Jenni Blomgren

Change in the total and independent effects of education and occupational social class on mortality: analyses of all Finnish men and women in the period 1971–2000

Objectives: To estimate changes in the total and independent effects of education and occupational social class on mortality over 30 years, and to assess the causes of changes in the independent effects. Methods: Census records linked with death records for 1971–2000 for all Finns aged 30–59 years were studied. The total and independent effects of education and social class on mortality were calculated from relative risks in nested Poisson regression models. Results: Among men and women, the model shows that the total effects of education, and particularly occupational social class on mortality, have increased over time. Among 40–59-year-old people, the effects of education are currently less independent of social class than in the 1970s, but among younger Finns the independent effects have remained stable. The effects of social class on mortality that are independent of education have grown among people of older ages, particularly among men. Conclusions: Changes in the independent effects of socioeconomic measures on mortality are determined by changes in their associations with mortality, and distributional changes that affect the strength of the associations between these measures. Distributional changes are driven by changes in educational systems and labour markets, and are of major importance for the understanding of socioeconomic inequalities in mortality.

Marital history 1971–91 and mortality 1991–2004 in England & Wales and Finland

Background Little is known about the effects of long-term marital history on mortality, and the relative importance of using marital history instead of baseline marital status in mortality analyses. No previous comparative studies on the associations of marital history and mortality exist. Methods Longitudinal data from England & Wales and from Finland were used to assess the effects of marital history, constructed from census records from years 1971, 1981 and 1991, on all-cause mortality in 1991–2004 among men and women aged ≥50 years. Data from England & Wales include 57 492 deaths; data from Finland include 424 602 deaths. Poisson regression analysis was applied. Results Adding marital history into models including baseline marital status was statistically significant when explaining male mortality, while it was generally not important for female mortality. Adjusted for socio-demographic covariates, those consistently married with no record of marital break-up had the lowest mortality rates among both men and women aged 50–74 in both countries. Those never married, those divorced with a history of divorce and those widowed with a history of widowhood showed the highest mortality risks. Associations between marital history and mortality were weaker among those aged 75+. Conclusions Consistent evidence in favour of both protective effects of long-lasting marriage and detrimental effects of marital dissolution were found. Studies would benefit from including marital history in the models instead of baseline marital status whenever possible, especially when studying male mortality.

Determinants of home-based formal help in community-dwelling older people in Finland

Knowledge of the determinants of use of formal home-based services among older people is of particular importance for predicting the need for and cost of care in the future. The aim of this study was to estimate the frequency of formal and informal help among community-dwelling older people and to assess the determinants of home-based formal help, with a special emphasis on the frequency of help from spouse, from children and other relatives and friends. We used nationally representative cross-sectional data from 1,166 community-dwelling Finnish persons aged 70–99. Determinants of formal help were assessed with logistic regression models. Receiving formal help was most strongly related to need factors such as age and functional capacity. Adjusted for need factors, receiving help from spouse or living with someone else than the spouse decreased the odds of receiving formal help. In contrast, the more frequently the children helped, the larger were the odds of receiving formal home-based help. Help from other informal sources did not affect receipt of formal help. Our results thus suggest that intra-household help from spouse or from other co-residents may partly offset expected cost increases in the formal care sector brought about by an aging population. The results further suggest that help from children and help from formal sources is likely to be concomitant and that children may act as agents seeking formal help also in a welfare state based on the universal and equal care services.

Help from spouse and from children among older people with functional limitations: comparison of England and Finland

ABSTRACT Future increases in need of old-age care warrant research on receipt of informal care among older people in different policy and cultural contexts. Separating informal care into help provided by spouse and by children may shed more light on dynamics of informal help, important in alleviating the demands on the formal sector. Using nationally representative data from England and Finland, we performed logistic regression analyses to study receipt of help from spouse and children among community-dwelling persons aged 70+ years with functional limitations. In both countries, women and those with more functional limitations had higher odds of receiving spousal and filial help. In England – but not in Finland – those receiving formal public help had lower odds of receiving spousal help than those with no formal help. Those with low education received more filial help in England, but no association was found between formal and filial help. In Finland, the effect of education was not significant but those receiving formal help had higher odds of also receiving filial help. The results suggest that in a liberal market-led state, the role of children may be to help their parents living alone and with low financial resources. In the context of a generous welfare state, children may function more as active agents bridging the gap between their parents and formal services.

Cross-Temporal and Cross-National Poverty and Mortality Rates among Developed Countries

A prime objective of welfare state activities is to take action to enhance population health and to decrease mortality risks. For several centuries, poverty has been seen as a key social risk factor in these respects. Consequently, the fight against poverty has historically been at the forefront of public health and social policy. The relationship between relative poverty rates and population health indicators is less self-evident, notwithstanding the obvious similarity to the debated topic of the relationship between population health and income inequality. In this study we undertake a comparative analysis of the relationship between relative poverty and mortality across 26 countries over time, with pooled cross-sectional time series analysis. We utilize data from the Luxembourg Income Study to construct age-specific poverty rates across countries and time covering the period from around 1980 to 2005, merged with data on age- and gender-specific mortality data from the Human Mortality Database. Our results suggest not only an impact of relative poverty but also clear differences by welfare regime that partly goes beyond the well-known differences in poverty rates between welfare regimes.

Occupational class differences in long sickness absence

Objectives Sickness absence is consistently higher in lower occupational classes, but attempts to analyse changes over time in socioeconomic differences are scarce. We examined trends in medically certified sickness absence by occupational class in Finland from 1996 to 2013 and assessed the magnitude and changes in absolute and relative occupational class differences. Design Population-based, repeated cross-sectional study. Setting A 70% random sample of Finns aged between 25 and 63 years in the years 1996–2013. Participants The study focused on 25- to 63 year-old female (n between 572 246 and 690 925) and male (n between 525 698 and 644 425) upper and lower non-manual and manual workers. Disability and old age pensioners, students, the unemployed, entrepreneurs and farmers were excluded. The analyses covered 2 160 084 persons, that is, 77% of the random sample. For primary and secondary outcome measures, we examined yearly prevalence of over 10 working days long sickness absence by occupational class. The Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) were used to assess the magnitude and changes in occupational class differences. Results Compared with mid-1990s, sickness absence prevalence was slightly lower in 2013 in all occupational classes except for female lower non-manual workers. Hierarchical occupational class differences in sickness absence were found. Absolute differences (SII) peaked in 2005 in both women (0.12, 95% CI 0.12 to 0.13) and men (0.15, 95% CI 0.14 to 0.15) but reached the previous level in women by 2009 and decreased modestly in men until 2013. Relative differences narrowed over time (p<0.001) but levelled off by 2013. Conclusions Sickness absence prevalence is currently slightly lower in almost all occupational classes than in the mid-1990s, but occupational class differences have remained large. Ill health and poor working conditions especially in the lower occupational classes should be targeted in order to reduce sickness absence and to achieve longer working lives.

Sickness allowance histories among disability retirees due to mental disorders: A retrospective case–control study

Objectives: The aim was to describe sickness allowance histories before disability retirement due to mental disorders and to examine whether receiving sickness allowance due to mental disorders and somatic conditions predicts future disability retirement. Method: Pre-retirement sickness allowance histories were traced backwards for 7 years among Finnish residents aged 25–64 years who had retired due to mental disorders in 2011 (n=5.544). For each retiree, five sex- and age-matched controls were drawn from the non-retired population. Conditional logistic regression was used to calculate the risk for disability retirement by sickness allowance history and to control for the effects of educational level, social class, marital status and the urbanisation level of the municipality. Results: The proportion of sickness allowance recipients increased steadily during the years preceding disability retirement, and was highest among those who retired due to bipolar disorders or depression. Those who had received sickness allowance due to mental disorders 6–7 years earlier had 6.5 times higher risk and those with sickness allowance 1–2 years earlier 11.7 times higher risk for disability retirement. Sickness allowance due to somatic conditions increased the risk for disability retirement 1.6–1.9 times. Sickness allowance most strongly predicted retirement due to bipolar disorders and depression. Adjustment for covariates had little effect. Conclusion: Those who retired due to mental disorders more often had sickness allowance due to both mental disorders and somatic conditions, but in particular sickness allowance due to mental disorders predicted disability retirement due to mental disorders.

Sickness allowance trajectories preceding disability retirement: a register-based retrospective study

OBJECTIVES To identify subgroups of disability retirees with different pre-retirement sickness allowance histories and to examine whether the diagnosis of disability pension and socio-demographic variables discriminate these subgroups. METHODS The data included all Finnish residents aged 30-64 years who were granted a full disability pension in 2011 (N = 17 208). Sickness allowance trajectories during the preceding 10 years were searched using latent trajectory analysis. Multinomial logistic regression analysis was used to explore determinants of the trajectories. RESULTS Six distinct sickness allowance trajectories were identified. Four large subgroups with a long sickness allowance period during the final pre-retirement year were found, characterized by increasing (29% of retirees), early high (21%), stable low (24%) or stable high (16%) sickness allowance histories. In addition, two small subgroups (6 and 4%) with only a little sickness allowance during the final year were identified. The diagnosis of disability pension strongly influenced assignment to the trajectory groups. Women were more likely to have followed the stable high or the early high sickness allowance trajectory. Older age strongly increased but being a lower non-manual employee or self-employed decreased the probability of belonging to the two small trajectory groups. Long-term unemployment slightly increased belonging to the stable low trajectory and was strongly associated with the small subgroups with little or no sickness allowance during the final year preceding retirement. CONCLUSIONS Different pre-retirement sickness allowance trajectories can be found. Assignment to the trajectories differed by the diagnosis of disability pension but associations with socio-demographic variables were weak.

Do debts lead to disability pension? Evidence from a 15-year follow-up of 54,000 Finnish men and women:

While over-indebtedness has emerged as a new social risk among Europeans as a consequence of economic recessions, its associations with health and disability are poorly understood. This study utilises longitudinal, register-based data to assess the associations of over-indebtedness with disability retirement. Severely over-indebted people were identified from the Finnish credit information register. For each over-indebted person, one matched control was retrieved from the population register (total N: 54,494). Register data on socio-demographics, health-related factors and pensions were used to analyse the incidence of disability pensions due to different diagnoses among over-indebted people and their controls during the period 1995–2009 using Cox regression analysis. The analyses showed that over-indebtedness was strongly associated with the risk of disability retirement in all diagnostic groups. The associations were stronger among women than among men. The adverse effects of over-indebtedness on health and disability should be acknowledged. In addition to standard socio-demographic indicators, debtor status may add to our knowledge of the predictors of poor health. Policymakers should adopt measures to prevent over-indebtedness and to overcome its harmful effects.

Transition to Retirement and Use of Private Health Care Evidence From a Universal Public Health Care System

Associations between retirement and changes in health care use have not been shown in a longitudinal setting. In the Finnish universal health care system, transition into retirement from employment entails loss of access to occupational health care that provides easily accessible primary health care services, which may cause changes in utilization of other health care sectors. The aim of this study was to find out whether transition into old-age retirement is associated with change in utilization of private health care. The panel data consist of a 30% random sample of the Finnish population aged 62–75 in 2006–2011. Register data on National Health Insurance compensation were linked to socio-demographic covariates. Fixed-effects logistic and Poisson regression models were used. Adjusted for changes in covariates, retirement from employment was associated especially with private general practitioner visits but also with specialist visits among both women and men. Interaction analyses showed that retirement was associated with an increase in private care use only among those with higher-than-median income. The results may indicate preferences for quick access to care, mistrust toward the universal system, and problems of the public system in delivering needed services.