Hanna Remes

The effects of family type on child mortality

BACKGROUND A growing number of children live in single-parent families, which seems to be associated with negative effects on a childs health. Little is known about the health of children in cohabiting two-parent families that are also increasingly common, and more susceptible to family break-up than married two-parent families. This study seeks to determine if family type is associated with child mortality and whether any association remains after controlling for socio-economic factors. METHODS We used longitudinal nationally representative register data from Statistics Finland to study deaths between ages 1-14 years (1780 deaths, N = 201,211) during 1990-2004. The relative effects of family characteristics on mortality were estimated using Cox regression models. RESULTS Compared with children of married parents, children of single parents carried an excess risk in mortality in ages 1-4 years [Hazard Ratio (HR) 2.02, 95% CI 1.63-2.51] and in ages 5-9 years (HR 1.44, 95% CI 1.15-1.80). The relationship between single parenthood and mortality was largely, but not entirely, explained by associated low parental education and lower household income. Mortality among children in cohabiting-parent families showed no difference from children of married parents. CONCLUSION Mainly due to accidental and violent causes of death, the largest excess mortality risks concentrated among children of single, less-educated and less-earning parents. The most vulnerable age period in this respect was early childhood (ages 1-4 years), whereas no association between mortality and family type was found among children aged 10-14 years.

Mortality Inequalities by Parental Education among Children and Young Adults in Finland 1990-2004

Background Knowledge on health inequalities in early life is less complete and less consistent than with the well-documented differentials in the adult population. This study examines the presence and strength of the association between parental education and mortality during different periods of childhood and young adulthood, and changes in the association over time. Methods Longitudinal individual level data were used in a register follow-up of 15 years. The data include an 11% sample of the Finnish population with an oversample of 80% of all deaths between the ages of 1 and 24. Mortalities and relative indices of inequality (RII) were calculated by parental education, sex, age group and cause of death. Results Lower parental education was associated with a higher risk of mortality during the whole period of 1990–2004. The differentials were largest among 1–4-year-old children (RII=2.4, 95% CI 1.57 to 3.56 for males and RII=4.5, 2.71 to 7.32 for females) and among young men aged 15–19 (RII=2.4, 2.00 to 2.98). The educational gradient was sharper in accidental and violent causes of death, but deaths from diseases contributed to differentials for both sexes among the youngest and the oldest. Conclusion The association between parental education and mortality in young age was consistent, although distinctively patterned by sex, age and cause of death. The results provide some support for the idea of equalisation of health inequalities during the child–youth transition. The convergence of differences in late childhood, and re-emergence in early adulthood, particularly among men, was, however, related to changes in the cause composition of deaths.

Living arrangements and external causes of deaths in early adulthood.

PURPOSE The mortality-lowering benefits of living in a union are well-known in the adult population, but the association between living arrangements and mortality among the young remains unclear. This study examines the association between current living arrangements and external causes of death in early adulthood, adjusting for factors such as parental socioeconomic position, current main activity, household income, and level of own education. METHODS The study is based on annually updated longitudinal register data that include a representative 11% sample of the whole Finnish population with an over-sample of 80% of all deaths. We used mortality rates and Cox proportional hazards models to study deaths in young adults aged between 17 and 29 years of age, from 1995 to 2004. RESULTS Compared with living in parental home with married parents, those living alone in late teens and early 20s had clearly higher risk of external mortality among both sexes. Young adults living in cohabiting- or one-parent families carried likewise a higher risk of death. Living with a partner was associated with lower mortality in early 20s, but especially in late 20s. The observed mortality differentials by living arrangements remained notable for the most part, even after adjustment for socioeconomic factors. CONCLUSIONS Strong excess mortalities among those living alone, single parents, children of single and cohabiting parents, the nonemployed, the less educated, and the less earning highlight the importance of late adolescence and early adulthood as a critical period for emerging health inequalities.

Intergenerational transmission of depressive symptoms – The role of gender, socioeconomic circumstances, and the accumulation of parental symptoms

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 antidepressant purchases 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.

Advanced maternal age and the risk of low birth weight and preterm delivery: a within-family analysis using Finnish population registers

Abstract 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 ≥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.

Young adult’s own and parental social characteristics predict injury morbidity: a register-based follow-up of 135 000 men and women

BackgroundSociodemographic differences in injury mortality are well-established, but population-level studies on social patterns of injury morbidity remain few in numbers, particularly among young adults. Yet injuries are the leading cause of mortality, morbidity and disability among young people. Studies among children have shown steep social gradients in severe injuries, but less is known on the social patterning of injuries in late adolescence and early adulthood, when young people are in the process of becoming independent adults. This study examines how young adults’ current living arrangements, education, main economic activity, and parental social background are associated with hospital-treated injuries in late adolescence and early adulthood.MethodsThe study uses prospective, individual-level data gathered from several administrative sources. From a representative 11% sample of the total Finnish population, we included young people between ages 17–29 years during the follow-up (N = 134 938). We used incidence rates and Cox proportional hazards models to study hospital-treated injuries and poisonings in 1998–2008.ResultsHigher rates of injury were found among young adults living alone, single mothers, the lower educated and the non-employed, as well as those with lower parental social background, experience of childhood family changes or living with a single parent, and those who had left the parental home at a young age. Injury risks were consistently higher among young adults with lower education, but current living arrangements and main economic activity showed some age-related nuances in the associations: both earlier and later than average transitions in education, employment, and family formation associated with increased injury risks. The social differentials were strongest in poisonings, intentional self-harm, and assaults, but social patterns were also found in falls, traffic-related injuries and other unintentional injuries, underlining the existence of multiple distinct mechanisms and pathways behind the differentials.ConclusionsThe transition to adulthood is a life period of heightened risk of injury, during which both parental social background and the young people’s own social position are important determinants of serious injuries that require inpatient care.

Work-Family Context and the Longevity Disadvantage of US Women

Female life expectancy is currently shorter in the United States than in most high-income countries. This study examines work-family context as a potential explanation. While work-family context changed similarly across high-income countries during the past half century, the United States has not implemented institutional supports, such as universally available childcare and family leave, to help Americans contend with these changes. We compare the United States to Finland—a country with similar trends in work-family life but generous institutional supports—and test two hypotheses to explain US women’s longevity disadvantage: (1) US women may be less likely than Finnish women to combine employment with childrearing; and (2) US women’s longevity may benefit less than Finnish women’s longevity from combining employment with childrearing. We used data from women aged 30–60 years during 1988–2006 in the US National Health Interview Survey Linked Mortality File and harmonized it with data from Finnish national registers. We found stronger support for hypothesis 1, especially among low-educated women. Contrary to hypothesis 2, combining employment and childrearing was not less beneficial for US women’s longevity. In a simulation exercise, more than 75 percent of US women’s longevity disadvantage was eliminated by raising their employment levels to Finnish levels and reducing mortality rates of non-married/non-employed US women to Finnish rates.

The Population Impact of Childhood Health Conditions on Dropout from Upper-Secondary Education

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.

Childhood Family Income and Violent Victimization During Youth and Young Adulthood: Trends in Hospital Care During 1988-2007 in Finland

The purpose of the current study was to examine whether the relationship between childhood family income and risk of violent victimization has changed between 1988 and 2007 in Finland, as prior studies have suggested that socioeconomic differences in exposure to violence have increased during the recent decades. Existing studies have mostly relied on survey data, while such trends in hospital discharge data—a data source that covers the total population well and is not compromised by attrition or self-report bias—have not been thoroughly investigated before. The current study used register-based individual-level data from 1988-2007 (n = 283,505) to study changes in the relationship between childhood family income and victimization risk among 15- to 30-year-old Finnish men and women. We found a persisting difference in violent victimization between the top and bottom income quintiles for both men and women. While the estimates suggest that this difference has increased rather than decreased during the observation period particularly among women, this change was not statistically significant. These conclusions remain after controlling for the composition of income quintiles. Research could benefit from more extensive use of administrative hospital records in analyzing of the trends and causes of serious violence.

Substance abuse in parents and subsequent risk of offspring psychiatric morbidity in late adolescence and early adulthood: A longitudinal analysis of siblings and their parents

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.