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  • 1. Bijlsma, Maarten J.
    et al.
    Tarkiainen, Lasse
    Myrskylä, Mikko
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Max Planck Institute for Demographic Research, Germany: University of Helsinki,, Finland.
    Unemployment and subsequent depression: A mediation analysis using the parametric G-formula2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 194, p. 142-150Article in journal (Refereed)
    Abstract [en]

    The effects of unemployment on depression are difficult to establish because of confounding and limited understanding of the mechanisms at the population level. In particular, due to longitudinal interdependencies between exposures, mediators and outcomes, intermediate confounding is an obstacle for mediation analyses. Using longitudinal Finnish register data on socio-economic characteristics and medication purchases, we extracted individuals who entered the labor market between ages 16 and 25 in the period 1996 to 2001 and followed them until the year 2007 (n = 42,172). With the parametric G-formula we estimated the population averaged effect on first antidepressant purchase of a simulated intervention which set all unemployed person years to employed. In the data, 74% of person-years were employed and 8% unemployed, the rest belonging to studying or other status. In the intervention scenario, employment rose to 85% and the hazard of first antidepressant purchase decreased by 7.6%. Of this reduction 61% was mediated, operating primarily through changes in income and household status, while mediation through other health conditions was negligible. These effects were negligible for women and particularly prominent among less educated men. By taking complex interdependencies into account in a framework of observed repeated measures data, we found that eradicating unemployment raises income levels, promotes family formation, and thereby reduces antidepressant consumption at the population-level.

  • 2. Bijlsma, Maarten J.
    et al.
    Wilson, Ben
    Stockholm University, Faculty of Social Sciences, Department of Sociology. London School of Economics and Political Science, United Kingdom.
    Tarkiainen, Lasse
    Myrskylä, Mikko
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Max Planck Institute for Demographic Research, Germany; University of Helsinki, Finland.
    The Impact of Unemployment on Antidepressant Purchasing: Adjusting for Unobserved Time-constant Confounding in the g-Formula2019In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 30, no 3, p. 388-395Article in journal (Refereed)
    Abstract [en]

    Background: The estimated effect of unemployment on depression may be biased by time-varying, intermediate, and time-constant confounding. One of the few methods that can account for these sources of bias is the parametric g-formula, but until now this method has required that all relevant confounders be measured.

    Methods: We combine the g-formula with methods to adjust for unmeasured time-constant confounding. We use this method to estimate how antidepressant purchasing is affected by a hypothetical intervention that provides employment to the unemployed. The analyses are based on an 11% random sample of the Finnish population who were 30–35 years of age in 1995 (n = 49,753) and followed until 2012. We compare estimates that adjust for measured baseline confounders and time-varying socioeconomic covariates (confounders and mediators) with estimates that also include individual-level fixed-effect intercepts.

    Results: In the empirical data, around 10% of person-years are unemployed. Setting these person-years to employed, the g-formula without individual intercepts found a 5% (95% confidence interval [CI] = 2.5%, 7.4%) reduction in antidepressant purchasing at the population level. However, when also adjusting for individual intercepts, we find no association (−0.1%; 95% CI = −1.8%, 1.5%).

    Conclusions: The results indicate that the relationship between unemployment and antidepressants is confounded by residual time-constant confounding (selection). However, restrictions on the effective sample when using individual intercepts can compromise the validity of the results. Overall our approach highlights the potential importance of adjusting for unobserved time-constant confounding in epidemiologic studies and demonstrates one way that this can be done.

  • 3. Einiö, Elina
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Risk of Hospitalization for Cancer, Musculoskeletal Disorders, Injuries, or Poisonings Surrounding Widowhood2019In: American Journal of Epidemiology, ISSN 0002-9262, E-ISSN 1476-6256, Vol. 188, no 1, p. 110-118Article in journal (Refereed)
    Abstract [en]

    Psychological distress has been indicated to affect the risk of death from cardiovascular disease, cancer, and external causes. Mortality from these major causes of death is also known to be elevated after widowhood when distress is at a heightened level. Surprisingly little is known about changes in health other than mental and cardiac health shortly before widowhood. We used longitudinal data on widowed (n = 19,185) and continuously married (n = 105,939) individuals in Finland (1996-2002) to assess the risk of hospitalization for cancer and for external and musculoskeletal causes surrounding widowhood or random dates. We fitted population-averaged logit models using longitudinal data of older adults aged 65 years or over. The results show that hospitalization for injuries had already increased prior to widowhood and clearly peaked after it. The increases were largely related to falls. A similar increasing pattern of findings was not found around a random date for a group of continuously married individuals. Hospitalizations for cancer and musculoskeletal disorders appeared to be unrelated to the process of widowhood. Hospitalizations for poisonings increased after widowhood. The results imply that the process of widowhood is multifaceted and that various types of health changes should be studied separately and before the actual loss.

  • 4. Einiö, Elina
    et al.
    Moustgaard, Heta
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Leinonen, Taina
    Does the risk of hospitalisation for ischaemic heart disease rise already before widowhood?2017In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 71, no 6, p. 599-605Article in journal (Refereed)
    Abstract [en]

    Background The death of a spouse has been shown to increase mortality from various causes, including ischaemic heart disease. It is unclear, however, whether cardiac problems are already on the rise before widowhood.

    Methods Using longitudinal register data of Finnish widows-to-be aged 65 and over at baseline (N=19 185), we assessed the risk of hospitalisation for ischaemic heart disease 18 months before and after widowhood. Hospital admissions were derived from national hospital discharge registers between 1996 and 2002. Analyses used population-averaged and fixed-effects logistic models, the latter of which controlled for unobserved time-invariant characteristics, such as genetic susceptibility, personality and behavioural and medical history.

    Results For men, fixed-effects model revealed that hospitalisation for ischaemic heart disease increased twofold already 0–3 months prior to the death of a spouse (OR=2.09, 95% CI 1.22 to 3.60), relative to the period of 15–18 months before widowhood. It stayed at a heightened level up to 6 months following bereavement (OR=2.15, 95% CI 1.07 to 4.30). Among women, the fixed-effects analysis detected no statistically significant increase in hospitalisation for ischaemic heart disease before or after widowhood.

    Conclusions These findings indicate that men are already vulnerable to cardiac problems before the death of a wife. Medical interventions and health counselling could be targeted to the husbands of terminally ill patients, in order to improve their cardiovascular health over the transition to widowhood.

  • 5. Einiö, Elina
    et al.
    Nisén, Jessica
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Number of children and later-life mortality among Finns born 1938-502016In: Population Studies, ISSN 0032-4728, E-ISSN 1477-4747, Vol. 70, no 2, p. 217-238Article in journal (Refereed)
    Abstract [en]

    We investigated the association between number of offspring and later-life mortality of Finnish men and women born 1938–50, and whether the association was explained by living conditions in own childhood and adulthood, chronic conditions, fertility timing, and unobserved characteristics common to siblings. We used a longitudinal 1950 census sample to estimate mortality at ages 50–72. Relative to parents of two children, all-cause mortality is highest among childless men and women, and elevated among those with one child, independently of observed confounders. Fixed-effect models, which control for unobserved characteristics shared by siblings, clearly support these findings among men. Cardiovascular mortality is higher among men with no, one, or at least four children than among those with two. Living conditions in adulthood contribute to the association between the number of children and mortality to a greater extent than childhood background, and chronic conditions contribute to the excess mortality of the childless.

  • 6. Elo, Irma T.
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Aaltonen, Mikko
    Children's educational attainment, occupation, and income and their parents' mortality2018In: Population Studies, ISSN 0032-4728, E-ISSN 1477-4747, Vol. 72, no 1, p. 53-73Article in journal (Refereed)
    Abstract [en]

    Using data from Finland, this paper contributes to a small but growing body of research regarding adult children's education, occupation, and income and their parents' mortality at ages 50+ in 1970-2007. Higher levels of children's education are associated with 30-36 per cent lower parental mortality at ages 50-75, controlling for parents' education, occupation, and income. This association is fully mediated by children's occupation and income, except for cancer mortality. Having at least one child educated in healthcare is associated with 11-16 per cent lower all-cause mortality at ages 50-75, an association that is largely driven by mortality from cardiovascular diseases. Children's higher white-collar occupation and higher income is associated with 39-46 per cent lower mortality in the fully adjusted models. At ages 75+, these associations are much smaller overall and children's schooling remains more strongly associated with mortality than children's occupation or income.

  • 7. Elstad, Jon Ivar
    et al.
    Hermansen, Åsmund
    Brønnum-Hansen, Henrik
    Martikainen, Pekka
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS).
    Tarkiainen, Lasse
    Income security in Nordic welfare states for men and women who died when aged 55–69 years old2019In: Journal of International and Comparative Social Policy, ISSN 2169-9763, E-ISSN 2169-978X, Vol. 35, no 2, p. 157-176Article in journal (Refereed)
    Abstract [en]

    Income security when health impairment or other social risks occur is a major objective of welfare states. This comparative study uses register data from four Nordic welfare states for examining equivalized disposable income during the last 12 years alive among men and women who died when aged 55–69 years old. The analysed outcome indicates the aggregate result of a varied set of income maintenance mechanisms. Median income increased in the Finnish, Norwegian and Swedish samples, but decreased somewhat in Denmark, probably due to relatively frequent transitions to retirement and larger income drops after retirement than in the other Nordic countries. Analyses of comparison samples weighted by propensity scores indicated a better income development among those who lived beyond the observation period than among those who died. The higher educated had a more favourable income development during the years prior to death than those with low education.

  • 8. Goisis, Alice
    et al.
    Remes, Hanna
    Barclay, Kieron
    Stockholm University, Faculty of Social Sciences, Department of Sociology. London School of Economics and Political Science, United Kingdom; Max Planck Institute for Demographic Research, Germany.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Myrskylä, Mikko
    Advanced Maternal Age and the Risk of Low Birth Weight and Preterm Delivery: a Within-Family Analysis Using Finnish Population Registers2017In: American Journal of Epidemiology, ISSN 0002-9262, E-ISSN 1476-6256, Vol. 186, no 11, p. 1219-1226Article in journal (Refereed)
    Abstract [en]

    Advanced maternal age at birth is considered a major risk factor for birth outcomes. It is unclear to what extent this association is confounded by maternal characteristics. To test whether advanced maternal age at birth independently increases the risk of low birth weight (< 2,500 g) and preterm birth (< 37 weeks' gestation), we compared between-family models (children born to different mothers at different ages) with within-family models (children born to the same mother at different ages). The latter procedure reduces confounding by unobserved parental characteristics that are shared by siblings. We used Finnish population registers, including 124,098 children born during 1987-2000. When compared with maternal ages 25-29 years in between-family models, maternal ages of 35-39 years and a parts per thousand<yen>40 years were associated with percentage increases of 1.1 points (95% confidence intervals: 0.8, 1.4) and 2.2 points (95% confidence intervals: 1.4, 2.9), respectively, in the probability of low birth weight. The associations are similar for the risk of preterm delivery. In within-family models, the relationship between advanced maternal age and low birth weight or preterm birth is statistically and substantively negligible. In Finland, advanced maternal age is not independently associated with the risk of low birth weight or preterm delivery among mothers who have had at least 2 live births.

  • 9. Goisis, Alice
    et al.
    Remes, Hanna
    Barclay, Kieron
    Stockholm University, Faculty of Social Sciences, Department of Sociology. London School of Economics and Political Science, UK; Max Planck Institute for Demographic Research, Germany.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Myrskylä, Mikko
    Paternal age and the risk of low birth weight and preterm delivery: a Finnish register-based study2018In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 72, no 12, p. 1104-1109Article in journal (Refereed)
    Abstract [en]

    Background Based on existing studies, there is no conclusive evidence as to whether and why paternal age matters for birth outcomes. Methods We used Finnish population registers on 106652 children born 1987-2000. We first document the unadjusted association between paternal age and the risk of low birth weight (LBW; <2500g) and preterm birth (<37 weeks' gestation). Second, we investigate whether the unadjusted association is attenuated on adjustment for child's, maternal and parental socioeconomic characteristics. Third, by adopting a within-family design which involves comparing children born to the same father at different ages, we additionally adjust for unobserved parental characteristics shared between siblings. Results The unadjusted results show that being born to a father aged 40+, as opposed to a father aged 30-34, is associated with an increased risk of LBW of 0.96% (95%CI 0.5% to 1.3%) and to a younger father (<25) with a 1% (95%CI 0.6% to 1.3%) increased risk. The increased risk at younger paternal ages is halved on adjustment for the child's characteristics and fully attenuated on adjustment for child/parental characteristics. The increased risk at paternal ages 40+ ispartially attenuated on adjustment for maternal characteristics (=0.62%; 95%CI 0.13% to 1.1%). Adjustment for unobserved parental characteristics shared by siblings further attenuates the 40+ coefficient (=0.4%; 95%CI -0.5% to -1.2%). Results for preterm delivery are similar. Conclusions The results underscore the importance of considering paternal age as a potential risk factor for adverse birth outcomes and of expanding research on its role and the mechanisms linking it to birth outcomes.

  • 10. Goisis, Alice
    et al.
    Remes, Hanna
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Max Planck Institute for Demographic Research, Germany; University of Helsinki, Finland.
    Klemetti, Reija
    Myrskylä, Mikko
    Medically assisted reproduction and birth outcomes: a within-family analysis using Finnish population registers2019In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 393, no 10177, p. 1225-1232Article in journal (Refereed)
    Abstract [en]

    Background Children born after medically assisted reproduction are at higher risk of adverse birth outcomes than are children conceived naturally. We aimed to establish the extent to which this excess risk should be attributed to harmful effects of treatment or to pre-existing parental characteristics that confound the association. Methods We used data from Finnish administrative registers covering a 20% random sample of households with at least one child aged 0-14 years at the end of 2000 (n=65 723). We analysed birthweight, gestational age, risk of low birthweight, and risk of preterm birth among children conceived both by medically assisted reproduction and naturally. First, we estimated differences in birth outcomes by mode of conception in the general population, using standard multivariate methods that controlled for observed factors (eg, multiple birth, birth order, and parental sociodemographic characteristics). Second, we used a sibling-comparison approach that has not been used before in medically assisted reproduction research. We compared children conceived by medically assisted reproduction with siblings conceived naturally and, thus, controlled for all observed and unobserved factors shared by siblings. Findings Between 1995 and 2000, 2776 (4%) children in our sample were conceived by medically assisted reproduction; 1245 children were included in the sibling comparison. Children conceived by medically assisted reproduction had worse outcomes than did those conceived naturally, for all outcomes, even after adjustments for observed child and parental characteristics-eg, difference in birthweight of -60 g (95% CI -86 to -34) and 2.15 percentage point (95% CI 1.07 to 3.24) increased risk of preterm delivery. In the sibling comparison, the gap in birth outcomes was attenuated, such that the relation between medically assisted reproduction and adverse birth outcomes was statistically and substantively weak for all outcomes-eg, difference in birthweight of -31 g (95% CI -85 to 22) and 1.56 percentage point (95% CI -1.26 to 4.38) increased risk of preterm delivery. Interpretation Children conceived by medically assisted reproduction face an elevated risk of adverse birth outcomes. However, our results indicate that this increased risk is largely attributable to factors other than the medically assisted reproduction treatment itself.

  • 11. Haukka, Jari
    et al.
    Suvisaari, Jaana
    Sarvimaki, Matti
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    The Impact of Forced Migration on Mortality A Cohort Study of 242,075 Finns from 1939-20102017In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 28, no 4, p. 587-593Article in journal (Refereed)
    Abstract [en]

    Background: The stresses and life changes associated with migration may have harmful long-term health effects, especially for mental health. These effects are exceedingly difficult to establish, because migrants are typically a highly selected group.

    Methods: We examined the impact of migration on health using naturally occurring historical events. In this article, we use the forced migration of 11% of the Finnish population after WWII as such a natural experiment. We observed the date and cause of death starting from 1 January 1971 and ending in 31 December 2010 for the cohort of 242,075 people. Data were obtained by linking individual-level data from the 1950 and 1970 population censuses and the register of death certificates from 1971 to 2010 (10% random sample). All-cause and cause-specific mortalities were modeled using Poisson regression.

    Results: Models with full adjustment for background variables showed that both all-cause mortality (RR 1.03, 95% CI 1.01, 1.05), and ischemic heart disease mortality (RR 1.11, 95% CI 1.08, 1.15) were higher in the displaced population than in the nondisplaced population. Suicide mortality was lower (RR 0.77, 95% CI 0.64, 0.92) in displaced than in the general population.

    Conclusions: In our long-term follow-up study, forced migration was associated with increased risk of death due to ischemic heart diseases. In contrast, lower suicide mortality was observed in association with forced migration 25 years or more.

  • 12. Herttua, Kimmo
    et al.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Influence of affordability of alcohol on educational disparities in alcohol-related mortality in Finland and Sweden: a time series analysis2017In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 71, no 12, p. 1168-1176Article in journal (Refereed)
    Abstract [en]

    Background: Prices of alcohol and income tend to influence how much people buy and consume alcohol. Price and income may be combined into one measure, affordability of alcohol. Research on the association between affordability of alcohol and alcohol-related harm is scarce. Furthermore, no research exists on how this association varies across different subpopulations. We estimated the effects of affordability of alcohol on alcohol-related mortality according to gender and education in Finland and Sweden.

    Methods: Vector-autoregressive time series modelling was applied to the quarter-annual aggregations of alcohol-related deaths and affordability of alcohol in Finland in 1988–2007 and in Sweden in 1991–2008. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. We calculated affordability of alcohol index using information on personal taxable income and prices of various types of alcohol.

    Results: Among Finnish men with secondary education,an increase of 1% in the affordability of total alcohol was associated with an increase of 0.028% (95% CI 0.004 to 0.053) in alcohol-related mortality. Similar associations were also found for affordability for various types of alcohol and for beer only in the lowest education group. We found few other significant positive associations for other subpopulations in Finland or Sweden. However, reverse associations were found among secondary-educated Swedish women.

    Conclusions: Overall, the associations between affordability of alcohol and alcohol-related mortality were relatively weak. Increased affordability of total alcoholic beverages was associated with higher rates of alcohol-related mortality only among Finnish men with secondary education.

  • 13. Hu, Yaoyue
    et al.
    Leinonen, Taina
    Myrskylä, Mikko
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Max Planck Institute for Demographic Research, Germany; University of Helsinki, Finland.
    Changes in Socioeconomic Differences in Hospital Days With Age: Cumulative Disadvantage, Age-as-Leveler, or Both?2019In: The journals of gerontology. Series B, Psychological sciences and social sciences, ISSN 1079-5014, E-ISSN 1758-5368Article in journal (Refereed)
    Abstract [en]

    Objectives: Length of hospital stay is inversely associated with socioeconomic status (SES). It is less clear whether socioeconomic disparities in numbers of hospital days diverge or converge with age.

    Method: Longitudinal linked Finnish registry data (1988-2007) from 137,653 men and women aged 50-79 years at the end of 1987 were used. Trajectories of annual total hospital days by education, household income, and occupational class were estimated using negative binomial models.

    Results: Men and women with higher education, household income, and occupational class had fewer hospital days in 1988 than those with lower SES. Hospital days increased between 1988 and 2007. For some age groups, higher SES was associated with a faster annual rate of increase, resulting in narrowing rate ratios of hospital days between SES groups (relative differences); the rate ratios remained stable for other groups. Absolute SES differences in numbers of hospital days appeared to diverge with age among those aged 50-69 years at baseline, but converge among those aged 70-79 years at baseline.

    Discussion: The hypotheses that socioeconomic disparities in health diverge or converge with age may not be mutually exclusive; we demonstrated convergence/maintenance in relative differences for all age groups, but divergence or convergence in absolute differences depending on age.

  • 14. Hu, Yaoyue
    et al.
    Leinonen, Taina
    van Hedel, Karen
    Myrskylä, Mikko
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS). Max Planck Institute for Demographic Research, Germany; University of Helsinki, Finland.
    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?2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 1011Article in journal (Refereed)
    Abstract [en]

    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 50-89years 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 10year 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 (50-59years, 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 50-59years who lived with their partner and (minor or adult) children. But odds were higher for individuals aged 60-79years 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 80-89years.

    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.

  • 15. Kilpi, Fanny
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Konttinen, Hanna
    Silventoinen, Karri
    Torssander, Jenny
    Stockholm University, Faculty of Social Sciences, The Swedish Institute for Social Research (SOFI).
    Kawachi, Ichiro
    Reply to Oude Groeniger and van Lenthe2018In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 29, no 4, p. e37-e37Article in journal (Other academic)
  • 16. Kilpi, Fanny
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Konttinen, Hanna
    Silventoinen, Karri
    Torssander, Jenny
    Stockholm University, Faculty of Social Sciences, The Swedish Institute for Social Research (SOFI).
    Kawachi, Ichiro
    The Spillover Influence of Partner’s Education on Myocardial Infarction Incidence and Survival2018In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 29, no 2, p. 237-245Article in journal (Refereed)
    Abstract [en]

    Background: Education is believed to have positive spillover effects across network connections. Partner’s education may be an important resource preventing the incidence of disease and helping patients cope with illness. We examined how partner’s education predicted myocardial infarction (MI) incidence and survival net of own education and other socioeconomic resources in Finland.

    Methods: A sample of adults aged 40–69 years at baseline in Finland in 1990 was followed up for MI incidence and mortality during the period 1991–2007 (n = 354,100).

    Results: Lower own and spousal education both contributed independently to a higher risk of MI incidence and fatality when mutually adjusted. Having a partner with basic education was particularly strongly associated with long-term fatality in women with a hazard ratio of 1.53 (95% confidence interval, 1.22–1.92) compared with women with tertiary level educated partners. There was some evidence that the incidence risk associated with basic spousal education was weaker in those with own basic education. The highest risks of MI incidence and fatality were consistently found in those without a partner, whereas the most favorable outcomes were in households where both partners had a tertiary level of education.

    Conclusions: Accounting for spousal education demonstrates how health-enhancing resources accumulate to some households. Marriage between people of similar educational levels may therefore contribute to the widening of educational differences in MI incidence and survival.

  • 17. Kilpi, Fanny
    et al.
    Silventoinen, Karri
    Konttinen, Hanna
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Disentangling the relative importance of different socioeconomic resources for myocardial infarction incidence and survival: a longitudinal study of over 300 000 Finnish adults2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no 2, p. 260-266Article in journal (Refereed)
    Abstract [en]

    Background: Lower socioeconomic position (SEP) is associated with an increased risk of myocardial infarction (MI) incidence and mortality, but the relative importance of different socioeconomic resources at different stages of the disease remains unclear. Methods: A nationally representative register-based sample of 40- to 60-year-old Finnish men and women in 1995 (n = 302 885) were followed up for MI incidence and mortality in 1996-2007. We compared the effects of education, occupation, income and wealth on first MI incidence, first-day and long-term fatality. Cox's proportional hazards regression and logistic regression models were estimated adjusting for SEP covariates simultaneously to assess independent effects. Results: Fully adjusted models showed greatest relative inequalities of MI incidence by wealth in both sexes, with an increased risk also associated with manual occupations. Education was a significant predictor of incidence in men. Low income was associated with a greater risk of death on the day of MI incidence [odds ratio (OR) = 1.40 in men and 1.95 in women when comparing lowest and highest income quintiles], and in men, with long-term fatality [hazard ratio (HR) = 1.74]. Wealth contributed to inequalities in first-day fatality in men and in long-term fatality in both sexes. Conclusion: The results show that different socioeconomic resources have diverse effects on the disease process and add new evidence on the significant association of wealth with heart disease onset and fatality. Targeting those with the least resources could improve survival in MI patients and help reduce social inequalities in coronary heart disease mortality.

  • 18. Kilpi, Fanny
    et al.
    Silventoinen, Karri
    Konttinen, Hanna
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute of Demographic Research, Germany.
    Early-life and adult socioeconomic determinants of myocardial infarction incidence and fatality2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 177, p. 100-109Article in journal (Refereed)
    Abstract [en]

    Social inequalities in coronary heart disease mortality have roots in childhood conditions, but it is unknown whether they are associated both with the incidence of the disease and the following survival. We studied how several different early-life socioeconomic factors, together with later socioeconomic attainment, were associated with myocardial infarction (MI) incidence and fatality in Finland. The data was based on a register-based sample of households from a census in 1950 that also provided information on childhood circumstances. MI hospitalizations and mortality in 1988-2010 were studied in those who were up to 14 years of age at the time of the census and resident in Finland in 1987 (n = 94,501). Parental education, occupation, household crowding, home ownership, and family type were examined together with adulthood education and income. Hazard and odds ratios with 95% confidence intervals (CI) were calculated using Cox regression (incidence and long-term fatality) and logistic regression (short-term fatality) models. Lower parental education, occupational background and greater household crowding were associated with MI incidence. In models adjusted for adulthood variables, crowding increased the risk by 16% (95% CI 5-29%) in men and 25% (95% CI 3-50%) in women. Shortterm survival was more favourable in sons of white-collar parents and daughters of owner-occupied households, but most aspects of childhood circumstances did not strongly influence long-term fatality risk. Socioeconomic attainment in adulthood accounted for a substantial part of the effects of childhood conditions, but the measured childhood factors explained little of the disparities by adulthood education and income. Moreover, income and education remained associated with MI incidence when adjusted for unobserved shared family factors in siblings. Though social and economic development in society seems to have mitigated the disease burden associated with poor childhood living conditions in Finland, low adult socioeconomic resources have remained a strong determinant of MI incidence and fatality.

  • 19. Konttinen, Hanna
    et al.
    Kilpi, Fanny
    Moustgaard, Heta
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Socioeconomic Position and Antidepressant Use as Predictors of Coronary Heart Disease Mortality: A Population-Based Registry Study of 362,271 Finns2016In: Psychosomatic Medicine, ISSN 0033-3174, E-ISSN 1534-7796, Vol. 78, no 2, p. 144-152Article in journal (Refereed)
    Abstract [en]

    Objective: The interplay between depression and socioeconomic position (SEP) in predicting cardiovascular outcomes has rarely been examined. We investigated whether SEP modified the effect of antidepressant use on coronary heart disease (CHD) mortality.

    Methods: The data consisted of an 11% random sample of the Finnish population aged 40 to 79 years at the end of 1999 with an oversample of 80% of those who died in 2000 to 2007. Participants free of CHD at baseline (n = 362,271) were followed up for CHD mortality in 2000 to 2007. SEP was assessed via registry-based information on education, occupational position, and income. Antidepressant use served as a proxy for depression and was derived from registry data on prescription medication purchases in the 5-year period preceding baseline. Age- and sex-adjusted Cox regression models with sampling weights were used.

    Results: Individuals with antidepressant purchases in any year 1995 to 1999 had a higher risk of CHD deaths (hazard ratio [HR] = 1.68, 95% confidence interval [CI] = 1.62-1.75) than did those without purchases. Basic level of education (HR = 2.09, 95% CI = 2.01-2.17), blue-collar occupations (HR = 1.70, 95% CI = 1.65-1.75), and the lowest income tertile (HR = 2.79, 95% CI = 2.69-2.91) were related to increased relative risks for CHD mortality. No significant (p < .05) interactions emerged between the SEP indicators and antidepressant purchases indicating that the effect of antidepressant use on the relative risk for CHD was similar across varying levels of SEP.

    Conclusions: Our study demonstrates that in a country with tax-funded universal health care services, low SEP does not exacerbate the adverse effects of depressionas measured by antidepressant treatmenton cardiovascular health.

  • 20. Korhonen, Kaarina
    et al.
    Einiö, Elina
    Leinonen, Taina
    Tarkiainen, Lasse
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Time-varying effects of socio-demographic and economic factors on the use of institutional long-term care before dementia-related death: A Finnish register-based study2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 6, article id e0199551Article in journal (Refereed)
    Abstract [en]

    Objectives The effects of socio-demographic and economic factors on institutional long-term care (LTC) among people with dementia remain unclear. Inconsistent findings may relate to time varying effects of these factors as dementia progresses. To clarify the question, we estimated institutional LTC trajectories by age, marital status and household income in the eight years preceding dementia-related and non-dementia-related deaths. Methods We assessed a population-representative sample of Finnish men and women for institutional LTC over an eight-year period before death. Deaths related to dementia and all other causes at the age of 70+ in 2001-2007 were identified from the Death Register. Dates in institutional LTC were obtained from national care registers. We calculated the average and time-varying marginal effects of age, marital status and household income on the estimated probability of institutional LTC use, employing repeated-measures logistic regression models with generalised estimating equations (GEE). Results The effects of age, marital status and household income on institutional LTC varied across the time before death, and the patterns differed between dementia-related and non-dementia-related deaths. Among people who died of dementia, being of older age, non-married and having a lower income predicted a higher probability of institutional LTC only until three to four years before death, after which the differences diminished or disappeared. Among women in particular, the probability of institutional LTC was nearly equal across age, marital status and income groups in the last year before dementia-related death. Among those who died from non-dementia-related causes, in contrast, the differences widened until death. Conclusions We show that individuals with dementia require intensive professional care at the end of life, regardless of their socio-demographic or economic resources. The results imply that the potential for extending community living for people with dementia is likely to be difficult through modification of their socio-demographic and economic environments.

  • 21. Korhonen, Kaarina
    et al.
    Remes, Hanna
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Education as a social pathway from parental socioeconomic position to depression in late adolescence and early adulthood: a Finnish population-based register study2017In: Social Psychiatry and Psychiatric Epidemiology, ISSN 0933-7954, E-ISSN 1433-9285, Vol. 52, no 1, p. 105-116Article in journal (Refereed)
    Abstract [en]

    There is inconsistent evidence for social differentials in the risk of depression in youth, and little is known about how education at this age influences the risk. We assess how parental socioeconomic position (SEP) and education predict depression from late adolescence to early adulthood, a time of major educational transitions. We followed a nationally representative 20 % sample of Finnish adolescents born in 1986-1990 (n = 60,829) over two educational transitory stages at the age of 17-19 and 20-23 covering the years 2003-2011. We identified incident depression using health care register data. We estimated the risk of depression by parental SEP and personal education using Cox regression, adjusting for family structure, parental depression and the individual's own psychiatric history. Lower parental income was associated with up to a twofold risk of depression. This effect was almost fully attributable to other parental characteristics or mediated by the individual's own education. Educational differences in risk were attenuated following adjustment for prior psychiatric history. Adjusted for all covariates, not being in education increased the risk up to 2.5-fold compared to being enrolled in general upper secondary school at the age of 17-19 and in tertiary education at the age of 20-23. Vocationally oriented women experienced a 20 % higher risk than their academically oriented counterparts in both age groups. Education constitutes a social pathway from parental SEP to the risk of depression in youth, whereby educational differences previously shown in adults are observed already before the establishment of adulthood SEP.

  • 22. Kröger, Hannes
    et al.
    Hoffmann, Rasmus
    Tarkiainen, Lasse
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Comparing Observed and Unobserved Components of Childhood: Evidence From Finnish Register Data on Midlife Mortality From Siblings and Their Parents2018In: Demography, ISSN 0070-3370, E-ISSN 1533-7790, Vol. 55, no 1, p. 295-318Article in journal (Refereed)
    Abstract [en]

    In this study, we argue that the long arm of childhood that determines adult mortality should be thought of as comprising an observed part and its unobserved counterpart, reflecting the observed socioeconomic position of individuals and their parents and unobserved factors shared within a family. Our estimates of the observed and unobserved parts of the long arm of childhood are based on family-level variance in a survival analytic regression model, using siblings nested within families as the units of analysis. The study uses a sample of Finnish siblings born between 1936 and 1950 obtained from Finnish census data. Individuals are followed from ages 35 to 72. To explain familial influence on mortality, we use demographic background factors, the socioeconomic position of the parents, and the individuals' own socioeconomic position at age 35 as predictors of all-cause and cause-specific mortality. The observed part-demographic and socioeconomic factors, including region; number of siblings; native language; parents' education and occupation; and individuals' income, occupation, tenancy status, and education-accounts for between 10 % and 25 % of the total familial influence on mortality. The larger part of the influence of the family on mortality is not explained by observed individual and parental socioeconomic position or demographic background and thus remains an unobserved component of the arm of childhood. This component highlights the need to investigate the influence of childhood circumstances on adult mortality in a comprehensive framework, including demographic, social, behavioral, and genetic information from the family of origin.

  • 23. Lahtinen, Hannu
    et al.
    Mattila, Mikko
    Wass, Hanna
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Karolinska Institutet, Sweden; University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Explaining Social Class Inequality in Voter Turnout: The Contribution of Income and Health2017In: Scandinavian Political Studies, ISSN 0080-6757, E-ISSN 1467-9477, Vol. 40, no 4, p. 388-410Article in journal (Refereed)
    Abstract [en]

    Occupation-based social class is an important, yet under-explored, factor in electoral participation. In this article, social class differences in voter turnout over time are measured, and how two other resources - namely income and health - mediate or modify this relationship is analysed. The analysis is based on an individual-level register-based 11 percent sample of the entire electorate in the 1999 Finnish parliamentary elections, and secondarily on smaller register-based samples in the 2012 presidential and municipal elections. Results show that income mediates part of the effects of social class on voting, while social class and utilised health indicators exert mainly independent effects on turnout. Social class differences remain largely stable in all income and hospital care groups, except that no differences between classes are observed among those most severely affected by health problems. Results are also mostly similar between those of working age and the older population, and between men and women, and remain stable over time and in different types of elections. The findings imply that social class should be taken account in theoretical and empirical models of turnout.

  • 24. Leinonen, Taina
    et al.
    Laaksonen, Mikko
    Chandola, Tarani
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Health as a predictor of early retirement before and after introduction of a flexible statutory pension age in Finland2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 158, p. 149-157Article in journal (Refereed)
    Abstract [en]

    Background: Little is known of how pension reforms affect the retirement decisions of people with different health statuses, although this is crucial for the understanding of the broader societal impact of pension policies and for future policy development. We assessed how the Finnish statutory pension age reform introduced in 2005 influenced the role of health as a predictor of retirement. Methods: We used register-based data and cox regression analysis to examine the association of health (measured by purchases of psychotropic medication, hospitalizations due to circulatory and musculoskeletal diseases, and the number of any prescription medications) with the risk of retirement at age 63-64 among those subject to the old pension system with fixed age limit at 65 (pre-reform group born in 1937-1941) and the new flexible system with 63 as the lower age limit (post-reform group born in 1941-1945) while controlling for socio-demographic factors. Results: Retirement at age 63-64 was more likely among the post- than the pre-reform group (HR = 1.50; 95% CI 1.43-1.57). This reform-related increase in retirement was more pronounced among those without a history of psychotropic medication or hospitalizations due to circulatory and musculoskeletal diseases, as well as among those with below median level medication use. As a result, poor health became a weaker predictor of retirement after the reform. Conclusion: Contrary to the expectations of the Finnish pension reform aimed at extending working lives, offering choice with respect to the timing of retirement may actually encourage healthy workers to choose earlier retirement regardless of the provided economic incentives for continuing in work.

  • 25. Leinonen, Taina
    et al.
    Maki, Netta
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Karolinska Institutet, Sweden; University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany .
    Trajectories of Antidepressant Medication before and after the Onset of Unemployment by Subsequent Employment Experience2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 1, article id e0169652Article in journal (Refereed)
    Abstract [en]

    Background The unemployed more often suffer from depression than the employed. We examined whether mental health deterioration occurs already before unemployment implicating health selection, or whether it mostly occurs after becoming exposed to the experience rendering causal explanations more likely. Methods We used nationally representative Finnish register data to examine changes in depressive morbidity as measured by antidepressant medication in 1995-2009 over four years before and since a new onset of unemployment (N = 28 000) at the age of 30-60 compared to the employed (N = 124 136). We examined separately those who became continuously long-term unemployed, intermittently unemployed and unemployed with eventual re-employment in the second, third or fourth year since the year of onset. Annual repeated measurements were analysed using generalised estimation equations. Results Among the employed antidepressant medication increased slowly but steadily over the study period and it was mainly at a lower level than among the unemployed. In the four years leading to unemployment there was excess increase in medication that was generally stronger among those with longer duration of the eventual unemployment experience. During unemployment medication decreased in all groups except among the intermittently unemployed. By the first year of re-employment antidepressant medication reached a level similar to that among the employed and afterwards followed no consistent trend. Conclusions The associations of unemployment and re-employment with depressive morbidity appear to be largely driven by health selection. The question of potential causal associations remains unresolved for intermittent unemployment in particular.

  • 26. Leinonen, Taina
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland.
    Myrskylä, Mikko
    Working Life and Retirement Expectancies at Age 50 by Social Class: Period and Cohort Trends and Projections for Finland2018In: The journals of gerontology. Series B, Psychological sciences and social sciences, ISSN 1079-5014, E-ISSN 1758-5368, Vol. 73, no 2, p. 302-313Article in journal (Refereed)
    Abstract [en]

    Objectives: The balance between the amount of time spent in work and in retirement underlies the long-term sustainability of the social security system. We examined socioeconomic differences in how increasing longevity is distributed between labor market statuses in Finland. Method: We used register data and the Sullivan method to analyze life expectancy at age 50 spent in different labor market statuses over the period 1989-2012 and across cohorts born in 1938-1953. We projected the future mortality and labor market participation rates of partially observed cohorts. Results: Both working life expectancy at age 50 and the share of remaining life spent in work have increased across periods following the recession of the early 1990s, and across successive cohorts. The trends were similar across the social classes, but there were large differences in the numbers of years spent in various states: for the most recent period and the youngest cohort, we find that compared with upper non-manual employees, male and female manual workers were expected to spend 3.6-3.7 fewer years in work, 1.7-4.7 fewer years in statutory retirement, and 3.2-3.9 more years in other forms of nonemployment. Discussion: Our finding that the share of remaining life at age 50 spent in work is increasing implies that pressure on the welfare system is not as severe as is commonly thought.

  • 27.
    Martikainen, Pekka
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Korhonen, Kaarina
    Moustgaard, Heta
    Aaltonen, Mikko
    Remes, Hanna
    Substance abuse in parents and subsequent risk of offspring psychiatric morbidity in late adolescence and early adulthood: A longitudinal analysis of siblings and their parents2018In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 217, p. 106-111Article, review/survey (Refereed)
    Abstract [en]

    The effects of substance abuse on other family members are not fully established. We estimate the contribution of parental substance abuse on offspring psychiatric morbidity in late adolescence and early adulthood, with emphasis on the timing and persistency of exposure. We used a nationally representative 20% sample of Finnish families with children born in 1986-1996 (n = 136,604) followed up in 1986-2011. We identified parental substance abuse and offspring psychiatric morbidity from hospital discharge records, death records and medication registers. The effects of parental substance abuse at ages 0-4, 5-9 and 10-14 on psychiatric morbidity after age 15 were estimated using population averaged and sibling fixed effects models; the latter controlling for unobserved factors shared by siblings. Parental substance abuse at ages 0-14 was associated with almost 2-fold increase in offspring psychiatric morbidity (HR = 1.86, 95% CI 1.78-1.95). Adjustment for childhood parental education, income, social class and family type reduced these effects by about 50%, with some further attenuation after adjustment for time-varying offspring characteristics. In the sibling fixed effects models those exposed at 0-4 or 5-9 years had 20% (HR = 1.20, 95% CI 0.90-1.60) and 33% (HR = 1.33, 95% CI 1.01-1.74) excess morbidity respectively. Also in sibling models those with early exposure at ages 0-4 combined with repeated exposure in later childhood had about 80-90% higher psychiatric morbidity as compared to never exposed siblings (e.g. for those exposed throughout childhood HR = 1.81, 95% CI 1.01-3.25). Childhood exposure to parental substance abuse is strongly associated with subsequent psychiatric morbidity. Although these effects are to a large extent due to other characteristics shared within the parental home, repeated exposure to parental substance abuse is independently associated with later psychiatric morbidity.

  • 28.
    Martikainen, Pekka
    et al.
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Murphy, Mike
    Moustgaard, Heta
    Mikkonen, Janne
    Living arrangements of older persons in 1987-2035 in Finland: trends by age, sex and educational attainment2019In: Ageing & Society, ISSN 0144-686X, E-ISSN 1469-1779, Vol. 39, no 2, p. 358-380Article in journal (Refereed)
    Abstract [en]

    Changes in household structure may have a major impact on the future wellbeing of older people. We evaluate changes in living arrangements of 65+ Finnish men and women from 1987 to 2011 and project living arrangements to 2035 by education level. We use an 11 per cent longitudinal sample of Finns drawn from the population registration data. We estimate proportions in various living arrangements and multi-state life table estimates of years lived in particular states. Projections are based on dynamic transition probability forecasts with constant and changing rates. We show that women more than men tend to live alone at older ages. These proportions are likely to start to decline slowly among women, particularly at 80+, but increase or stabilise among men. Apart from living with a marital or co-habiting partner, other living arrangements are growing increasingly rare. The number of basic educated older people is declining rapidly. Educational differences in living arrangements are modest among women, but among men living with a partner is more common among the higher educated. Future living arrangements of older people are strongly determined by past partnership behaviour and future changes in mortality. If life expectancy differences between men and women continue to converge, so will sex differences in the remaining years of life spent living with a partner.

  • 29. Mikkonen, Janne
    et al.
    Moustgaard, Heta
    Remes, Hanna
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Intergenerational transmission of depressive symptoms - The role of gender, socioeconomic circumstances, and the accumulation of parental symptoms2016In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 204, p. 74-82Article in journal (Refereed)
    Abstract [en]

    Background

    The relationship between parental and offspring depression is well established. Evidence regarding the significance of gender, socioeconomic circumstances, and the accumulation of parental symptoms in intergenerational transmission is, however, mixed and scarce.

    Methods

    Using a 20% random sample of Finns born between 1986 and 1996 (n=138,559), we performed a Cox proportional hazards regression to analyze the incidence of depressive symptoms between ages 15–20 by exposure to maternal and paternal depressive symptoms earlier in life. Depressive symptoms were inferred from antidepressantpurchases and/or a diagnosis of depression at outpatient or inpatient health services.

    Results

    Exposure to maternal depressive symptoms posed an equal risk for girls and boys (hazard ratio, HR, 2.09 vs. 2.28 respectively, p=0.077), whereas the effect of paternal depressive symptoms was weaker for girls (HR 1.77 vs. 2.22, p<0.001). Parental socioeconomic status neither confounded nor moderated these effects. Dual exposure to both maternal and paternal depressive symptoms posed a larger risk than single exposure, and children exposed recurrently at ages 0–5 and 9–14 faced an elevated risk compared with those exposed at only one period.

    Limitations

    Since depressive symptoms were inferred from prescription purchases and treatment records, we were unable to observe untreated depression or to determine the underlying condition the antidepressants were prescribed for.

    Conclusions

    Our results support the idea that maternal depression affects both genders equally, whereas paternal depression affects girls less than boys. We show that parental depression and low socioeconomic status are mainly independent risk factors of adolescent depressive symptoms and do not cause an interactive effect.

  • 30. Mikkonen, Janne
    et al.
    Moustgaard, Heta
    Remes, Hanna
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    The Population Impact of Childhood Health Conditions on Dropout from Upper-Secondary Education2018In: Journal of Pediatric Surgery Case Reports, ISSN 0022-3476, E-ISSN 2213-5766, Vol. 196, p. 283-290.e4Article in journal (Refereed)
    Abstract [en]

    Objectives To quantify how large a part of educational dropout is due to adverse childhood health conditions and to estimate the risk of dropout across various physical and mental health conditions. Study design A registry-based cohort study was conducted on a 20% random sample of Finns born in 1988-1995 (n = 101 284) followed for school dropout at ages 17 and 21. Four broad groups of health conditions (any, somatic, mental, and injury) and 25 specific health conditions were assessed from inpatient and outpatient care records at ages 10-16 years. We estimated the immediate and more persistent risks of dropout due to health conditions and calculated population-attributable fractions to quantify the population impact of childhood health on educational dropout, while accounting for a wide array of sociodemographic confounders and comorbidity. Results Children with any health condition requiring inpatient or outpatient care at ages 10-16 years were more likely to be dropouts at ages 17 years (risk ratio 1.71, 95% CI 1.61-1.81) and 21 years (1.46, 1.37-1.54) following adjustment for individual and family sociodemographic factors. A total of 30% of school dropout was attributable to health conditions at age 17 years and 21% at age 21 years. Mental disorders alone had an attributable fraction of 11% at age 21 years, compared with 5% for both somatic conditions and injuries. Adjusting for the presence of mental disorders reduced the effects of somatic conditions. Conclusions More than one fifth of educational dropout is attributable to childhood health conditions. Early-onset mental disorders emerge as key targets in reducing dropout.

  • 31. Mortensen, Laust H.
    et al.
    Rehnberg, Johan
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Dahl, Espen
    Diderichsen, Finn
    Elstad, Jon Ivar
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Rehkopf, David
    Tarkiainen, Lasse
    Fritzell, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Shape of the association between income and mortality: a cohort study of Denmark, Finland, Norway and Sweden in 1995 and 20032016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 12, article id e010974Article in journal (Refereed)
    Abstract [en]

    Objectives: Prior work has examined the shape of the income-mortality association, but work has not compared gradients between countries. In this study, we focus on changes over time in the shape of income-mortality gradients for 4 Nordic countries during a period of rising income inequality. Context and time differentials in shape imply that the relationship between income and mortality is not fixed. Setting: Population-based cohort study of Denmark, Finland, Norway and Sweden. Participants: We collected data on individuals aged 25 or more in 1995 (n=12.98 million individuals, 0.84 million deaths) and 2003 (n=13.08 million individuals, 0.90 million deaths). We then examined the household size equivalised disposable income at the baseline year in relation to the rate of mortality in the following 5 years. Results: A steep income gradient in mortality in men and women across all age groups except the oldest old in Denmark, Finland, Norway and Sweden. From the 1990s to 2000s mortality dropped, but generally more so in the upper part of the income distribution than in the lower part. As a consequence, the shape of the income gradient in mortality changed. The shift in the shape of the association was similar in all 4 countries. Conclusions: A non-linear gradient exists between income and mortality in most cases and because of a more rapid mortality decline among those with high income the income gradient has become steeper over time.

  • 32.
    Moustgaard, Heta
    et al.
    University of Helsinki, Finland.
    Avendano, Mauricio
    Department of Social and Behavioral Sciences, Harvard, USA.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Parental Unemployment and Offspring Psychotropic Medication Purchases: A Longitudinal Fixed-Effects Analysis of 138,644 Adolescents2018In: American Journal of Epidemiology, ISSN 0002-9262, E-ISSN 1476-6256, Vol. 187, no 9, p. 1880-1888Article in journal (Refereed)
    Abstract [en]

    Parental unemployment is associated with worse adolescent mental health, but prior evidence has primarily been based on cross-sectional studies subject to reverse causality and confounding. We assessed the association between parental unemployment and changes in adolescent psychotropic medication purchases, with longitudinal individual-level fixed-effects models that controlled for time-invariant confounding. We used data from a large, register-based panel of Finnish adolescents aged 13-20 years in 1987-2012 (n = 138,644) that included annual measurements of mothers' and fathers' employment and offspring psychotropic medication purchases. We assessed changes in the probability of adolescent psychotropic medication purchases in the years before, during, and after the first episode of parental unemployment. There was no association between mother's unemployment and offspring psychotropic purchases in the fixed-effects models, suggesting this association is largely driven by unmeasured confounding and selection. By contrast, father's unemployment led to a significant 15%-20% increase in the probability of purchasing psychotropic medication among adolescents even after extensive controls for observed and unobserved confounding. This change takes at least 1 year to emerge, but it is long-lasting; thus, policies are needed that mitigate the harm of father's unemployment on offspring's mental well-being.

  • 33. Moustgaard, Heta
    et al.
    Joutsenniemi, Kaisla
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    A longitudinal study of educational differences in antidepressant use before and after hospital care for depression2016In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no 6, p. 1034-1039Article in journal (Refereed)
    Abstract [en]

    Background: Despite social inequalities in depression various studies report small or even reversed social gradients for antidepressant treatment, suggesting unmet need for treatment among those with low social position. However, few studies assess need for treatment or compare longitudinal antidepressant use patterns between socioeconomic groups. Methods: We used a nationally representative register cohort of Finnish adults with hospital care for depression in 1998–2007 (n = 7249). We compared the prevalence of any use and daily use of antidepressants across educational groups in consecutive 3-month periods up to 5 years before admission and 5 years after discharge, adjusting for important confounders. Results: We found no educational differences in any antidepressant use in the 5 years leading to hospital care for depression but a 3–4 percentage-point higher prevalence among those with high education in the 3-month periods immediately preceding and following hospital care for depression. Furthermore, decline in the prevalence of antidepressant use after discharge was more rapid in low education resulting in a significant 4–6 percentage-point higher prevalence among the highly educated lasting until 2.5 years after discharge. Daily use was significantly more common among the highly educated for a year before admission, immediately after discharge and for 2.5 years thereafter, the excess being 3–8 percentage-points. Conclusion: Our results suggest rather equitable access to antidepressant treatment at the time of evident need, i.e. immediately after discharge from hospital care for depression. However, early discontinuation of treatment as well as below guideline use of antidepressants were more common among the low educated.

  • 34. Mäki, Netta E.
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Premature mortality after suicide attempt in relationto living arrangements. A register-based study in Finland in 1988-20072017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 1, p. 73-79Article in journal (Refereed)
    Abstract [en]

    Background: Several studies have shown that individuals with a history of suicide attempt form a high-risk mortality group. Completed suicide is the main cause of death among them, but excess mortality for other causes of death is much less studied. Furthermore, little is known whether living with others modifies the excess risk of mortality among suicide attempters. Methods: We evaluated an 11% sample from the population registration data of Finns aged 15 years and older in the period 1988-2007 with an 80% oversample of death records and a linkage with information on causes of hospitalisation. We estimate standardised mortality rates and Poisson regression models separately for the general population and those treated in hospital for suicide attempt. Results: Compared with the general population, all-cause mortality risk was similar to 10-fold among women and well over 10-fold among men during the first 3 months following suicide attempt. The risk for suicide was even greater, but in addition to external causes of death, mortality from smoking-and alcohol-related diseases was elevated. Instead, the proportion of alcohol-associated suicides was smaller among the suicide attempters. Among suicide attempters, the association between living arrangements and mortality was much weaker than in the general population. Conclusion: Premature mortality is extremely high after suicide attempt, especially in the first year. Our results do not support the idea that the resources provided by living with others ameliorate the effects of suicide attempt on subsequent mortality. Suicide prevention should focus on designing adequate aftercare following the attempt, especially for those with alcohol problems.

  • 35. Nisen, Jessica
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Myrskylä, Mikko
    Silventoinen, Karri
    Education, Other Socioeconomic Characteristics Across the Life Course, and Fertility Among Finnish Men2018In: European Journal of Population, ISSN 0168-6577, E-ISSN 1572-9885, Vol. 34, no 3, p. 337-366Article in journal (Refereed)
    Abstract [en]

    The level of education and other adult socioeconomic characteristics of men are known to associate with their fertility, but early-life socioeconomic characteristics may also be related. We studied how men's adult and early-life socioeconomic characteristics are associated with their eventual fertility and whether the differences therein by educational level are explained or mediated by other socioeconomic characteristics. The data on men born in 1940-1950 (N = 37,082) were derived from the 1950 Finnish census, which is linked to later registers. Standard and sibling fixed-effects Poisson and logistic regression models were used. Education and other characteristics were positively associated with the number of children, largely stemming from a higher likelihood of a first birth among the more socioeconomically advantaged men. The educational gradient in the number of children was not explained by early socioeconomic or other characteristics shared by brothers, but occupational position and income in adulthood mediated approximately half of the association. Parity-specific differences existed: education and many other socioeconomic characteristics predicted the likelihood of a first birth more strongly than that of a second birth, and the mediating role of occupational position and income was also strongest for first births. Relatively small differences were found in the likelihood of a third birth. In men, education is positively associated with eventual fertility after controlling for early socioeconomic and other characteristics shared by brothers. Selective entry into fatherhood based on economic provider potential may contribute considerably to educational differentials in the number of children among men.

  • 36. Paljärvi, Tapio
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Leinonen, Taina
    Vuori, Erkki
    Mäkelä, Pia
    Purchases of prescription drugs before an alcohol-related death: A ten-year follow-up study using linked routine data2018In: Drug And Alcohol Dependence, ISSN 0376-8716, E-ISSN 1879-0046, Vol. 186, p. 175-181Article in journal (Refereed)
    Abstract [en]

    Background: Physician's intention to prescribe drugs could potentially be used to improve targeting of alcohol interventions and enhanced disease management to patients with a high risk of severe alcohol-related harm within outpatient settings. Methods: Comparison of ten-year incidence trajectories of 13.8 million reimbursed purchases of prescription drugs among 303,057 Finnish men and women of whom 7490 ultimately died due to alcohol-related causes (Ale+), 14,954 died without alcohol involvement (Alc-), and 280,613 survived until the end of 2007. Results: 5-10 years before death, 88% of the persons with an Alc+ death had received prescription medication, and over two-thirds (69%) had at least one reimbursed purchase of drugs for the alimentary tract and metabolism, the cardiovascular system, or the nervous system. Among persons with an Alc+ death, the incidence rate (IR) for purchases of hypnotics, and sedatives was L38 times higher (95% confidence interval (C1):1.32,1.44) compared to those with an Alc death, and 4.07 times higher (95%C1:3.92,4.22) compared to survivors; and the IR for purchases of anxiolytics was 1.40 times higher (95%Ck1.34,1.47) compared to those with an Ale death, and 3.61 times higher (95%C1:3.48,3.78) compared to survivors. Conclusions: Using physician's intention to prescribe drugs affecting the alimentary tract and metabolism, cardiovascular system and nervous system could potentially be used to flag patients who might benefit from screening, targeted interventions or enhanced disease management. In particular, patients who are to be prescribed anxiolytics, hypnotics, and sedatives, and antidepressants may benefit from enhanced interventions targeted to problem drinking.

  • 37. Peltonen, Riina
    et al.
    Ho, Jessica Y.
    Elo, Irma T.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Karolinska Institutet, Sweden; Max Planck Institute for Demographic Research, Germany.
    Contribution of smoking-attributable mortality to life expectancy differences by marital status among Finnish men and women, 1971-20102017In: Demographic Research, ISSN 1435-9871, Vol. 36, p. 255-280, article id 8Article in journal (Refereed)
    Abstract [en]

    BACKGROUND Smoking is known to vary by marital status, but little is known about its contribution to marital status differences in longevity. We examined the changing contribution of smoking to mortality differences between married and never married, divorced or widowed Finnish men and women aged 50 years and above in 1971-2010. DATA AND METHODS The data sets cover all persons permanently living in Finland in the census years 1970, 1975 through 2000 and 2005 with a five-year mortality follow-up. Smoking-attributable mortality was estimated using an indirect method that uses lung cancer mortality as an indicator for the impact of smoking on mortality from all other causes. RESULTS Life expectancy differences between the married and the other marital status groups increased rapidly over the 40-year study period because of the particularly rapid decline in mortality among married individuals. In 1971-1975 37-48% of life expectancy differences between married and divorced or widowed men were attributable to smoking, and this contribution declined to 11-18% by 2006-2010. Among women, in 1971-1975 up to 16% of life expectancy differences by marital status were due to smoking, and the contribution of smoking increased over time to 10-29% in 2006-2010. CONCLUSIONS In recent decades smoking has left large but decreasing imprints on marital status differences in longevity between married and previously married men, and small but increasing imprints on these differences among women. Over time the contribution of other factors, such as increasing material disadvantage or alcohol use, may have increased.

  • 38. Remes, Hanna
    et al.
    Moustgaard, Heta
    Kestilä, Laura M.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute of Demographic Research, Germany.
    Parental education and adolescent health problems due to violence, self-harm and substance use: what is the role of parental health problems?2019In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 73, no 3, p. 225-231Article in journal (Refereed)
    Abstract [en]

    Background Adolescent health problems are more prevalent in families with low socioeconomic position, but few studies have assessed the role of parental health in this association. This study examines the extent to which parental health problems, particularly those related to high-risk health behaviour, might explain the association between parental education and adolescent health problems due to violence, self-harm and substance use.

    Methods We used longitudinal register data on a 20% representative sample of all families with children aged 0-14 years in 2000 in Finland with information on parental social background and parental and offspring health problems based on hospital discharge data. We estimated discrete-time survival models with the Karlson-Holm-Breen method on hospital admissions due to violence, self-harm and substance use among adolescents aged 13-19 years in 2001-2011 (n=145 404).

    Results Hospital admissions were 2-3 times more common among offspring of basic educated parents than tertiary educated parents. Similar excess risks were observed among those with parental mental health problems and parental health problems due to violence, self-harm and substance use. The OR for offspring of basic educated parents was attenuated from OR 2.73 (95% CI 2.34 to 3.18) to OR 2.38 (2.04 to2.77) with adjustment for parental health problems, particularly those due to violence, self-harm and substance use. Having both low parental education and parental health problems showed simple cumulative effects.

    Conclusions The excess risks of hospital admissions due to violence, self-harm and substance use among adolescents with lower educated parents are largely independent of severe parental health problems.

  • 39. Ronka, Sanna
    et al.
    Karjalainen, Karoliina
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Makela, Pia
    Social determinants of drug-related mortality in a general population2017In: Drug And Alcohol Dependence, ISSN 0376-8716, E-ISSN 1879-0046, Vol. 181, p. 37-43Article in journal (Refereed)
    Abstract [en]

    Background: We investigated the association between social determinants and a broad selection of drug-related deaths in a general population. Methods: We conducted a follow-up of an 11% random sample of working-age Finnish residents for 1996-2007 linked with an oversampling of deaths and population registration data on social characteristics. We defined total drug-related deaths as those from psychoactive substance use disorders and drug-induced poisonings (drug induced deaths) as well as drug-related accidents, homicides, illnesses, and suicides. Results: The number of drug-related deaths was three times that of drug-induced deaths. We found the highest hazard ratios (HRs) for total drug-related mortality for long-term unemployment (4.9; 95% confidence interval [CI], 4.3-5.6), short-term unemployment (3.9; 95% CI, 3.5-4.4), and retirement (5.8; 95% CI, 5.1-6.8). The HRs were highest for mortality related to psychoactive substance use disorders and lowest for mortality related to drug-related suicides. The differences were large for both sexes. Conclusions: Drug-related mortality was associated with social disadvantage; however, the strength of the association varied by drug-related cause of death. Primary and secondary prevention of drug use should particularly target disadvantaged groups.

  • 40.
    Rostila, Mikael
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Mäki, Netta
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Does the death of a child influence parental use of psychotropic medication? A follow-up register study from Finland2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 5, article id e0195500Article in journal (Refereed)
    Abstract [en]

    Background Several studies have found that the loss of a child is associated with psychiatric health problems, yet few studies examined whether child loss influences psychotropic medication use. This study examined short-and long-term use of psychotropic medication, both before and after the death of a child, and its potential effect modifiers. Methodology/Principal findings A random sample of 205,456 parents, including 902 bereaved parents, were selected from a Finnish total population registry. The analyses were based on linear regressions using generalised estimation equations (GEE) and adjusted for sociodemographic factors. Annual psychotropic use was defined as having purchased prescribed psychotropic medication between 1996 and 2012. Bereaved parents were followed for four years prior to and up to four years after the death of their child. An increase in the use of antidepressants and anxiolytics was found in parents following their loss. The highest percentage of use was found around one year after bereavement, followed by a steady decrease although this remained higher than the level of use among non-bereaved four years after the death. Between 20-25% of bereaved mothers and 10-15% of bereaved fathers used antidepressants or anxiolytics one year after bereavement while the corresponding number in non-bereaved was 5-10%. An increase in psychotropic medication was also found several years before the disease-related loss of a child. Conclusions/Significance The use of psychotropic medication is markedly higher among parents after losing a child. Patterns of use leading up to and following the death of a child should be further examined in relation to clinical risk factors so as to identify at risk populations.

  • 41. Sirnio, Outi
    et al.
    Kauppinen, Timo M.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsink, Finland; Max Planck Institute for Demographic Research, Germany.
    Cohort differences in intergenerational income transmission in Finland2017In: Acta Sociologica, ISSN 0001-6993, E-ISSN 1502-3869, Vol. 60, no 1, p. 21-39Article in journal (Refereed)
    Abstract [en]

    Major social changes such as occupational restructuring, educational expansion and increasing income inequality are likely to significantly influence the intergenerational transmission of income. The aim in this article is to investigate this question in an analysis of the transmission of low and high income in Finland in five birth cohorts born between 1956 and 1978. The focus is on the contribution of parental social class and personal educational level to this association. The analyses are based on a longitudinal register-based data set that is a representative 11-per-cent sample of the Finnish population. The level of intergenerational income transmission among those with a low- and a high-income parental background is stable among men, and is increasing slightly among women. Simultaneously, the role of achieved education as a mechanism strengthens slightly upon entry to the lowest income level, and declines upon entry to the highest level. These results indicate that despite the increasing income inequality, intergenerational transmission remains rather stable, but the mediating role of educational qualifications may have changed. Occupational restructuring seems to have no clear influence on the process.

  • 42. Sirnio, Outi
    et al.
    Kauppinen, Timo M.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Income trajectories after graduation: An intergenerational approach2016In: Advances in Life Course Research, ISSN 1569-4909, E-ISSN 1879-6974, Vol. 30, p. 72-83Article in journal (Refereed)
    Abstract [en]

    Labor-market outcomes depend on educational attainment, but parental background also plays a role. By applying sociological perspective to income and combining the classical intergenerational approach with a study of intragenerational mobility, we analyze the direct association between parental background and achieved labor-market outcomes. We focus on income trajectories within the same level of achieved education by parental income. Using register-based data covering the whole Finnish population, we analyze those who graduated in 1995-2000 for eight years after graduation by means of repeated measures linear regression. The results show that following entry into the labor market higher parental income is associated with higher incomes even after adjustment for education, labor market status, and childbearing. The effects of parental income are observed within all education groups except for those with highest education, and for men and women. We further demonstrate that parental income is associated with either higher starting level or faster growth of incomes within most education groups. The implication is that intergenerational associations are complex processes that are shaped across the whole life course.

  • 43.
    Sirniö, Outi
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Sociology. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Kauppinen, Timo M.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Intergenerational determinants of joint labor market and family formation pathways in early adulthood2017In: Advances in Life Course Research, ISSN 1569-4909, E-ISSN 1879-6974, Vol. 34, p. 10-21Article in journal (Refereed)
    Abstract [en]

    Early adulthood life courses have become diversified in recent decades, but little is known about how different dimensions of early life courses (i.e., education, labor market participation and family formation) co-evolve and are associated with parental background. This study describes the most typical joint labor market and family formation pathways of young adults and assesses whether belonging to these pathway groups is associated with parental origin. We use annually updated register-based data and analyze Finnish men and women born between 1972 and 1975 with follow-up until their mid-30s. By using multichannel sequence analyses, we identified six distinct pathway types to adulthood that are defined by educational attainment, labor market participation, and family formation, and demonstrate that these pathways are primarily dominated by the educational achievements of young adults. Educational choices and trajectories, thus, also strongly shape the patterns of other life paths and events in early adulthood. Gender differences were particularly evident for pathways characterized by low education, women entering pathways dominated by early partnership and motherhood, and men remaining without a partner or any children. We further show that parental resources particularly parental income predict the paths upon which the young adults embark. Parental resources in particular are most strongly linked with the educational differentiation between the paths.

  • 44. Sirniö, Outi
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Kauppinen, Timo M.
    Entering the highest and the lowest incomes: Intergenerational determinants and early-adulthood transitions2016In: Research in Social Stratification and Mobility, ISSN 0276-5624, E-ISSN 1878-5654, Vol. 44, p. 77-90Article in journal (Refereed)
    Abstract [en]

    Early-adulthood transitions contribute to socioeconomic attainment, and these early-adulthood life courses are partly influenced by family background. Less is known about how parental background and early-adulthood transitions jointly determine chances of entering the most and the least affluent positions in society. Using a longitudinal, register-based data set, this study examines the intergenerational and life-course mechanisms related to entry into income quintiles in Finland among those born between 1972 and 1975, with follow-up until their mid-30s. The specific focus is to test whether a more affluent origin compensates for less favorable transitions in early adulthood. Parental income predicts entry to the lowest and the highest incomes in adulthood. Those with high income parents are less likely to enter the middle income than those with low parental income, especially among men. The effects of lower educational achievement are compensated for by higher parental income among men, whereas women with higher education are more likely to benefit from their higher origin. High-income parents also protect from the harmful effects of long-term unemployment on adult income, although this compensatory effect disappears when long-term unemployment spells are very frequent. The positive parental income effect does not vary according to the age of having the first child, however, and does not apply to women with a more highly educated partner. These results indicate that the effects of early-adulthood transitions on income attainment differ across parental background groups, implying that those with higher origin have more beneficial resources. The mechanisms also vary by gender, possibly reflecting the strongly segregated labor markets in Finland.

  • 45. Sund, Reijo
    et al.
    Lahtinen, Hannu
    Wass, Hanna
    Mattila, Mikko
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; University of Eastern Finland, Finland; Max Planck Institute for Demographic Research, Germany .
    How voter turnout varies between different chronic conditions? A population-based register study2017In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 71, no 5, p. 475-479Article in journal (Refereed)
    Abstract [en]

    Background While poor self-rated health is known to decrease an individual's propensity to vote, disaggregation of the components of health on turnout has thus far received only little attention. This study deepens on the understanding of such relationships by examining the association between chronic diseases and voting. Methods The study uses an individual-level register-based data set that contains an 11% random sample of the entire electorate in the 1999 Finnish parliamentary elections. With information on hospital discharge diagnoses and reimbursements for drugs prescribed, we identify persons with chronic hospital-treated diseases (coronary heart disease, chronic obstructive pulmonary disease (COPD) and asthma, depression, cancer, psychotic mental disease, diabetes, cerebrovascular disease, rheumatic disease, epilepsy, arthrosis, alcoholism, dementia, atherosclerosis, Parkinson's disease, other degenerative brain diseases, multiple sclerosis and kidney disease). Results After adjusting for gender, age, education, occupational class, income, partnership status, cohabitation with underaged children and hospitalisation during Election Day, neurodegenerative brain diseases had the strongest negative relationship with voting (dementia OR = 0.20, 95% CI 0.18 to 0.22; others up to OR = 0.70). Alcoholism (OR = 0.66) and mental disorders also had a negative association (depression OR = 0.91; psychotic mental disease OR = 0.79), whereas cancer and COPD/asthma had a positive association (both OR = 1.05). Having more than one condition at a time further decreased voting probability. Conclusions By showing how different health conditions are related to voter turnout, this study provides essential information for identifying gaps in the potential for political participation and for further inquiries aiming to develop models that explain the link between health and voting probability.

  • 46. Tarkiainen, Lasse
    et al.
    Rehnberg, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Finland.
    Fritzell, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Income trajectories prior to alcohol-attributable death in Finland and Sweden2019In: Addiction, ISSN 0965-2140, E-ISSN 1360-0443, Vol. 114, no 5, p. 807-814Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIMS: Mortality from alcohol-attributable causes is patterned by income. We study analysed 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 sociodemographic 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 socioeconomic position.

    SETTING: Finland and Sweden Participants: The subjects comprised an 11-percent sample of the Finnish population in 2006-07 and the total population of Sweden aged 45-64 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 sociodemographic characteristics.

    FINDINGS: The median income 17-19 years prior to death from alcohol-attributable causes was 92% (Finland) and 91% (Sweden) of survivor income: one 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. The baseline sociodemographic 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.

  • 47.
    Torssander, Jenny
    et al.
    Stockholm University, Faculty of Social Sciences, The Swedish Institute for Social Research (SOFI).
    Moustgaard, Heta
    Peltonen, Riina
    Kilpi, Fanny
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Partner resources and incidence and survival in two major causes of death2018In: SSM - Population Health, ISSN 2352-8273, Vol. 4, p. 271-279Article in journal (Refereed)
    Abstract [en]

    Because people tend to marry social equals – and possibly also because partners affect each other’s health – the social position of one partner is associated with the other partner’s health and mortality. Although this link is fairly well established, the underlying mechanisms are not fully identified. Analyzing disease incidence and survival separately may help us to assess when in the course of the disease a partner’s resources are of most significance. This article addresses the importance of partner’s education, income, employment status, and health for incidence and survival in two major causes of death: cancer and cardiovascular diseases (CVD). Based on a sample of Finnish middle-aged and older couples (around 200,000 individuals) we show that a partner’s education is more often connected to incidence than to survival, in particular for CVD. Once ill, any direct effect of partner’s education seems to decline: The survival chances after being hospitalized for cancer or CVD are rather associated with partner’s employment status and/or income level when other individual and partner factors are adjusted for. In addition, a partner’s history of poor health predicted higher CVD incidence and, for women, lower cancer survival. The findings suggest that various partner’s characteristics may have different implications for disease and survival, respectively. A wider focus on social determinants of health at the household level, including partner’s social resources, is needed.

  • 48. Trias-Llimós, Sergi
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Mäkelä, Pia
    Janssen, Fanny
    Comparison of different approaches for estimating age-specific alcohol-attributable mortality: The cases of France and Finland2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 3, article id e0194478Article in journal (Refereed)
    Abstract [en]

    Background Accurate estimates of the impact of alcohol on overall and age-specific mortality are crucial for formulating health policies. However, different approaches to estimating alcohol-attributable mortality provide different results, and a detailed comparison of age-specific estimates is missing. Methods Using data on cause of death, alcohol consumption, and relative risks of mortality at different consumption levels, we compare eight estimates of sex- and age-specific alcohol-attributable mortality in France (2010) and Finland (2013): five estimates using cause-of-death approaches (with one accounting for contributory causes), and three estimates using attributable fraction (AF) approaches. Results AF-related approaches and the approach based on alcohol-related underlying and contributory causes of death provided estimates of alcohol-attributable mortality that were twice as high as the estimates found using underlying cause-of-death approaches in both countries and sexes. The differences across the methods were greatest among older age groups An inverse U-shape in age-specific alcohol-attributable mortality (peaking at around age 65) was observed for cause-of-death approaches, with this shape being more pronounced in Finland. AF-related approaches resulted in different estimates at older ages: i.e., mortality was found to increase with age in France; whereas in Finland mortality estimates depended on the underlying assumptions regarding the effects of alcohol consumption on cardiovascular mortality. Conclusions While the most detailed approaches (i.e., the AF-related approach and the approach that includes underlying and contributory causes) are theoretically able to provide more accurate estimates of alcohol-attributable mortality, they especially the AF approaches- depend heavily on data availability and quality. To enhance the reliability of alcohol-attributable mortality estimates, data quality for older age groups needs to be improved.

  • 49. van Hedel, Karen
    et al.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany; Karolinska Institutet, Sweden.
    Moustgaard, Heta
    Myrskylä, Mikko
    Cohabitation and mental health: Is psychotropic medication use more common in cohabitation than marriage?2018In: SSM - Population Health, ISSN 2352-8273, Vol. 4, p. 244-253Article in journal (Refereed)
    Abstract [en]

    Marriage is associated with better mental health. While research on the mental health of cohabiting individuals has increased in recent years, it has yielded mixed results thus far. We assessed whether the mental health of cohabiters is comparable to that of married individuals or those living alone using longitudinal data on psychotropic medication purchases. Panel data from an 11% random sample of the population residing in Finland for the years 1995 to 2007, with annual measurements of all covariates, were used. Ordinary least squares (OLS) models were applied to disentangle the relation between cohabitation and psychotropic medication purchases while controlling for relevant time-varying factors (age, education, economic activity, and number of children), and individual fixed effects (FE) models to further account for unobserved time-invariant individual factors. Our sample consisted of 63,077 men and 61,101 women aged 25 to 39 years in 1995. Descriptive results and the OLS model indicated that the likelihood of purchasing psychotropic medication was lowest for married individuals, higher for cohabiters, and highest for individuals living alone. This difference between cohabiting and married individuals disappeared after controlling for time-varying covariates (percent difference [% diff] for men: 0.3, 95% confidence interval [CI]: -0.0, 0.6; % diff for women: -0.2, 95% CI: -0.6, 0.2). Further controlling for unobserved confounders in the FE models did not change this non-significant difference between cohabiting and married individuals. The excess purchases of psychotropic medication among individuals living alone compared to those cohabiting decreased to 1.2 (95% CI: 1.0, 1.4) and 1.4 (95% CI: 1.1, 1.6) percentage-points in the fully-adjusted FE model for men and women, respectively. Similar results were found for all subcategories of psychotropic medication. In summary, these findings suggested that the mental health difference between cohabiting and married individuals, but not the difference between cohabiting individuals and those living alone, was largely due to selection.

  • 50. van Raalte, Alyson A
    et al.
    Sasson, Isaac
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Max Planck Institute for Demographic Research, Germany; University of Helsinki, Finland.
    The case for monitoring life-span inequality2018In: Science, ISSN 0036-8075, E-ISSN 1095-9203, Vol. 362, no 6418, p. 1002-1004Article in journal (Refereed)
    Abstract [en]

    Inequality in length of life is the most fundamental of all inequalities; every other type of inequality is conditional upon being alive. As has long been recognized in studies of economic inequality, we can compare populations based on per capita gross national income, but there is a pressing need to further examine how income varies within populations via Gini coefficients and percentile-based metrics. Mortality inequalities should be approached in the same way. Human population health is generally monitored by average mortality levels, typically in terms of life expectancies, which belie substantial variation in length of life. Variation in ages at death, captured by a metric of life-span variation, should be used to supplement measures of average longevity when comparing or monitoring societies and population subgroups (1). Although life-span variation has historically been strongly inversely correlated with life expectancy (2, 3), we are beginning to see this relationship reversed, resulting in positive correlation in some countries or subnational populations. Often these changes reflect midlife mortality crises with roots in stratified education and wealth. We discuss these measures and trends and how they can have profound implications for how individuals might plan and live their lives, and for how societies might organize and manage health care, insurance, pensions, and other social policies and programs.

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