Social inequalities in health are a major challenge to public health in Europe and reducing them is a priority for the European Union. The objectives of DEMETRIQ are (i) to develop, evaluate and refine methodologies for assessing the effects of social, economic and health policies on the pattern and magnitude of health inequalities among socioeconomic groups, (ii) to assess the differential health effects by socioeconomic group of ‘natural policy experiments’ in the fields of unemployment and poverty reduction; tobacco and alcohol control; and access to education and preventive health care, and (iii) to synthesize the evidence from the findings of objectives 1-2, and to actively engage users in the research to promote effective exchange of knowledge for policy and practice. In our work package, we will examine population-wide behavioral change in terms of alcohol control. We will collect information on relevant aspects of alcohol control policies in EU countries, and carry out time series analyses of the impact of these variations on inequalities in alcohol consumption and related mortality and morbidity.

Key words: public health, social inequalities, Europe, alcohol control, policy, change, time series analysis

Researchers: Kimmo Herttua and Pekka Martikainen

Several individual-level observational follow-up studies have shown that, after adjusting for age, mortality is higher among the unemployed than among the employed, and the effects are especially strong with respect to suicide.  The reasons for this association are not fully established. Strong inferences about the causal effects of unemployment on mortality are still not warranted, because the possibility that individuals with a high risk of mortality might be selected for unemployment cannot be fully ruled out. We estimate the effects of unemployment and establishment downsizing on mortality in periods of low (1989) and high (1994) unemployment.  Unemployment was found to be associated with a notably larger increase in the hazard of mortality during economic boom than in the recession. By showing that, in the context of either a high level of unemployment or rapid downsizing, the effects of unemployment on mortality are modest these studies provides strong evidence of unaccounted confounding. Also, high relative suicide mortality among the unemployed during times of economic boom suggests that selective processes may be responsible for some of the employment status differences in suicide. However, long-term unemployment seems to have causal effects on suicide, which, especially among men, partly stem from low income. Altogether, individual-level studies may overestimate the causal effects of unemployment on mortality.

Key words: unemployment, mortality, suicide, selection, causal effects, economic boom, recession

Researchers: Netta Mäki and Pekka Martikainen

Key publications:

Mäki, N., & Martikainen, P. (2012). A register-based study on excess suicide mortality among unemployed men and women during different levels of unemployment in Finland. Journal of Epidemiology & Community Health, 66(4), 302-307.

Martikainen P., Mäki N., & Jäntti M. (2007). The Effects of Unemployment on Mortality following Workplace Downsizing and Workplace Closure: A Register-based Follow-up Study of Finnish Men and Women during Economic Boom and Recession. American Journal of Epidemiology, 165(9), 1070–75.

Healthy life expectancy is a composite measure of length and quality of life and thus an important indicator of health in aging populations. In this study, we estimated educational differences in disability-free life expectancy (DFLE) for eight countries from all parts of Europe in the early 2000s.  Long-standing severe disability was measured as a Global Activity Limitation Indicator (GALI) derived from the European Union Statistics on Income and Living Conditions (EU-SILC) survey. Census-linked mortality data were collected by a project comparing health inequalities between European countries (the EURO-GBD-SE project). The lowest DFLE was found among Lithuanians, the highest among Italians. Both life expectancy and DFLE were longer the higher the education, but educational differences were much larger in the latter in all countries. Highly educated Europeans cannot only expect to live longer, but they also spend more years in better health than those with lower education. However, the size of the educational difference in DFLE varies significantly between countries: the smallest differences appear to be in Southern Europe and the largest in Eastern and Northern Europe.

Key words: educational differences, Europe, disability-free life expectancy, long-standing activity limitation, Sullivan’s method, Census-linked mortality data, EU-SILC survey data

Researchers: Netta Mäki and Pekka Martikainen

In the BIRTHFAM consortium (Population Research Unit & Institute for Molecular Medicine Finland) funded by the Academy of Finland we aim to gain a fuller understanding of the social and genetic determinants of poor health and social disadvantage. To achieve this we will build a cluster of family cohorts and develop novel, interdisciplinary study designs and methodology. Family data encompass a broader range of exposures within and across generations than data on individuals only, providing a more comprehensive view of life-course epidemiology. Furthermore, family data enable stronger causal inference by allowing for comparisons of family members with differing degrees of shared genetic and environmental exposures.

Building on existing data and expertise, we bring together two complementary types of data: 1) family-based register data with long follow-ups of large cohorts and 2) twin data with in-depth information of participants and their genetic makeup. We will develop and document family cohorts for three research initiatives that rely on the internationally unique linked Finnish data: 1) a multigenerational data set of up to five generations for examining intergenerational associations in health and social disadvantage; 2) a data set of participants with different degrees of relatedness (twins, siblings, cousins etc.) for estimating heritability and familial clustering of ill health; 3) harmonised data sets of family cohorts born over 50 years apart for assessing changes in the importance of early life circumstances on adult health.
We will also adapt and share new study designs and methods, organise training and build an international research network for sharing expertise and facilitate access to these exceptional data for top scientists around the world.

The consortium builds research infrastructure with diversity and flexibility for long-term research needs and innovative ideas yet to surface. Understanding how families transmit ill health and social disadvantage across generations highlight new opportunities for improving population health.

Researchers: Hanna Remes, Heta Moustgaard

Reproductive history is known to affect the life expectancy of women. International evidence suggests that women with two children have lower mortality than those with fewer children. This study will contribute to the debate on reproductive history and cause-specific mortality in contemporary populations, and examine how the number of biological children and the timing of childbirth relate to the later-life mortality of Finnish men and women. A novel feature of the study is that it will control for parents’ childhood living conditions, which, to our knowledge, has not been done in the previous studies.

Key words: mortality, reproductive history, fertility

Researcher: Elina Einiö

Depression is a major public health burden accounting for over 15% of healthy life years lost in high-income countries. Depression often has a chronic course which leads to disability, requires frequent hospitalisation, and is a risk factor for premature death—particularly suicide. This project focuses on how the adverse outcomes of depression vary according to socioeconomic position, employment, and living arrangements, and whether the variation is explained by differences in psychiatric comorbidities or depression treatment. Our results suggest that depression outcomes vary only modestly according to social factors. Comorbid alcohol-use disorders seem to have an important role in determining depression outcomes.

Key words: depression, mental health, antidepressants, socio economic position, employment status, living arrangements, mortality, suicide, alcohol

Researcher: Heta Moustgaard

Key publications:

Moustgaard, H., Joutsenniemi, K. & Martikainen, P. (2016). A longitudinal study of educational differences in antidepressant use before and after hospital care for depression. European Journal of Public Health, 26, 6, 1034-1039.

Moustgaard, H., Joutsenniemi, K., Myrskylä, M., & Martikainen, P. (2014). Antidepressant Sales and the Risk for Alcohol-Related and Non-Alcohol-Related Suicide in Finland—An Individual-Level Population Study. PloS one, 9(6), e98405.

Moustgaard, H., Joutsenniemi, K., & Martikainen, P. (2014). Does hospital admission risk for depression vary across social groups? A population-based register study of 231,629 middle-aged Finns. Social psychiatry and psychiatric epidemiology, 49(1), 15-25.

Moustgaard, H., Joutsenniemi, K., Sihvo, S., & Martikainen, P. (2013). Alcohol-related deaths and social factors in depression mortality: a register-based follow-up of depressed in-patients and antidepressant users in Finland. Journal of affective disorders, 148(2), 278-285.

Yang, L., Korhonen, A. K., Moustgaard, H. L., Silventoinen, K. T. & Martikainen, P. T. (2018) Pre-existing depression predicts survival in cardiovascular disease and cancer. Journal of Epidemiology & Community Health. 72, 7, 617-622.

Social inequalities in infant and adult mortality are well documented, but previous findings on children, adolescents and young adults are less complete and less consistent. Despite the relatively low levels of mortality, and a continuous decline, population-representative register data reveal a systematic association between parental social background and mortality in childhood, adolescence and early adulthood in the 1990s and 2000s in Finland. Among young adults, the associations between mortality and their own social position appear much stronger, but parental social background remains nevertheless influential in conditioning the pathways from childhood to the current life situation. Current research interests expand the focus from mortality to other health outcomes, such as hospital-treated injuries.

Key words: mortality, health, childhood, early adulthood, social inequalities

Researcher: Hanna Remes

Key publications:

Remes, H., & Martikainen, P. (2012). Social determinants of mortality after leaving the parental home–Childhood and current factors. Advances in Life Course Research, 17(4), 199-209.

Remes, H., Martikainen, P., & Valkonen, T. (2010). Mortality Inequalities by Parental Education among Children and Young Adults in Finland 1990–2004. Journal of Epidemiology & Community Health, 64(2), 130-135.

A low socioeconomic position is an important risk factor for disability retirement. We found that it was strongly associated with retirement particularly on the grounds of musculoskeletal diseases. Education, occupational social class and household disposable income were all independent determinants of disability retirement with the former two having the largest effects. However, the effects of these indicators were also largely explained by or mediated through each other. Further analyses indicate that the association between social class and disability retirement was largely mediated through physical working conditions and, especially in mental disorders, also though job control. The contribution of health behaviours and work arrangements to the association was modest.

Keywords: disability retirement, socioeconomic position, working conditions, health behaviours

Researcher: Taina Leinonen

Key Publications:

Leinonen T, Martikainen P, Lahelma E. Interrelationships between education, occupational social class, and income as determinants of disability retirement. Scand J Public Health 2012;40:157–66.

Leinonen T, Pietiläinen O, Laaksonen M, Rahkonen O, Lahelma E, Martikainen P. Occupational social class and disability retirement among municipal employees – the contribution of health behaviors and working conditions. Scand J Work Environ Health 2011;37:464–72.

Mortality disparity between socioeconomic groups has increased in Finland over the last decades and according to our studies the increasing disparity is particularly pronounced between income groups. The characteristics of this changing association between income and mortality are not known. We include the temporal aspect in exploring the association between income and mortality as it provides insight to mechanisms behind the income-mortality relationship. Considering the history of the individual is beneficial as the income changes over the life course and childhood living conditions are possibly related to underlying mechanisms. The research seeks to understand the causes of the mortality trends of income groups, clarify the association between income and mortality, and the changes in the association since the late 1980s by using nationally representative and internationally unique data which combine information from various administrative registers.

Key words: income, mortality, socioeconomic disparity, mortality trends

Researcher: Lasse Tarkiainen

Key publications:

Tarkiainen, L., Martikainen, P., & Laaksonen, M. (2012). The changing relationship between income and mortality in Finland, 1988-2007. Journal of Epidemiology & Community Health, 67(1), 21-27.

Tarkiainen, L., Martikainen, P., Laaksonen, M., & Valkonen, T. (2012). Trends in life expectancy by income from 1988 to 2007: decomposition by age and cause of death. Journal of epidemiology and community health, 66(7), 573-578.