Reserve Capacity and other Adolescent Pathways in Socioeconomic Inequalities in Mortality and Education: A Three-Generation Study in Finland

Laaja joukko tutkimuksia on osoittanut, kuinka matala sosioekonominen asema (SES) heikentää terveyttä ja kuinka vaikutus kasaantuu ajan myötä näkyen sairastavuudessa ja kuolleisuudessa. Lisäksi on saatu uutta näyttöä siitä, kuinka isovanhempien sosioekonominen pääoma siirtyy jopa lapsenlapsille. Näin voidaan olettaa, että matalan sosioekonomisen aseman siirtyminen yli sukupolvien voi pahentaa sosioekonomisen huono-osaisuuden kierrettä ja siten lisätä terveydellistä ja sosioekonomista eriarvoisuutta. Tutkimuksessa käytetyssä viitekehyksessä sosioekonomisen aseman ja terveyden välisen yhteyden ajateltiin toteutuvan elämänkulunaikaisten polkujen välityksellä. Nämä polut yhdistävä viitekehys painotti psykososiaalisten resurssien (“reserve capacity”) merkitystä terveyserojen synnyn taustalla. Tässä työssä käytetty englanninkielinen käsite “reserve capacity” käännetään suomenkieliseksi sanaksi “suorituskykyvaranto”. Matalan sosioekonomisen aseman nähdään lisäävän yksilön altistumista ympäristön kuormitustekijöille ja pienentävän yksilön suorituskykyvarantoa. Täten negatiiviset emotionaaliset ja fysiologiset vasteet laukeavat vaikuttaen terveyteen biologisten tai käyttäytymiseen liittyvien muutosten kautta. Samanlaisten prosessien oletetaan vaikuttavan myös yksilön aikuisena saavuttamaan koulutustasoon ja lopulta hänen tulevaan sosioekonomiseen asemaansa. Suorituskykyvarantoa koskeva viitekehys laajenee koskemaan myös terveyttä tukevaa käyttäytymistä, koska myös sen taustalla ymmärretään olevan psykososiaalisia resursseja. Tutkimuksessa käytettiin Nuorten terveystapatutkimuksen (NTTT) aineistoja, joihin oli liitetty Tilastokeskuksen rekisteritietoa. Yhdistetyn aineiston perusteella tutkittiin kuolleisuuden ja aikuisiässä saavutetun koulutuksen sosioekonomista eriarvoisuutta. Lisäksi arvioitiin suorituskykyvarannon sekä eräiden muiden välittävien polkujen kuten puberteetin ajoittumisen sekä koulumenestyksen roolia tutkituille elämänkulunaikaisille prosesseille. Tutkimuksen kohteena oli myös isovanhempien sosioekonomisen aseman vaikutus lastenlasten sosioekonomisiin asemiin. NTTT sisälsi koko maata edustavat aineistot 12-18-vuotiaista suomalaisista. Yhdistetty aineisto sisälsi kunkin NTTT:n kyselyihin vastanneen henkilön tietojen lisäksi hänen vanhempiensa ja isovanhempiensa kuolemaa ja sosioekonomista asemaa koskevat tiedot vuoteen 2009 asti. Coxin regressiota, multinomiaalista logistista regressioanalyysia sekä rakenneyhtälömallinnusta käytettiin vastaamaan tutkimuskysymyksiin. Tutkimustulokset osoittivat kuolleisuuden ja aikuisiän koulutuksen sosioekonomisen eriarvoisuuden käytetyssä aineistossa. Lisäksi osoitettiin, että suorituskykyvaranto ja koulumenestys olivat voimakkaita ja toisistaan riippumattomia kuolemanriskin ja aikuisiän koulutuksen ennustajia. Ensimmäisessä osatyössä korkea suoritusvaranto ja hyvä koulumenestys vähensivät kuolemanriskiä. Pojilla nämä lisäksi lievensivät matalan sosioekonomisen aseman vaikutusta kuolleisuuteen. Toisessa osatyössä suorituskykyvaranto ja koulumenestys toisistaan riippumatta ennustivat aikuisiän koulutustasoa, ja näiden kautta välittyi myös perheen sosioekonomisen aseman vaikutus aikuisuuden koulutustasoon. Lisäksi osoitettiin, kuinka isovanhempien sosioekonomiset olosuhteet ennustivat lastenlasten koulutusta, mikä antoi näyttöä sosioekonomisen eriarvoisuuden syntymekanismeista. Suorituskykyvarannon ja koulumenestyksen suorasta vaikutuksesta aikuisiän koulutukseen saatiin näyttöä kolmannessa osatyössä. Osoitettiin myös, että puberteetin ajoittuminen oli eräs mahdollinen biologinen polku, joka vaikutti nuoren koulu-uraan. Lisäksi epäsuorat polut perheen sosioekonomisesta asemasta aikuisiän koulutustasoon kulkivat suorituskykyvarannon ja koulumenestyksen kautta. Tutkimus osoitti myös, että perheen matala sosioekonominen asema lisäsi matalan suorituskykyvarannon, myöhäisen puberteetin ja heikon koulumenestyksen mahdollisuutta. Aikaisempien tutkimusten kanssa yhtäpitävästi saatiin näyttöä siitä, että perheen sosioekonominen asema vaikuttaa suoraan terveyteen ja lapsen tulevaan koulutukseen. Kuitenkin nuoruudessa tärkeät mekanismit, nimittäin suorituskykyvaranto, puberteetin ajoitus ja menestys koulussa, välittävät perheen sosioekonomisen aseman ja lopputulosten välisiä yhteyksiä. Vaikka perheen sosioekonomisen aseman merkitystä ei voida unohtaa, suorituskykyvaranto ja menestys koulussa ovat asioita, joihin poliittisin toimin ja terveyspoliittisin keinoin voidaan vaikuttaa. Näin tekemällä voidaan vähentää terveysriskejä ja kuolleisuutta ja parantaa tulevien sukupolvien sosioekonomista asemaa. Tulosten perusteella voidaan päätellä, että sosioekonomisia terveys- ja koulutuseroja voidaan todennäköisesti vähentää tukemalla suorituskykyvarannon kehittymistä sekä perheissä yli sukupolvien että kouluissa (esim. parantamalla koettua terveyttä, kannustamalla terveyttä edistävään käyttäytymiseen ja tarjoamalla sosiaalista tukea) ja tukemalla nuorten koulumenestystä, erityisesti heidän jotka tulevat huono-osaisista perheistä.Studies have extensively shown that low socioeconomic status (SES) has cumulative adverse effects on morbidity and mortality. In addition, recent evidence showed that grandparents’ socioeconomic capital could also be transmitted to their grandchildren. This implies that transmission of low SES across generations of families could perpetuate a cycle of socioeconomic disadvantage, creating further health and socioeconomic inequalities. The strong SES-health connection was theorised to occur through different intermediate pathways in the life-course. An integrative framework emphasised the role of psychosocial resources called “reserve capacity” in causing health inequalities. This framework specifies that low SES increases one’s exposure to environmental stressors and depletes “reserve capacity.” Thus, negative emotional and physiological responses are triggered, affecting health via altered biological and behavioural pathways. We propose that similar processes also affect attained educational level and ultimately, one’s future SES. We also extend the reserve capacity framework to include health-promoting behaviours because of their underlying psychosocial resources. Using 1985-1995 data from the Adolescent Health and Lifestyle Surveys (AHLS) linked with data from the registries of Statistics Finland, we determined the existence of socioeconomic inequalities in mortality and education. Moreover, we assessed the roles of reserve capacity and other intermediate pathways in adolescence such as pubertal timing and school achievement in these life-course trajectories. We further studied if grandparents’ socioeconomic circumstances affected their grandchildren’s education. The AHLS dataset contained information on representative samples of 12- to 18year old Finns while the linked data from the registries updated until 2009 had relevant mortality and socioeconomic information for the AHLS participants, their parents and grandparents. Cox and multinomial logistic regression models as well as structural equation models were fitted to answer the aims of this dissertation. In general, we found the existence of socioeconomic inequalities in mortality and education in our setting. We also found that reserve capacity and school achievement were both good and independent predictors of mortality and education. In Study I, high reserve capacity and good school achievement reduced the risk of mortality. Among boys, these also mitigated the negative effect of low SES on mortality. In Study II, both reserve capacity and school achievement independently predicted educational attainment and mediated the effect of family SES on education. We also found out that the socioeconomic circumstances of grandparents predicted their grandchildren’s educational outcomes, providing evidence on the origin of socioeconomic inequalities. The direct effects of reserve capacity and school achievement on education were further confirmed in Study III. Additionally, we have shown that pubertal timing was a potential biological pathway which influenced adolescents’ educational trajectories. Moreover, indirect pathways from family SES to education existed through reserve capacity and school achievement. In this study, we have also provided evidence that a low family SES increased the probabilities of low reserve capacity, delayed pubertal timing and low school achievement. Consistent with previous research, all the studies clearly showed that family SES directly influenced health and one’s future education. Important mechanisms in adolescence, however, namely, reserve capacity, pubertal timing and school achievement, mediated the relationships of family SES with these outcomes. Even though family SES also influenced these pathways, reserve capacity and school achievement are amenable to policies and public health measures and thus, could be improved to reduce health risks, avert untimely mortality and improve the socioeconomic status of subsequent generations. Our findings suggest that strengthening multiple generations of families and schools in building reserve capacities (e.g., improving perceived health, encouraging health-promoting behaviour and providing social support), and supporting the school performance of adolescents, particularly those with disadvantaged socioeconomic backgrounds, could likely reduce socioeconomic inequalities in health and education

Psychosocial Reserve Capacity, Family Background and Selection of an Educational Path – A Longitudinal Study From Finland

Finnish students start academic or vocational track in upper secondary education at age 16 years. Track placement is based on grades, but family background and psychosocial resources may have influences. Using 2014 survey data of Grade 9 students in Helsinki Metropolitan area linked to the Joint Application Registry data as of 2017, we fitted two-level, sex-stratified, generalized structural equation models to determine how reserve capacity (academic self-efficacy and social support), family background, and the comprehensive schools predict track placement. Adjusting for the effect of grades, low reserve capacity and disadvantaged family background increased probabilities of vocational track and non-placement of students. Schools also affected track placement, suggesting differences among comprehensive schools in the area. Findings imply that building reserve capacities of adolescents, through enhancing academic self-efficacy and social support, particularly in those with disadvantaged backgrounds, could increase chances of academic track placement in upper secondary school

Social determinants of adolescent smoking over three generations

Aim: We studied how multigenerational socioeconomic circumstances influence adolescents’ smoking. Previous studies have shown that low academic achievement as well as parents’ low socioeconomic circumstances are associated with adolescents’ smoking, but there are few studies on grandparents’ influence on their grandchildren’s smoking. For the chain of three generations, we hypothesised that high socioeconomic circumstances of both parents and grandparents decrease the probability of smoking and adolescents’ own education and circumstances contribute to this association. We further investigated the role of intergenerational social mobility. Method: Survey data from 1979 to 1997 on 12- to 18-year-old Finns (n=54,487) were linked with 1970–2009 registry-based data of their grandparents, parents and themselves. Socioeconomic circumstances among parents and grandparents were measured by socioeconomic status, education and material resources and among adolescents by academic achievement, educational orientation, family structure and parental smoking. Logistic regression analysis was used to study the associations. Results: Associations of adolescent smoking with grandparental socioeconomic circumstances were weak and mediated through parental circumstances. Parental smoking and divorce and living in a non-intact family increased smoking. Adolescents’ low academic achievement and orientation to low education level were the most important predictors of smoking. Upward intergenerational social mobility between fathers and children decreased the risk of smoking, whereas downward mobility increased it. Conclusions: The influence of grandparents’ low socioeconomic circumstances on grandchildren’s smoking is mediated through parents’ socioeconomic circumstances. Low academic achievement in adolescence is a strong predictor of smoking and adolescents orient towards the group of their future education level, not that of their parents.</p

Psychosocial reserve capacity, family background and selection of an educational path – a longitudinal study from Finland

Finnish students start academic or vocational track in upper secondary education at age 16 years. Track placement is based on grades, but family background and psychosocial resources may have influences. Using 2014 survey data of Grade 9 students in Helsinki Metropolitan area linked to the Joint Application Registry data as of 2017, we fitted two-level, sex-stratified, generalized structural equation models to determine how reserve capacity (academic self-efficacy and social support), family background, and the comprehensive schools predict track placement. Adjusting for the effect of grades, low reserve capacity and disadvantaged family background increased probabilities of vocational track and non-placement of students. Schools also affected track placement, suggesting differences among comprehensive schools in the area. Findings imply that building reserve capacities of adolescents, through enhancing academic self-efficacy and social support, particularly in those with disadvantaged backgrounds, could increase chances of academic track placement in upper secondary school.</p

Health and socioeconomic circumstances over three generations as predictors of youth unemployment trajectories

BackgroundYouth unemployment is a critical life event, which may trigger other labour market-related disadvantages and detrimental health implications. To better understand the processes causing unemployment, we study how socioeconomic circumstances of successive generations and familial and health factors in adolescence predict youth unemployment trajectories between ages 16 and 28 in Finland from 2000 to 2009.MethodsWe used survey data from 1979 to 1997 on 12- to 18-year-old Finns (n = 43 238) linked with 1970–2009 registry-based data of their grandparents, parents and themselves. Growth mixture modelling and multivariate logistic regression analyses were used.ResultsThree latent youth unemployment trajectories emerged; low (46%), decreasing (38%) and high (16%) risk groups. Of adolescent factors, low school achievement was the most important predictor of youth unemployment followed by smoking, stress symptoms and poor self-rated health. Grandparents’ education predicted their grandchildren’s unemployment but the effects of other grandparental socioeconomic circumstances mediated through parents’ socioeconomic status (SES). Parents’ low SES and education, and long-term unemployment increased the risk of the child’s unemployment. Youth unemployment was related to low education at the age of 29.ConclusionGrandparents’ education, family socioeconomic circumstances and adolescents’ health and school achievement predict the developmental trajectory of youth unemployment. Youth unemployment is also related to low education in early adulthood. Our findings suggest that the health selection of unemployment works already in adolescence.</p

How socioeconomic circumstances, school achievement and reserve capacity in adolescence predict adult education level: a three-generation study in Finland

Family socioeconomic circumstances directly influence adult educationlevel. Adolescent psychosocial resources and health-promoting behaviourcollectively termed as ‘reserve capacity’ and school achievement maylikely mediate the effect of family socioeconomic circumstances on adulteducation level. We tested these relationships using 1985–1995 survey dataon 12–18-year-old Finns (N = 41,822) linked with three-generation registrydata of Statistics Finland until 2009. Results of the multinomial logisticregression models, adjusted for sex and age at end of follow-up, showedthat socioeconomic circumstances of parents and grandparents predictedadult education level. School achievement and reserve capacity dimensionsof perceived health, health-promoting behaviour and social support inadolescence also positively predicted adult education. Moreover, thesetended to decrease the effect of family socioeconomic circumstances oneducational level. Our findings suggest that formulating interventions whichbuild reserve capacity and improve school performance, especially amongadolescents from disadvantaged socioeconomic backgrounds, could likelyreduce educational inequalities.</p

Timing of puberty and reserve capacity in adolescence as pathways to educational level in adulthood – a longitudinal study

Background. Family socioeconomic status (SES) is related to a child´s educational success. Intermediate pathways for this relationship, such as through pubertal timing and reserve capacity, occur in adolescence.Aim. To study whether family SES affects a child’s adult education through a psychosocial and behavioural pathway (reserve capacity) and/or a biological pathway (pubertal timing) or only through school achievement in adolescence.Subjects and methods. Finnish adolescents sampled in five cross-sectional surveys from 1985-1995 (N = 37,876) were followed through the Registry of Completed Education and Degrees until 2009, when they were 29-43 years old. Family SES data also came from this registry. Structural equation modelling adjusted for ages at baseline and follow-up was used.Results. Low family SES increased the probability of low adult education, delayed pubertal timing (in boys), weak reserve capacity and low school achievement. Reserve capacity and school achievement directly affected adult education and mediated the relationship of family SES with the outcome. Delayed pubertal timing predicted low adult education except when school achievement was added to the model.Conclusions. Our results show that family SES affects the child’s adult education level through psychosocial and biobehavioural pathways, but the biological pathway is mediated by school achievement.</p

A Micro-analysis Approach in Understanding Electronic Medical Record Usage in Rural Communities: Comparison of Frequency of Use on Performance Before and During the COVID-19 Pandemic

In strengthening eHealth in the Philippines to support the universal health care (UHC) law, the scaling up and full adoption of electronic medical record (EMR) systems was strategically scheduled and supposedly completed in 2020. The Covid-19 pandemic, however, delayed these strengthening efforts. We wanted to assess the status of EMR adoption in primary clinics of rural health units (RHUs) and understand the frequency of use, particularly during the pandemic. Through analyses of EMR usage logs from selected RHUs in 2020, we estimated frequency of EMR usage based on duration of use and tested if this was influenced by the performing RHU and pandemic event. We also determined the most frequent EMR activities through process maps and tested if there were differences in the conduct of these activities before and during the pandemic. Results showed that EMR use during work hours was significantly dependent on the performing RHU (

A Micro-analysis Approach in Understanding Electronic Medical Record Usage in Rural Communities : Comparison of Frequency of Use on Performance Before and During the COVID-19 Pandemic

In strengthening eHealth in the Philippines to support the universal health care (UHC) law, the scaling up and full adoption of electronic medical record (EMR) systems was strategically scheduled and supposedly completed in 2020. The Covid-19 pandemic, however, delayed these strengthening efforts. We wanted to assess the status of EMR adoption in primary clinics of rural health units (RHUs) and understand the frequency of use, particularly during the pandemic. Through analyses of EMR usage logs from selected RHUs in 2020, we estimated frequency of EMR usage based on duration of use and tested if this was influenced by the performing RHU and pandemic event. We also determined the most frequent EMR activities through process maps and tested if there were differences in the conduct of these activities before and during the pandemic. Results showed that EMR use during work hours was significantly dependent on the performing RHU (p<0.001). High-performing RHUs used EMRs more than 3 hours/day while low-performing RHUs used the systems for less. The pandemic either significantly decreased or increased EMR use during work hours by around 5 hours/day in some RHUs (p<0.01). Process maps revealed that there were additional activities performed by RHUs during the pandemic. Except for Update Patient Profile and Add Patient EMR features, significant differences (p<0.01) were observed in accessing frequently used features before and during the pandemic. The results suggest some uneven level of utilization of EMRs at the primary care level which can impact readiness to support full implementation of the UHC law. The study shows the potential of using a more granular approach in studying adoption to help improve the quality of EMR use and contribute to improving health service delivery and financing.publishedVersionPeer reviewe

The 2019 Philippine UHC Act, Pandemic Management and Implementation Implications in a Post-COVID-19 World: A Content Analysis

The 2019 Philippine Universal Health Care Act (Republic Act 11223) was set for implementation in January 2020 when disruptions brought on by the pandemic occurred. Will the provisions of the new UHC Act for an improved health system enable agile responses to forthcoming shocks, such as this COVID-19 pandemic? A content analysis of the 2019 Philippine UHC Act can identify neglected and leverage areas for systems’ improvement in a post-pandemic world. While content or document analysis is commonly undertaken as part of scoping or systematic reviews of a qualitative nature, quantitative analyses using a two-way mixed effects, consistency, multiple raters type of intraclass correlation coefficient (ICC) were applied to check for reliability and consistency of agreement among the study participants in the manual tagging of UHC components in the legislation. The intraclass correlation reflected the individuals’ consistency of agreement with significant reliability (0.939, p \u3c 0.001). The assessment highlighted a centralized approach to implementation, which can set aside the crucial collaborations and partnerships demonstrated and developed during the pandemic. The financing for local governments was strengthened with a new ruling that could alter UHC integration tendencies. A smarter allocation of tax-based financing sources, along with strengthened information and communications systems, can confront issues of trust and accountability, amidst the varying capacities of agents and systems