6243 respondents aged 40-60 years (response rate 68%). Six socioeconomic indicators were used: education, occupational status, household income per consumption unit, housing tenure, economic difficulties and economic satisfaction. Their associations with current smoking were examined by fitting sequential logistic regression models.

RESULTS

All socioeconomic indicators were strongly associated with smoking among both men and women. When the indicators were examined simultaneously their associations with smoking attenuated, especially when education and occupational status were considered together, and when income and housing tenure were introduced into the models already containing education and occupational status. After mutual adjustment for all socioeconomic indicators, housing tenure and economic satisfaction remained associated with smoking in men. In women, all indicators except income and economic difficulties were inversely associated with smoking after adjustments.

CONCLUSIONS

Smoking was associated with structural, material as well as perceived dimensions of socioeconomic disadvantage. Attempts to reduce smoking among the socioeconomically disadvantaged need to target several dimensions of socioeconomic position.

The role of school context in the increase in young people's health complaints in Finland

According to biological indicators trends in young people's health appear favourable, but the psychosocial aspects suggest a different pattern. We studied the differences across schools in common health complaints and in three groups of factors behind them: pupils' individual characteristics, family related factors and school-related factors. Multilevel linear regression models were used to analyse repeated cross-sectional data from Finnish 8th and 9th graders (14- and 15-year-olds, n=60347) in 109 schools that were surveyed in 1996, 1998 and 2000. Common health complaints increased steadily during the follow-up for all schools and they varied across schools. Both individual and school-level factors contributed significantly to the variation in common health complaints. The study suggests that young people's psychosocial health involves a range of influences deriving from individual susceptibility and from the social and educational functioning of schools. However, none of these factors can account for the rapid decrease in young people's psychosocial health.

The contribution of lone parenthood and economic difficulties to smoking

Smoking is more prevalent among lower socioeconomic status groups, among those who perceive economic difficulties and among lone mothers. Less is known of how these factors contribute to smoking independently. The aim of this study was first to examine the association between smoking and both economic difficulties and lone parenthood. We then also studied to what extent smoking among people experiencing economic difficulties and lone parenthood is due to other factors such as socioeconomic status and social relations. The data derive from surveys conducted among the employees of the City of Helsinki, Finland, in 2000 and 2001 including 6243 respondents aged 40-60 yr (response rate 68%). The measures were daily smoking, economic difficulties and family type, as well as socioeconomic status (education, occupational social class, household income, housing tenure) and social relations. The more had respondents experienced economic difficulties, the more prevalent was their smoking. Smoking among lone parents was more common than among parents living together; this was true for both men and women. After controlling for socioeconomic status and housing tenure, the association between smoking and economic difficulties, as well as that between smoking and lone parenthood, attenuated but remained statistically significant. However, after controlling for social relations the associations became stronger. Both economic difficulties and lone parenthood were associated with smoking independent of education, occupational social class, household disposable income, housing tenure or social relations for both men and women.

Does religiousness explain regional differences in alcohol use in Finland?

AIMS

Because religiousness, a protective factor for alcohol use, is much more prevalent in rural regions, we examined its importance in explaining the differences in adolescent alcohol use found in the rural and the urban regions. In rural Ostrobothnia (hereafter referred to as the rural region), alcohol use is at the lowest level in all of Finland, whereas in Uusimaa, the urban region that surrounds Helsinki (hereafter referred to as the urban region), alcohol use is at the highest level.

METHODS

We analysed cross-sectional questionnaire data collected from Finnish adolescents and their mothers, during 1991-1995.

RESULTS

Abstinence was more prevalent, drinking less frequent, and religiousness higher in the rural region. In the urban region, there was but a negligible correlation between alcohol use and religiousness, whereas in the rural region, the correlation was clear, especially when abstainers were included. In modelling the relationship between region and adolescent abstinence, we found an interaction between mothers' religiousness and region: high religiousness among mothers was more protective of abstinence in the rural region.

CONCLUSIONS

Our results show the importance of religiousness in explaining differences in adolescent alcohol use in regions with different religious traditions, but further studies will be required to explain why mothers' religiousness affects rates of adolescent abstinence differently in the two regions.

Household educational level as a determinant of consumption of raw vegetables among male and female adolescents

BACKGROUND

This study aimed to examine the association between household educational level and consumption of raw vegetables among adolescents and to assess the influence of other determinants on the association, such as family factors, school achievement, health behavior, meal pattern, and weight-related factors. A further aim was to investigate whether the associations were the same for male and female adolescents.

METHODS

The study is based on data from the School Health Promotion Survey 1997-1998. Data were collected by a classroom-administered questionnaire, which was completed by 76,201 secondary school pupils. The study recorded the consumption of raw vegetables, but not the consumption of cooked vegetables. Multivariate logistic regressions were used in the analyses.

RESULTS

A clear positive association between educational level of the household and daily consumption of raw vegetables was found among adolescents. The adolescent's own school achievement explained part of the association between household educational level and consumption of raw vegetables. Other factors explained the association to a small degree, with meal pattern and weight factors having no effect. The associations were similar for both genders.

CONCLUSIONS

Educational level in the household is an important determinant of consumption of raw vegetables. A household with a high educational level will also presumably contain adolescents who have good school achievement, another strong predictor of frequent consumption of raw vegetables.

Patterns of health-related behaviour and their cross-cultural validity--a comparative study on two populations of young people

The study aimed at exploring health-related behaviour patterns among young people. The approach was cross-cultural and the study was focused on identifying culturally valid behaviour patterns in two countries, Finland (F) and Switzerland (CH). Data came from two surveys and included 16- and 18-year-old respondents (F: study year 1993, n = 280, CH: study year 1992/3, n = 272). Three intake behaviours--eating, drinking and smoking--were analysed by means of cluster and logistic regression analyses. Three cross-culturally valid behaviour clusters emerged: a healthy, an unhealthy and a mixed pattern where unhealthy eating behaviours were combined with non-smoking and low alcohol use. The determinants of the patterns were tested by comparing the two countries in relation to the socio-demographic characteristics of the young people that belonged in the same cluster. In both countries the structure of the determinants was almost identically indicating high cross-cultural stability. The study suggests that among young people of this age there is clear and cross-culturally consistent patterning of health-related behaviours.

Individual differences in adolescent religiosity in Finland: familial effects are modified by sex and region of residence

Data from 16-year-old Finnish twin pairs were used to estimate familial effects on religiosity and the modification of those effects by sex and residential region. The sample of 2265 twin boys and 2521 twin girls formed 779 monozygotic and 1614 dizygotic pairs, 785 of the same sex and 829 of opposite sex. We compared religiosity scores of twins living in more rural and traditional northern Finland with those living in the more urban and secular southern region. Girls had higher religiosity scores than did boys, and twins living in northern Finland had higher religiosity scores than those resident in southern Finland. Correlations for monozygotic twins were slightly higher than those for dizygotic twins, and covariance modeling found modest heritability of religiosity [11% (95% CI 0-24) for girls; 22% (95% CI 6-38) for boys], and substantial shared environmental effects [60% (95% CI 49-69) and 45% (95% CI 31-57)] among girls and boys, respectively. The correlation between shared environmental effects in boys and girls was estimated to be 0.84 (95% CI 0.73-0.99). In analyses distinguishing region of residence, girls living in southern Finland were found to have significantly higher unshared environmental effects than girls in northern Finland, while boys living in the urban south appeared to have lower shared environmental effects, and higher additive genetic effects, than boys living in the rural north.