IMPORTANCE Children who are placed in out-of-home care may have poorer outcomes in adulthood, on average, compared with their peers, but the direction and magnitude of these associations need clarification.

OBJECTIVE To estimate associations between being placed in out-of-home care in childhood and adolescence and subsequent risks of experiencing a wide range of social and health outcomes in adulthood following comprehensive adjustments for preplacement factors.

DESIGN, SETTING, PARTICIPANTS This cohort and cosibling study of all children born in Finland between 1986 and 2000 (N = 855622) monitored each person from their 15th birthday either until the end of the study period (December 2018) or until they migrated, died, or experienced the outcome of interest. Cox and Poisson regression models were used to estimate associations with adjustment for measured confounders (from linked population registers) and unmeasured familial confounders (using sibling comparisons). Data were analyzed from October 2020 to August 2021.

EXPOSURES Placement in out-of-home care up to age 15 years.

MAIN OUTCOMES AND MEASURES Through national population, patient, prescription drug, cause of death, and crime registers, 16 specific outcomes were identified across the following categories: psychiatric disorders; low socioeconomic status; injuries and experiencing violence; and antisocial behaviors, suicidality, and premature mortality.

RESULTS A total of 30127 individuals (3.4%) were identified who had been placed in out-of-home care for a median (interquartile range) period of 1.3 (0.2-5.1) years and 2 (1-3) placement episodes before age 15 years. Compared with their siblings, individuals who had been placed in out-of-home care were 1.4 to 5 times more likely to experience adverse outcomes in adulthood (adjusted hazard ratio [aHR] for those with a fall-related injury, 1.40; 95% CI, 1.25-1.57 and aHR for those with an unintentional poisoning injury, 4.79; 95% CI, 3.56-6.43, respectively). The highest relative risks were observed for those with violent crime arrests (aHR, 4.16; 95% CI, 3.74-4.62; cumulative incidence, 24.6% in individuals who had been placed in out-of-home care vs 5.1% in those who had not), substance misuse (aHR, 4.75; 95% CI, 4.25-5.30; cumulative incidence, 23.2% vs 4.6%), and unintentional poisoning injury (aHR 4.79; 95% CI, 3.56-6.43; cumulative incidence, 3.1% vs 0.6%). Additional adjustments for perinatal factors, childhood behavioral problems, and traumatic injuries, including experiencing violence, did not materially change the findings.

CONCLUSIONS AND RELEVANCE Out-of-home care placement was associated with a wide range of adverse outcomes in adulthood, which persisted following adjustments for measured preplacement factors and unmeasured familial factors.

Several studies have found that parental absences in childhood are associated with individuals' reproductive strategies later in life. However, these associations vary across populations and the reasons for this heterogeneity remain debated. In this paper, we examine the diversity of parental associations in three ways. First, we test whether different kinds of parental availability in childhood and adolescence are associated with women's and men's ages at first birth using the intergenerational and longitudinal Uppsala Birth Cohort Study (UBCoS) dataset from Sweden. This cultural context provides a strong test of the hypothesis that parents influence life history strategies given that robust social safety nets may buffer parental absences. Second, we examine whether investments in education help explain why early parental presence is associated with delayed ages at first birth in many post-industrial societies, given that parents often support educational achievement. Third, we compare parental associations with reproductive timing across two adjacent generations in Sweden. This historical contrast allows us to control for many sources of heterogeneity while examining whether changing educational access and norms across the 20th-century change the magnitude and pathways of parental influence. We find that parental absences tend to be associated with earlier first births, and more reliably so for women. Many of these associations are partially mediated by university attendance. However, we also find important differences across cohorts. For example, the associations with paternal death become similar for sons and daughters in the more recent cohort. One possible explanation for this finding is that fathers start influencing sons and daughters more similarly. Our results illustrate that historical changes within a population can quickly shift how family affects life history.

Background Genetic vulnerability to coronary heart disease (CHD) is well established, but little is known whether these effects are mediated or modified by equally well-established social determinants of CHD. We estimate the joint associations of the polygenetic risk score (PRS) for CHD and education on CHD events.

Methods The data are from the 1992, 1997, 2002, 2007 and 2012 surveys of the population-based FINRISK Study including measures of social, behavioural and metabolic factors and genome-wide genotypes (N=26 203). Follow-up of fatal and non-fatal incident CHD events (N=2063) was based on nationwide registers.

Results Allowing for age, sex, study year, region of residence, study batch and principal components, those in the highest quartile of PRS for CHD had strongly increased risk of CHD events compared with the lowest quartile (HR=2.26; 95% CI: 1.97 to 2.59); associations were also observed for low education (HR=1.58; 95% CI: 1.32 to 1.89). These effects were largely independent of each other. Adjustment for baseline smoking, alcohol use, body mass index, igh-density lipoprotein (HDL) and total cholesterol, blood pressure and diabetes attenuated the PRS associations by 10% and the education associations by 50%. We do not find strong evidence of interactions between PRS and education.

Conclusions PRS and education predict CHD events, and these associations are independent of each other. Both can improve CHD prediction beyond behavioural risks. The results imply that observational studies that do not have information on genetic risk factors for CHD do not provide confounded estimates for the association between education and CHD.

This study examined trends and inequalities in road traffic accident (RTA) mortality in the Baltic countries (Estonia, Latvia, Lithuania) and Finland in relation to large-scale macroeconomic changes in the 2000s. Educational inequalities in RTA mortality in 2000-2003, 2004-2007, 2008-2011 and 2012-2015 among 30-74 year olds were examined using census-linked longitudinal mortality data and by estimating the relative and slope index of inequality. Overall RTA mortality decreased substantially between 2000-2003 and 2012-2015. From 2004-2007 to 2008-2011, the RTA mortality decline accelerated but was larger in the Baltic countries. Among men the RTA mortality decline was mostly driven by a larger fall among the high and middle educated. Among women, the changes in RTA mortality by educational level had no clear pattern. From 2000-2003 to 2012-2015 relative educational inequalities in RTA mortality increased among men, although more in the Baltic countries. Among women the pattern was mixed across countries. Absolute inequalities fell in all countries among both sexes. Educational inequalities in male RTA mortality may be growing because of increasingly less access to safer cars and a more hazardous driving culture among the lower educated.

This study investigated mental health in schoolchildren in different living arrangements after parental separation. The study population included 31,519 children from the Danish National Birth Cohort, followed-up at age 11 in 2010-2014. Child mental health was measured with a maternal report of the Strength and Difficulties Questionnaire (SDQ). Associations between living arrangements and mental health were analyzed using logistic and linear regression models, taking into account early childhood indicators of the parents' relations, income, education and psychiatric care. At age 11, children living in a nuclear family had the lowest rate of total SDQ score, 8.9%. Of the children who had experienced parental separation, children in joint physical custody had the lowest adjusted odds ratio (OR)1.25 (95%-CI 1.09-1.44), for a high SDQ score relative to children living in a nuclear family, with adjusted ORs of 1.63 (1.42-1.86) and OR 1.72 (1.52-1.95) for sole physical custody arrangements with and without a new partner. An analysis of change in SDQ scores between ages 7 and 11 in children showed a similar pattern. This study indicates that joint physical custody is associated with slightly more favorable mental health in schoolchildren after parental separation than sole physical custody arrangements.

Socioeconomic disadvantage in childhood is common among youth not in education, employment or training (NEETs). However, the evidence on other adverse childhood experiences as determinants of NEET remains scarce. We use Finnish longitudinal register data on a 20% random sample of households with 0-14-year-old children in 2000 to assess the childhood determinants of NEET. For an analytical sample of 99,137 children born 1986-1993, family socioeconomic resources, parental psychiatric disorders and substance abuse, parental death, living in a single-parent household and out-of-home placement under age 13 were used to predict NEET at the age of 18. We show that family socioeconomic disadvantage is strongly associated with NEET (e.g. odds ratio for parental basic education 5.33, 95% confidence interval 4.77, 5.95), whereas associations between adverse childhood experiences and NEET are more moderate (e.g. odds ratio for parent hospitalised for psychiatric disorder 1.86, 95% confidence interval 1.63, 2.12) and largely explained by socioeconomic factors. These associations were mostly similar by gender. The results suggest that parental socioeconomic resources are more important than adverse childhood experiences for the educational and employment transitions of young adults. Thus, supportive social policy for socioeconomically disadvantaged families may smooth these transitions.

Purpose - Early identification of persons at risk is essential in suicide prevention. Undocumented migrants (UM) live under limited conditions and are to a high degree invisible, both in research and in suicide prevention programmes. The aim of this study was to investigate prevalence rates of suicidal thoughts among UM in Sweden.

Design/methodology/approach - This cross-sectional study was part of the Swedish Health Research on Undocumented Migrants project (SHERUM). The study population consisted of 104 UM over 18 years of age recruited through informal networks. Data on 112 multiple choice questions was collected via trained interviewers in Gothenburg, Stockholm and Malmo during 2014-2016. To assess suicidal thoughts (the last two weeks) one item asking about suicidal thought in the Beck Depression Inventory scale (BDI-II) was used. Logistic regression and chi-square analyses were made to identify risk and protective factors.

Findings - Suicidal thoughts were found in 43.2% of the 88 UM that answered the question on suicidal thoughts. Being a parent had some protective influence on the prevalence of suicidal thoughts while the housing situation, having been exposed to crime and having mental illness were all statistically significant risk factors for suicidal thoughts. However, due to low sample size, few variables presented statistically significant differences.

Originality/value - This study presents an alarmingly high prevalence of suicidal thoughts among undocumented migrants in Sweden, a difficult-to reach, vulnerable and rarely studied group. Targeted strategies are imperative to include undocumented migrants in suicidal prevention programmes.

Objective: To determine whether the Institute Of Medicine's (IOM) 2009 guidelines for weight-gain during pregnancy are predictive of maternal and infant outcomes in ethnic minority populations.

Methods: We designed a population-based study using administrative data on 181,948 women who delivered live singleton births in Washington State between 2006–2008. We examined risks of gestational hypertension, preeclampsia/eclampsia, cesarean delivery, and extended hospital stay in White, Black, Native-American, East-Asian, Hispanic, South-Asian and Hawaiian/Pacific islander women according to whether they gained more or less weight during pregnancy than recommended by IOM guidelines. We also examined risks of neonatal outcomes including Apgar score <7 at 5 min, admission to NICU, requirement for ventilation, and a diagnosis of small or large for gestational age at birth.

Results: Gaining too much weight was associated with increased odds for gestational hypertension (adjusted OR (aOR) ranged between 1.53–2.22), preeclampsia/eclampsia (aOR 1.44–1.81), cesarean delivery (aOR 1.07–1.38) and extended hospital stay (aOR 1.06–1.28) in all ethnic groups. Gaining too little weight was associated with decreased odds for gestational hypertension and delivery by cesarean section in Whites, Blacks and Hispanics. Gaining less weight or more weight than recommended was associated with increased odds for small for gestational age and large for gestational age infants respectively, in all ethnic groups.

Conclusions: Adherence to the 2009 IOM guidelines for weight gain during pregnancy reduces risk for various adverse maternal outcomes in all ethnic groups studied. However, the guidelines were less predictive of infant outcomes with the exception of small and large for gestational age.

Aim: The aim of this review was to evaluate the evidence for interventions for behavioural sleep problem in infants.

Methods: Systematic review based on a search in MEDLINE, Web of Science and PsychINFO in December 2017 for articles published in English during 2007-2017 about preventive and treatment interventions for sleep problems in infants. The review included controlled trials and meta-analyses with at least 20 infants in study groups assessed according to the Grading of Recommendations Assessment, Development and Evaluation criteria.

Results: Out of 476 original articles assessed for eligibility, 12 studies were included in the synthesis. Interventions with behavioural, educational and massage strategies were evaluated. No intervention was evaluated in more than one trial. Five interventions with behavioural methods for establishing consistent routines or controlled crying showed modest short-term effects, while the evidence for elements of education was inconsistent. Studies of massage were of poor quality. Knowledge gaps were identified regarding interventions in cross-cultural context, involving fathers, in children below six months of age, in high-risk populations and consequences of interventions that include extinction.

Conclusion: Some support for short-term effects of behavioural treatment strategies was found, but more studies are needed to establish evidence.

Aim: The aim of this review was to evaluate the evidence for interventions for infantile colic.

Methods: This was a systematic review based on a literature search in December 2017 for articles published during 2007-2017 about preventive and treatment interventions for infantile colic in infants. The review included original randomised controlled trials (RCTs) and meta-analyses with at least 20 infants in each study group that were assessed according to GRADE criteria.

Results: The review found moderately strong evidence that administration of Lactobacillus reuteri DSM 17938 shortened the crying duration, with positive evidence from three out of four national contexts. There were four RCTs of acupuncture, all with no or minimal effect on crying duration. All studies reviewed with a follow-up until or beyond three months of age show a quite steep decline over time in crying duration in both treatment and control groups.

Conclusion: Lactobacillus reuteri DSM 17938 is a promising treatment for infantile colic with moderately strong evidence in this review, but studies in more populations are needed. Acupuncture is not an effective treatment for infantile colic. Systematic support strategies to parents with infantile colic are important knowledge gaps.

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.

We examined urban-rural differences in educational inequalities in mortality in the Baltic countries (Estonia, Latvia, Lithuania) and Finland in the context of macroeconomic changes. Educational inequalities among 30-74 year olds were examined in 2000-2003, 2004-2007, 2008-2011 and 2012-2015 using census-linked longitudinal mortality data. We estimated age-standardized mortality rates and the relative and slope index of inequality. Overall mortality rates were larger in rural areas except among Finnish women. Relative educational inequalities in mortality were often larger in urban areas among men but in rural areas among women. Absolute inequalities were mostly larger in rural areas excepting Finnish men. Between 2000-2003 and 2012-2015 relative inequalities increased in most countries while absolute inequalities decreased except in Lithuania. In the Baltic countries the changes in both relative and absolute inequalities tended to be more favorable in urban areas; in Finland they were more favorable in rural areas. The overall pattern changed during the reccessionary period from 2004-2007 to 2008-2011 when relative inequalities often diminished or the increase slowed, while the decrease in absolute inequalities accelerated with larger improvements observed in urban areas. Despite substantial progress in reducing overall mortality rates in both urban and rural areas in all countries, low educated men and women in rural areas in the Baltic countries are becoming increasingly disadvantaged in terms of mortality reduction.

Background: Non-European international adoptees in Sweden were shown to have a three-to fourfold higher risk of suicidal behaviour in youth during 1986-1995 compared with the general population. The aim of this study was to investigate whether this high risk persists beyond youth and in later cohorts.

Methods: A register study of Swedish national cohorts born 1972-86 including 20 625 non-European international adoptees, and comparison populations of 10 915 non-European immigrants and 1 435 167 Swedish born was performed. The study population was followed from age 18 between 1991 and 2016, with suicide and hospital admissions due to suicide attempt as outcomes. Poisson regression models of person time in the study, adjusted for gender and household income at age 17, were fitted to calculate relative risks (RR).

Findings: Adjusted RR for suicide in non-European international adoptees was high at age 18-22, 2.74 (95% C. I. 1.95-3.86), but decreased gradually to age 33-43 when the risk was similar to Swedish-born. Adjusted RR for suicide attempts in international adoptees was 2.33 (2.15-2.52) at age 18-22, decreased slightly with older age, but remained higher than Swedish born in all age-classes. Risks for both outcomes were greatest, around three times higher compared with the Swedish-born in the oldest birth cohorts of non-European international adoptees, born 1972-76. Risks for both suicidal outcomes increased with higher age at adoption.

Interpretation: The risk of suicidal behaviour in non-European international adoptees in Sweden decreases with age and is lower in later birth cohorts and in infant adoptions.

Previous studies have demonstrated a negative, significant impact on birthweight associated with the current economic crisis in Spain, which has also been reported for other European countries. Effects by parity are not known. Our aim is to compare the trends in low birthweight (LBW) by parity in Spain from 1996 to 2016. Using the National Vital Statistics data, joinpoint regression analysis was used to identify the time periods of significant changes in the prevalence of LBW by parity. Adjusted relative risk (RR) of LBW by year of birth was calculated in order to confirm that the time trend differences in LBW by parity were independent of possible confounders. The prevalence of LBW among live births to primiparous increased from 5.12% to 6.87% in 2008 and then stabilised at maximum values, while among live births to multiparous LBW increased from 3.96% to a maximum of 5.20% and then significantly reduced. Trends in adjusted RR of LBW by parity confirm that primiparous and multiparous were affected differently by the economic crisis. Older, nulliparous women may have felt more biosocial pressure to reproduce during the economic crisis, compared to women who were already mothers. This biosocial pressure may have increased the risks for LBW.

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

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

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

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

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

MAIN RESULTS AND THE ROLE OF CHANCE: A total of 56026 children, 2624 of whom were conceived through MAR treatments, were included in the study. Among the mothers who used MAR to conceive, maternal age was not associated with an increased risk of LBW (the overall prevalence was 12.6%) at ages 25-39. For example, compared to the risk of LBW at ages 30-34, the risk was 0.22 percentage points lower (95% CI: -3.2, 2.8) at ages 25-29 and was 1.34 percentage points lower (95% CI: -4.5, 1.0) at ages 35-39. The risk of LBW was increased only at maternal ages >= 40 (six percentage points, 95% CI: 0.2, 12). Adjustment for maternal characteristics only marginally attenuated these associations. In contrast, among the mothers who conceived naturally, the results showed a clear age gradient. For example, compared to the risk of LBW (the overall prevalence was 3.3%) at maternal ages 30-34, the risk was 1.1 percentage points higher (95% CI: 0.6, 1.6) at ages 35-39 and was 1.5 percentage points higher (95% CI: 0.5, 2.6) at ages >= 40. The results were similar for preterm births.

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

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

Objective To compare mortality in children aged <5 years from two causes amenable to healthcare prevention in England and Sweden: respiratory tract infection (RTI) and sudden unexpected death in infancy (SUDI).

Design Birth cohort study using linked administrative health databases from England and Sweden.

Setting and participants Singleton live births between 2003 and 2012 in England and Sweden, followed up from age 31 days until the fifth birthday, death or 31 December 2013.

Main outcome measures The main outcome measures were HR for RTI-related mortality at 31-364 days and at 1-4 years and SUDI mortality at 31-364 days in England versus Sweden estimated using Cox proportional hazards models. We calculated unadjusted HRs and HRs adjusted for birth characteristics (gestational age, birth weight, sex and congenital anomalies) and socioeconomic factors (maternal age and socioeconomic status).

Results The English cohort comprised 3 928 483 births, 768 RTI-related deaths at 31-364 days, 691 RTI-related deaths at 1-4 years and 1166 SUDIs; the corresponding figures for the Swedish cohort were 1 012 682, 131, 118 and 189. At 31-364 days, unadjusted HR for RTI-related death in England versus Sweden was 1.52 (95% CI 1.26 to 1.82). After adjusting for birth characteristics, the HR reduced to 1.16 (95% CI 0.96 to 1.40) and for socioeconomic factors to 1.11 (95% CI 0.92 to 1.34). At 1-4 years, unadjusted HR was 1.58 (95% CI 1.30 to 1.92) and decreased to 1.32 (95% CI 1.09 to 1.61) after adjusting for birth characteristics and to 1.30 (95% CI 1.07 to 1.59) after further adjustment for socioeconomic factors. For SUDI, the respective HRs were 1.59 (95% CI 1.36 to 1.85) in the unadjusted model, and 1.40 (95% CI 1.20 to 1.63) after accounting for birth characteristics and 1.19 (95% CI 1.02 to 1.39) in the fully adjusted model.

Conclusion Interventions that improve maternal health before and during pregnancy to reduce the prevalence of adverse birth characteristics and address poverty could reduce child mortality due to RTIs and SUDIs in England.

Background: Fathers may affect expectant mothers’ daily living situations, which in turn might influence pregnancy outcomes. We investigated the association between paternal violent criminality and risk of preterm birth (≤36 weeks). Methods: We conducted a register-based study with all live singleton births in the Swedish Medical Birth Register from 1992 to 2012, linked with records of paternal violent crime convictions from the National Crime Register from 1973 to 2012. Results: Paternal violent criminality was associated with increased risk of preterm birth and lower gestational age. The association was especially pronounced among infants of reoffenders: men convicted of three or more violent crimes (adjusted odds ratio [aOR] 1.23 [95% CI 1.17, 1.29]). Maternal half sibling-comparisons, an analytic approach controlling for maternal factors stable across pregnancies, also suggested increased risk of preterm birth and lower gestational age when exposed to a violently reoffending father compared to a father without violent criminal convictions (aOR 1.30 [0.99, 1.72], adjusted mean difference − 1.07 [− 1.78, − 0.36]). Conclusions: Persistent paternal violent criminality was associated with increased risk of preterm birth, even after controlling for maternal characteristics that did not change between pregnancies.

Socio-economic circumstances influence later-life employment participation, which may take different forms as retirement processes are complex. We aimed to explore the diverse effects of various socio-economic sub-domains on pre- and post-retirement employment. We used Finnish register data to examine socio-economic predictors of time to retirement (i.e. receiving the statutory pension) using Cox regression analysis and on time spent in post-retirement employment using repeated negative binomial regression analysis over a follow-up between the ages of 63 and 68, i.e. the flexible pension age range. An average wage earner still employed at age 62 spent 13.5 months in pre-retirement employment (this corresponds to time to retirement) and 4.8 months in post-retirement employment. Those with tertiary education retired later, but the educational differences in the total time spent in employment were small when post-retirement employment was also considered. There was little variation in the timing of retirement by household income, but those in the highest quintile spent the longest time in post-retirement employment. Upper non-manual employees, home renters and those with high household debt retired later, and those with high household debt also spent a longer time in post-retirement employment. In a national flexible pension age system, high occupational class and household income thus appear to encourage either later retirement or participation in post-retirement employment. However, economic constraints also appear to necessitate continued employment.

AIMS: We investigate (a) alcohol consumption in association with type 2 diabetes, taking heavy episodic drinking (HED), socioeconomic, health and lifestyle, and psychosocial factors into account, and (b) whether a seemingly protective effect of moderate alcohol consumption on type 2 diabetes persists when stratified by occupational position.

METHODS: This population-based longitudinal cohort study comprises 16,223 Swedes aged 18-84 years who answered questionnaires about lifestyle, including alcohol consumption in 2002, and who were followed-up for self-reported or register-based diabetes in 2003-2011. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated in a multivariable-adjusted logistic regression model for all participants and stratified by high and low occupational position. We adjusted for HED, socioeconomic (occupational position, cohabiting status and unemployment), health and lifestyle (body mass index (BMI), blood pressure, smoking, physical inactivity, poor general health, anxiety/depression and psychosocial (low job control and poor social support) characteristics one by one, and the sets of these factors.

RESULTS: Moderate consumption was inversely associated with type 2 diabetes after controlling for health and lifestyle (OR=0.47; 95% CI: 0.29-0.79) and psychosocial factors (OR=0.40; 95% CI: 0.22-0.79) when compared to non-drinkers. When adjusting for socioeconomic factors, there was still an inverse but non-significant association (OR=0.59; 95% CI: 0.35-1.00). In those with high occupational position, there was no significant association between moderate consumption and type 2 diabetes after adjusting for socioeconomic (OR=0.67; 95% CI: 0.3-1.52), health and lifestyle (OR=0.70; 95% CI: 0.32-1.5), and psychosocial factors (OR=0.75; 95% CI: 0.23-2.46). On the contrary, in those with low occupational position, ORs decreased from 0.55 (95% CI: 0.28-1.1) to 0.35 (95% CI: 0.15-0.82) when adjusting for psychosocial factors, a decrease that was solely due to low job control. HED did not influence any of these associations.

CONCLUSIONS: Moderate alcohol consumption is associated with a lower risk of type 2 diabetes, after adjusting for HED, health and lifestyle, and psychosocial characteristics. The association was inverse but non-significant after adjusting for socioeconomic factors. When stratified by occupational position, there was an inverse association only in those with low occupational position and after adjusting for low job control.

Low birth weight has been shown to be related to increased risk of depression later in life - but the evidence is not conclusive. We examined the association of size at birth with repeatedly measured depressive symptoms in 947 individuals from the Northern Swedish Cohort, a community-based age-homogeneous cohort born in 1965, and followed with questionnaires between ages 16 and 43 (participation rate above 90% in all the surveys). Information on birth size was retrieved from archived birth records. Length of gestation was known for a subsample of 512 individuals (54%). We studied the association of birth weight and ponderal index with self-reported depressive symptoms at ages 16, 21, 30 and 43; with the life-course average of depressive symptoms score and with longitudinal trajectories of depressive symptoms retrieved by latent class growth analysis. Socioeconomic background, mental illness or alcohol problems of a parent, exposure to social adversities in adolescence and prematurity were accounted for in the analyses. We did not find any relationship between weight or ponderal index at birth and our measure of depressive symptoms between ages 16 and 43 in a series of different analyses. Adjustment for length of gestation did not alter the results. We conclude that size at birth is not associated with later-life depressive symptoms score in this cohort born in the mid-1960s in Sweden. The time and context need to be taken into consideration in future studies.

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

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

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

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

Most European countries have systematic health assessments of refugees with a main focus on infectious diseases. The aim of this study was to describe the broader health care needs identified in newly settled refugee children in a school health setting. The study population consisted of all 609 recently settled Non-European refugee and asylum-seeking children in the age range 6-15 years who were enrolled in the schools of Malmo, Sweden during the autumn semester of 2015, of which 265 had arrived in Sweden unaccompanied. The data were collected in a structured routine intake interview by an experienced school nurse. Almost half of the children had obvious untreated caries. For the unaccompanied children, prominent mental health needs were present in almost one in three. Previously unidentified vision and/or hearing problems were identified in one in ten and around 5% had a daily medication, and 4.5% of the unaccompanied children and 1.2% of the accompanied children were judged to be in need of immediate care and were referred accordingly. Newly settled refugee children in northern Europe have considerable health care needs apart from communicable diseases. School health services have a unique platform to identify and initiate this care.

Background: More than 800 000 asylum-seeking children were registered in Europe during 2015-2017. Many of them arrived with accumulated needs of healthcare. In this study, we examined the legislation for health examinations on arrival for migrant children in the EU/EAA area.

Methods: We did a survey to child health professionals within the EU-funded MOCHA project, supplemented by desktop research of official documents.

Results: In all but three surveyed countries in the EU/EEA, there were systematic health examinations of newly settled migrant children. In most eastern European countries and Germany, this health examination was mandatory; while in the rest of western and northern Europe it was mostly voluntary. All countries that had a mandatory policy of health examinations screened for communicable diseases to protect the host population. Almost all countries with a voluntary policy also aimed to assess a child's individual healthcare needs, but this was rarely the case in countries with a mandatory policy.

Conclusion: Systematic health examinations of migrant children are routinely performed in most countries in the EU/EEA; but in many countries, it could be improved considerably by extending the focus from screening for communicable diseases to assessing and addressing individual needs of healthcare.

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.

Background: The concept of social foreground describes how adult offspring's socioeconomic resources may influence older adults' health and several studies have shown an association between socioeconomic position of adult offspring and the health of their older parents. However, little is known about the factors that generate these associations. We study 1) how adult offspring's social class is associated with physical function (PF) among older adults, 2) whether geographical closeness and contact frequency with offspring modify the association, and 3) whether intergenerational social mobility of offspring is associated with PF of older adults. Method: Data are obtained from the 2002 (n = 621) and 2011 (n = 931) waves of the Swedish Panel Study of Living Conditions of the Oldest Old. Multivariable linear regression models were employed and adjusted for own and partner's prior social class and offspring's age and gender. Results: Compared to offspring with non-manual occupation, offsprings with manual occupation was associated with poorer PF in older adults ( -0.14, CI95%: -0.28;0.00). In stratified analyses, offspring's social class was only associated with older adults' PF among those who lived geographically close. Contact frequency between the offspring and the older adults did not modify the associations. Older adults whose offspring experienced downward intergenerational social mobility were associated with the poorest PF. Conclusion: This study supports evidence of a relationship between social foreground and older adults' PF where geographical closeness and social mobility are important components.

Objective:

There is evidence suggesting that the prevalence of disability in late life has declined over time while the prevalence of chronic diseases has increased. The dynamic equilibrium of morbidity hypothesis suggests that these patterns are due to the attenuation of the morbidity-disability link over time. This study aimed to test this assumption empirically.

Methods:

Data were drawn from three repeated cross-sections of SWEOLD, a nationally representative survey of the Swedish population aged 77 years and older. Poisson regression models were fitted to assess the trends in the prevalence of Activities of Daily Living (ADL) disability, Instrumental ADL (IADL) disability, and selected groups of chronic conditions. The changes in the associations between chronic conditions and disabilities were examined on both multiplicative and additive scales.

Results:

Between 1992 and 2011, the prevalence of both ADL and IADL disabilities decreased whereas the prevalence of nearly all chronic morbidities increased. Significant attenuations of the morbidity-disability associations were found for cardiovascular diseases, metabolic disorders, poor lung function, and psychological distress.

Discussion:

In agreement with the dynamic equilibrium of morbidity hypothesis, this study concludes that the morbidity-disability associations among the Swedish older adults largely waned between 1992 and 2011.

This register-based study examined the importance of education on labour market participation among young refugees in Sweden. The study population consisted of unaccompanied (n = 1606) and accompanied refuges (n = 4142), aged 23–26 years in 2006–2010, after 7 years of residence in Sweden. Native Swedish, aged 24 years (n = 347,255) constituted the comparison population, with intercountry adoptees (n = 6689) as an alternative reference group. Gender-stratified multinomial regression models indicated that unaccompanied and accompanied male and female young refugees had higher risks of being in insecure work force and NEET compared to native Swedes with comparable levels of education. However, young refugees and intercountry adoptees with primary education had similar risks of poor labour market outcomes. The educational differences within each group concerning the risk of being in insecure work force were comparable. With the exception of unaccompanied females, secondary education seemed to be less protective against being in NEET among young refugees compared to native Swedes and intercountry adoptees. We conclude that while young refugees face employment disadvantages, education has the potential of mitigating poor labour market outcomes in this group.

Background Despite the growing prevalence of depression in the Chinese elderly, there is conflicting evidence of life course socioeconomic position (SEP) and depression onset in China, and whether this association is akin to that observed in Western societies. We compared incident risk of mid-late life depression by childhood and adulthood SEP in China and England, a country where mental health inequality is firmly established. Methods Depression-free participants from the China Health and Retirement Longitudinal Study (N=8508) and the English Longitudinal Study of Ageing (N=6184) were studied over 4 years. Depressive symptoms were classified as incident cases using the Center for Epidemiologic Studies Depression Scale criteria. Associations between SEP (education, wealth, residence ownership and childhood/ adolescent deprivation) and depression symptom onset were assessed using Cox proportional hazards models. In China, we also investigated children's government employment status as a SEP marker. Results Higher education and wealth predicted lower incidence of depression in both countries. The association with non-ownership of residence appeared stronger in England (HR 1.61, 95% CI 1.41 to 1.86) than in China (HR 1.11, 95% CI 0.95 to 1.29), while that with childhood/adolescent deprivation was stronger in China (HR 1.43, 95% CI 1.29 - 1.60) than in England (HR 1.33, 95% CI 0.92 to 1.92). Chinese adults whose children were employed in high-status government jobs, had lower rates of depression onset. Conclusions Consistent findings from China and England demonstrate that SEP is a pervasive determinant of mid-late life depression in very diverse social contexts. Together with conventional measures of SEP, the SEP of children also affects the mental health of older Chinese.

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.

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.

Background No consensus has been reached on whether depression decreases or increases with age in later life. Majority of the evidence comes from Western societies, while little is known about this relationship and its rural-urban disparities in the Chinese context. Methods Three waves of data from 15,501 Chinese adults aged 45-85 years from the China Health and Retirement Longitudinal Study, Chinese sister study of Health and Retirement Study, were used. Depression caseness was identified using the 10-item Center for Epidemiologic Studies Depression Scale (score >= 12). Urbanisation levels were determined by combining rural-urban residence and rural-urban Hukou (a household registration system). Odds ratios and predicted probabilities of depression caseness were estimated using generalised linear mixed models. Results For both men and women and across all ages, the crude predicted probability of depression caseness was the highest in the rural group, followed by the semi-urban group, and the lowest in the urban group. The probability was stable over age among urban men (around 0.05), but it increased at an accelerated rate with age among semi-urban men (0.25 at age 85, 95% confidence interval [CI]: 0.13-0.44) and rural men (0.29 at age 85, 95% CI: 0.22-0.39). Among women the age pattern was similar between the urbanisation groups: the probability increased with age, reached a peak at ages 75-80 (urban women: 0.16, 95% CI: 0.13-0.20; semi-urban women: 0.28, 95% CI: 0.20-0.39; rural women: 0.41, 95% CI: 0.36-0.46), and decreased slightly afterwards. These differences were significantly attenuated when socio-demographic characteristics and physical disability, but not when behaviour-related factors, were controlled for. Conclusion The age trajectories of later-life depression caseness varied by gender and urbanisation levels, and were not U-shaped as in many Western societies. The increasing depression caseness with age and the large rural disadvantage were substantially driven by socio-demographic characteristics and physical disability.

Objective Case-fatality rates (CFRs) for myocardial infarction (MI) and ischaemic stroke (IS) have decreased over time due to better prevention, medication and hospital care. It is unclear whether these improvements have been equally distributed according to socioeconomic position (SEP) and sex. The aim of this study is to analyse differences in short-term and long-term CFR for MI and IS by SEP and sex between the periods 1990-1994 to 2005-2009 for the entire Swedish population.

Design Population-based cohort study based on Swedish national registers.

Methods We used logistic regression and flexible parametric models to estimate short-term CFR (death before reaching the hospital or on the disease event day) and long-term CFR (1 year case-fatality conditional on surviving short-term) across five distinct SEP groups, as well as CFR differences (CFRDs) between SEP groups for both MI and IS from 1990-1994 to 2005-2009.

Results Overall short-term CFR for both MI and IS decreased between study periods. For MI, differences in short-term and long-term CFR between the least and most favourable SEP group were generally stable, except in long-term CFR among women; intermediate SEP groups mostly managed to catch up with the most favourable SEP group. For IS, short-term CFRD generally decreased compared with the most favourable group; but long-term CFRD were mostly stable, except for an increase for older subjects.

Conclusion Despite a general decline in CFR for MI and IS across all SEP groups and both sexes as well as some reductions in CFRD, we found persistent and even increasing CFRD among the least advantaged SEP groups, older patients and women. We speculate that targeted prevention rather than treatment strategies have the potential to reduce these inequalities.

Previous studies have found a U-shaped relationship between mortality and (weekday) sleep duration. We here address the association of both weekday and weekend sleep duration with overall mortality. A cohort of 43,880 subjects was followed for 13 years through record-linkages. Cox proportional hazards regression models with attained age as time-scale were fitted to estimate multivariable-adjusted hazard ratios and 95% confidence intervals for mortality; stratified analyses on age (<65 years, >= 65 years) were conducted. Among individuals <65 years old, short sleep (<= 5 hr) during weekends at baseline was associated with a 52% higher mortality rate (hazard ratios 1.52; 95% confidence intervals 1.15-2.02) compared with the reference group (7 hr), while no association was observed for long (>= 9 hr) weekend sleep. When, instead, different combinations of weekday and weekend sleep durations were analysed, we observed a detrimental association with consistently sleeping <= 5 hr (hazard ratios 1.65; 95% confidence intervals 1.22-2.23) or >= 8 hr (hazard ratios 1.25; 95% confidence intervals 1.05-1.50), compared with consistently sleeping 6-7 hr per day (reference). The mortality rate among participants with short sleep during weekdays, but long sleep during weekends, did not differ from the rate of the reference group. Among individuals >= 65 years old, no association between weekend sleep or weekday/weekend sleep durations and mortality was observed. In conclusion, short, but not long, weekend sleep was associated with an increased mortality in subjects <65 years. In the same age group, short sleep (or long sleep) on both weekdays and weekend showed increased mortality. Possibly, long weekend sleep may compensate for short weekday sleep.

Background: Previous cross-sectional studies show that low income is associated with poor mental health. However, longitudinal research has produced varying results. We assess whether low income is associated with increased psychotropic drug use after accounting for confounding by observed time-varying, and unobserved stable individual differences. Methods: The longitudinal register-based data comprises an 11% nationally representative random sample of Finnish residents aged 30-62 years between the years 2003 and 2013. The analytic sample includes 337,456 individuals (2,825,589 person-years). We estimate the association between annual income and psychotropic purchasing using ordinary-least-squares and fixed effects models, the latter controlling for all unobserved time-invariant individual characteristics. Results: The annual prevalence of psychotropic purchasing was 15%; 13% among men and 18% among women. Adjusted for age squared, sex and calendar year, the doubling of income decreased the probability of purchases by 4 percentage points (95% confidence interval: 4,4) in the ordinary-least-squares model. We observed no association after further adjusting for observed sociodemographic characteristics and unobserved individual differences in the fixed effects specification. Conclusions: Following adjustment for an extensive set of confounders, no contemporaneous association between variations in annual individual income and psychotropic drug purchasing was observed. Similar results were obtained irrespective of baseline income level and sex. The results imply that indirect selection based on preexisting individual characteristics plays a major role in explaining the association between variations in income measured over the short term, and psychotropic drug purchases. The association appears largely attributable to unobserved, stable individual characteristics. See video abstract at, http://links.lww.com/EDE/B463.

Background: Previous Swedish studies have shown a social gradient on paediatric care for viral gastroenteritis. Aim: To study the effect of a free rotavirus vaccine programme on hospital care for viral gastroenteritis. Method: A register-based national cohort study of paediatric in- and outpatient care for viral gastroenteritis in children <2 years old in two Swedish counties in 2014-2017, with the rest of the country as comparison. Adjusted hazard ratios were estimated by the differences-in-differences (DiD) estimator in Cox regression in the entire cohort and by social indicators. Results: Reductions of 37% and 24% for inpatient care, and 11 % and 21% for outpatient care for viral gastroenteritis were found in the Stockholm and Jonkoping counties, respectively, after adjusting for time trends and social indicators. For inpatient care, the change was similar over social groups in both counties. In the larger county of Stockholm, smaller reductions in outpatient care were detected for children in socially disadvantaged families. Conclusions: A free rotavirus vaccination programme moderately reduced paediatric care for viral gastroenteritis. There were indications of an increase in socioeconomic differences in paediatric outpatient care for viral gastroenteritis, but further studies are needed to confirm this result in a broader health care perspective.

In this article, the authors set out to study the time use of men and women in Sweden, comparing self-employed and employed individuals. Previous studies indicate that there are reasons to believe that both gendered time use and mechanisms related to time use might differ between the self-employed and employees. Employing time use data, the aim was to study whether there are differences in gendered time use between self-employed individuals and employees in Sweden, and furthermore, which mechanism relates to gendered time use among self-employed individuals and employees. The results show that self-employed men and women distribute their time in a more gender-traditional manner than employees. In addition, relative resources are found to be an important factor related to gendered time use among the self-employed. For employees, gender relations tend to be a mechanism related to gendered time use. The conclusion is that working conditions are important for gendered time use and should be considered in future studies.

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.

Robust evidence suggesting a strong association between greater educational attainment, betterhealth and lower mortality, has led to speculation that the quality of schooling can also have effectson health. This review critically summarises findings from 15 studies in a growing area of researchconcerning the effects of school quality on health. Findings suggested positive, long-term benefits ofhigh-quality pre-school. Other findings suggested that higher teacher wages, lower pupil–teacherratios, a longer school year, and higher college selectivity had mostly positive long-term effects onhealth and mortality. Several studies found that school quality modified the effect of years of completededucation on various health outcomes. Some measures of school quality including smallerclass size in relation to mortality, and higher college selectivity in the case of smoking were not consistentlyrelated to better health. While studies varied in their consistency and significance, theweight of the evidence together, suggests that some health inequalities over the life course wereexplained partly by differences in school quality. This may be related to improved cognition, occupationalcharacteristics, and the incomes of those exposed to better quality schooling. Direct healthknowledge and behaviour may also play a role.

Aim

This study examined the long-term cognitive and educational outcomes of being born small for gestational age (SGA) and assessed whether the family's attitude towards education modified the effect of being born SGA on educational attainment.

Methods

We used anonymised data on 9598 individuals from the Stockholm Birth Cohort. This study focused on babies born in 1953 in the Stockholm metropolitan area, who were followed up for 50 years, and included educational data at the age of 13 and 48. Ordinary least squares regression analyses, modification analyses and logistic regression analyses were conducted.

Results

The findings suggested that individuals who were born SGA (n = 798) had lower mean verbal, spatial and numerical test scores than those born appropriate for gestational age (AGA) (n = 7364) and large for gestational age (n = 1436). The SGA/AGA differences were small, but statistically significant, and the effects of being born SGA on the test scores was modified by the family's attitude towards education. The findings also suggested that attaining higher education was largely, but not entirely, explained by the family's attitude towards education.

Conclusion

The detrimental effects of being born SGA were limited on cognitive and educational outcomes, but may have been reduced by positive family attitudes.

Sleep disturbance is common in the working population, often associated with work stress, health complaints and impaired work performance. This study evaluated a group intervention at work, based on cognitive behavioral therapy (CBT) for insomnia, and the moderating effects of burnout scores at baseline. This is a randomized controlled intervention with a waiting list control group. Participants were employees working at least 75% of full time, reporting self-perceived regular sleep problems. Data were collected at baseline, post-intervention and at a 3-month follow-up through diaries, wrist-actigraphy and questionnaires including the Insomnia Severity Index (ISI) and the Shirom-Melamed Burnout Questionnaire (SMBQ). Fifty-one participants (63% women) completed data collections. A multilevel mixed model showed no significant differences between groups for sleep over time, while there was a significant effect on insomnia symptoms when excluding participants working shifts (N = 11) from the analysis (p = 0.044). Moreover, a moderating effect of baseline-levels of burnout scores was observed on insomnia symptoms (p = 0.009). A post-hoc analysis showed that individuals in the intervention group with low burnout scores at baseline (SMBQ < 3.75) displayed significantly reduced ISI scores at follow-up, compared to individuals with high burnout scores at baseline (p = 0.005). Group CBT for insomnia given at the workplace did not reduce sleep problems looking at the group as a whole, while it was indicated that the intervention reduced insomnia in employees with regular daytime work. The results also suggest that workplace-based group CBT may improve sleep in employees with primary insomnia if not concomitant with high burnout scores.

BACKGROUND: Child psychiatric treatment facilities vary greatly worldwide and are virtually non-existent in many low-income countries. One of the most common psychiatric disorders in childhood is ADHD, with an estimated prevalence of 3-5% in Sweden. Previous studies have shown a similar prevalence of ADHD in minority and majority children in Sweden and the UK. However, clinical studies demonstrated that children from immigrant families living in Sweden received less psychiatric care than those of native-born parents. We tested the hypothesis that the consumption of child psychiatric care in immigrant families would be determined by the availability of such treatment in the parents' country of origin. Patterns of medication for attention-deficit hyperactivity disorder (ADHD) were studied as a proxy for child psychiatric care.

METHODS: This was a register study of dispensed stimulant medication during 2013-2014 in Swedish national birth cohorts from 1995-2009. The study population, consisting of nearly 1.4 million children, was divided by national income of the parental country of origin and whether the parents were native Swedes, European immigrants, non-European immigrants or a mixture. Logistic regression was used to calculate the odds ratios of having been dispensed at least one ADHD drug during 2013, with adjustments for gender, family status indicating whether the child is living with both parents, household income and area of residence.

RESULTS: Having parents born in low-income (OR [95% confidence interval] 0.27 [0.24-0.29]) or middle-income (European: OR 0.23 [0.20-0.26], non-European: OR 0.39 [0.34-0.41]) countries was associated with lower ADHD treatment levels than having parents born in high-income countries (European: OR 0.60 [0.54-0.66], non-European: OR 0.68 [0.59-0.79]), when compared to children of parents born in Sweden. In families with a background in low or middle income countries, there was no significant association between household income and ADHD medication, while in children with Swedish and mixed backgrounds high level of disposable income was associated with lower levels of ADHD medication.

CONCLUSION: The use of child psychiatric care by immigrant families in Sweden was largely associated with the income level of the country of origin.

IMPORTANCE Childhood adversity (CA) is associated with an increased risk of suicide in young adulthood that might be explained by maladaptive trajectories during adolescence. Although adolescent violent offending is linked with suicide, little is known about its role in the association between CA and suicide. OBJECTIVE To examine whether adolescent violent offending mediates the association between CA and suicide in early adulthood. DESIGN, SETTING, AND PARTICIPANTS This population-based, longitudinal cohort study with a follow-up time spanning 5 to 9 years included 476 103 individuals born in Sweden between 1984 and 1988. The study population was prospectively followed up from 20 years of age until December 31, 2013, with respect to suicide. Data analysis was performed from January 1, 1984, to December 31, 2013. EXPOSURES Register-based CAs included parental death, parental substance abuse and psychiatric disorder, parental criminal offending, parental separation, public assistance recipiency, child welfare intervention, and residential instability. Adolescent violent offending was defined as being convicted of a violent crime between the ages of 15 and 19 years. MAIN OUTCOMES AND MEASURES Estimates of risk of suicide after 20 years of age (from 2004 if born in 1984 and from 2008 if born in 1988) until the end of 2013 were calculated as incidence rate ratios (IRRs) with 95% CIs using Poisson regression analysis. Adjustments were made for demographics and psychiatric disorder. In addition, binary mediation analysis with logistic regression was used. RESULTS A total of 476 103 individuals (231 699 [48.7%] female) were included in the study. Those with a conviction for violent offending had been exposed to all CAs to a greater extent than those with no violent offending. Cumulative CA was associated with risk of suicide in nonconvicted (adjusted IRR, 2.4; 95% CI, 1.5-3.9) and convicted youths, who had a higher risk of suicide (adjusted IRR, 8.5; 95% CI, 4.6-15.7). Adolescent violent offending partly mediated the association between CA and suicide. CONCLUSIONS AND RELEVANCE Individuals with a history of CA who also engage in violent offending in adolescence have a high risk of suicide. Interventions to prevent externalizing behavior during childhood and increased support to youths with delinquent behavior may have the potential to prevent suicide related to CA.

Objective Causes of Parkinson disease are largely unknown, but recent evidence suggests associations with physical activity and anthropometric measures.

Methods We prospectively analyzed a cohort of 41,638 Swedish men and women by detailed assessment of lifestyle factors at baseline in 1997. Complete follow-up until 2010 was achieved through linkage to population-based registers. We used multivariable Cox proportional hazards models to estimate hazard ratios with 95% confidence intervals (CIs).

Results We identified 286 incident cases of Parkinson disease during follow-up. Multivariable adjusted hazard ratios were 1.06 (95% CI 0.76-1.47) for sitting time >= 6 vs <6 hours per day; and 1.13 (95% CI 0.60-2.12) for body mass index >= 30 vs < 25 kg/m(2). Results did not differ by sex.

Conclusions No association between prolonged sitting time per day or obesity and risk of Parkinson disease was found.

Background

Child mortality is almost twice as high in England compared with Sweden. We aimed to establish the extent to which adverse birth characteristics and socioeconomic factors explain this difference.

Methods

We developed nationally representative cohorts of singleton livebirths between Jan 1, 2003, and Dec 31, 2012, using the Hospital Episode Statistics in England, and the Swedish Medical Birth Register in Sweden, with longitudinal follow-up from linked hospital admissions and mortality records. We analysed mortality as the outcome, based on deaths from any cause at age 2-27 days, 28-364 days, and 1-4 years. We fitted Cox proportional hazard regression models to estimate the hazard ratios (HRs) for England compared with Sweden in all three age groups. The models were adjusted for birth characteristics (gestational age, birthweight, sex, and congenital anomalies), and for socioeconomic factors (maternal age and socioeconomic status).

Findings

The English cohort comprised 3932886 births and 11392 deaths and the Swedish cohort comprised 1013360 births and 1927 deaths. The unadjusted HRs for England compared with Sweden were 1.66 (95% Cl 1.53-1.81) at 2-27 days, 1.59 (1.47-1.71) at 28-364 days, and 1.27 (1.15-1.40) at 1-4 years. At 2-27 days, 77% of the excess risk of death in England was explained by birth characteristics and a further 3% by socioeconomic factors. At 28-364 days, 68% of the excess risk of death in England was explained by birth characteristics and a further 11% by socioeconomic factors. At 1-4 years, the adjusted HR did not indicate a significant difference between countries.

Interpretation

Excess child mortality in England compared with Sweden was largely explained by the unfavourable distribution of birth characteristics in England. Socioeconomic factors contributed to these differences through associations with adverse birth characteristics and increased mortality after 1 month of age. Policies to reduce child mortality in England could have most impact by reducing adverse birth characteristics through improving the health of women before and during pregnancy and reducing socioeconomic disadvantage.

Children whose parents experience adverse social, economic, or health-related living conditions are more likely to face similar types of disadvantage in their adult life. However, a limitation of many earlier studies is that they do not account for the multidimensionality of the concept of living conditions, and that the child generation’s life courses are targeted as static and independent from the societal context in which they are imbedded. The current investigation addressed these aspects by focusing on the complexity, duration, and timing of disadvantage with regard to how adverse circumstances in the family of origin are associated with trajectories of social, economic, and health-related living conditions across adulthood. We also examined the role of educational attainment for these associations. Analyses were based a Swedish cohort born in 1953 (n = 14,294). We first conducted sequence analysis, followed by hierarchical cluster analysis, to generate ‘outcome profiles’, i.e. trajectories of adult disadvantage. Second, several indicators of adverse circumstances in childhood were analysed by means of multinominal regression analysis, showing the odds of ending up in the different trajectories. The results indicated that individuals who grew up under adverse conditions were more likely to experience disadvantaged social, economic, and health-related trajectories. This was particularly the case for trajectories characterised by a high degree of complexity, i.e. coexisting disadvantages, and—among men only—by a longer duration of disadvantage. Educational attainment was identified as a powerful mediator, suggesting that efforts to increase equal educational opportunity may be a way of reducing the intergenerational transmission of disadvantage.

This study contributes to the literature on preventing social exclusion, here indicated by collecting disability pension in adulthood, by asking whether the pattern and strength of childhood related risk factors is the same for high-risk child welfare clients, as for their peers in the majority population. Longitudinal register data on > 500,000 Swedes, including around 18,000 former child welfare clients, were analyzed by means of linear probability models and calculations of population attributable fractions. Systematic comparisons of effect sizes suggest that the differences in pattern were marginal, but there were significant differences in strength. Overall, poor educational achievement and low educational attainment were the two most prominent risk factors across all groups, also when prevalence was taken into account. In the majority population, the hypothetical reduction of collecting disability pension was on the scale of 20% if either of the two risk factors could be eliminated. Among child welfare alumni, however, the hypothetical reduction was even larger, nearly 30% on average. Prevention strategies targeting poor school performance and low educational attainment may thus substantially reduce the prevalence of disability pension among adults with a history of child welfare involvement.

We investigated the stability and the directionality of being body bullied and a set of four variables– 1) Body Mass Index (BMI), 2) moderate and vigorous physical activity (MVPA), 3) television time (TV) and 4) video game/computer time (VG)-, termed in the present study as ‘health-related state and behaviours (HRSB)’–across adolescence. The Adolescent Nutritional Assessment Longitudinal Study (ELANA) is a cohort study conducted among middle school students from two public and four private schools in Rio de Janeiro-Brazil. We analysed data from 2010 (T1) and 2012 (T2) among 810 adolescents (aged 9–15 at T1). Gender-specific structural equation models (SEM) were estimated, including autoregressive paths for the HRSB and being body bullied over time, correlations at T1 and T2, respectively, and cross-lagged effects. The results presented significant stability coefficients for almost all variables over time in both genders (except for MVPA in boys and girls and TV time among girls). There were positive correlations between BMI and being body bullied, as well as between TV and VG for boys (0.32, p<0.001 and 0.24, p<0.001, respectively) and girls (0.30, p<0.001 and 0.30, p<0.001, respectively) at T1. It remained significant at T2 (boys: 0.18, p<0.05 and 0.16, p<0.01; girls: 0.21, p<0.01 and 0.22, p<0.01, respectively). Examining the cross-lagged paths between being body bullied and HRSB, we observed that the reciprocal model provided the best fit for boys, indicating that BMI at T1 had a significant effect in being body bullied at T2 (0.12, p<0.05) and being body bullied at T1 had an effect on VG at T2 (0.14, p<0.01). Among girls the forward causation model showed the best fit, demonstrating a significant effect of being body bullied at T1 on VG at T2 (0.16, p<0.01). Apart from MVPA, both being body bullying and HRSB were largely stable across adolescence. For boys and girls alike, exposure to being body bullied seemed to increase their time spent on VG, while for boys BMI also predicted being body bullied. This study highlighted the complex interplay between being body bullied and HRSB and the importance of acknowledging gender differences in this context.

We used Swedish national registers to analyse dental health care among young adults with childhood experience of out-of-home care (OHC), in Cox regression analyses. All 1.7 million Swedish residents born in 1980-1994 were included, of whom 4% had been in OHC. The population was followed up in the Dental Health Register from age 20 to 29, during the period 2009-2014. We found that persons with short or long OHC experience made emergency dental care visits more often than their majority-population peers: 17-23% versus 9-10%, (adjusted Hazard ratios [HR:s] 1.60-2.02); they more often had tooth extractions, 9-12% versus 3% (HR:s 2.33-3.03); but less regularly visited a dentist for planned check-ups, 61-77% versus 80-87% (HR:s 0.76-0.78). Since dental health in young adulthood reflects dental health and dental care in childhood, the findings of this study call for improved preventive dental health care for children in OHC.