The risk of outpatient mental health care service use following departure from work: a cohort register study of migrant and non-migrant women.

BACKGROUND: Non-workforce participation is associated with increased risk of mental disorder in the general population. Migrant women face disadvantage in the labour market but use mental health services to a lesser extent. This study investigates the risk of using mental health services following departure from the workforce among women in Norway, and if the strength of the relationship varies for migrant and non-migrant women. METHODS: Using linked registry data, we followed a cohort of 746,635 women who had a stable workforce attachment over a three-year period. We used Cox proportional hazard models to determine the risk of using outpatient mental health services (OPMH) following departure from the workforce. We included an interaction analysis to determine if the relationship differed by migrant group and length of stay and conducted subsequent stratified analyses. RESULTS: Departure from the workforce was associated with a 40% increased risk of using OPMH services among all women. Interaction analyses and subsequent stratified analyses indicated that departure from the workforce was associated with an increased risk of using OPMH services among non-migrant women and among women from countries outside of the European Economic Area, regardless of length of stay. For women from the European Economic Area with 2-6 years or 7-15 years in Norway, however, there was no increased risk. CONCLUSIONS: Departure from the workforce is associated with increased risk of mental health service use, also among migrant women. Migrant women as a group, are more often temporarily employed and therefore at greater risk of falling out of the workforce and developing a mental disorder. However, women with shorter length of stays may experience greater barriers to care and service use may be a poorer indicator of actual mental disorder.

Use of outpatient mental healthcare services and upper-secondary school completion in young women with migrant background - A population-based study.

Mental disorders typically develop during adolescence, with young women being particularly at risk. Mental disorders during this period can negatively affect both current and future life prospects such as school completion. Migrants are at increased risk of developing mental disorders as a result of their experiences prior to, during and after migration. Additionally, they are less likely to complete upper-secondary school when compared to the majority population. Thus, being a young migrant woman with a mental disorder may have adverse consequences for school completion, which in turn can affect socioeconomic status later in life. In this study, we aimed to investigate the association between mental disorders, defined as having used outpatient mental healthcare services (OPMH), and completion of upper-secondary school among young women living in Norway, using national registry data. Additionally, we examined differences in probability of school completion between Norwegian majority, migrants and migrant descendants between those who used and did not use OPMH. The sample consisted of women born between 1990 and 1993 (N = 122,777). We conducted hierarchical, multivariable logistic regression analysis. In unadjusted analysis, we found that young women who used OPMH services had lower odds of school completion than those who did not, even after adjustment for migrant background and parental education. However, by calculating predictive margins, we found that descendant women, who had used OPMH services, had significantly higher probability of completing upper-secondary education than Norwegian majority women who had used services. None of the four migrant groups differed significantly from majority women. Use of OPMH services, had most adverse effect on majority, migrants from Nordic and Western countries and descendants, when compared to non-users. Future interventions should aim to increase school completion among young women with mental disorders.

Long-term sickness absence among young and middle-aged workers in Norway: the impact of a population-level intervention.

BACKGROUND: The study objective was to evaluate the impact of a population-level intervention (the IA Agreement) on the of one-year risk for long-term sickness absence spells (LSAS) among young and middle aged workers in Norway. METHODS: Using an observational design, we conducted a quasi-experimental study to analyse registry data on individual LSAS for all employed individuals in 2000 (n = 298,690) and 2005 (n = 352,618), born in Norway between 1976 and 1967. The intervention of interest was the tripartite agreement for a more inclusive working life (the IA Agreement). We estimated difference in pre-post differences (DID) in LSAS between individuals working in IA companies with the intervention and companies without, in 2000 and 2005. We used logistic regression models and present odds ratios (DID OR) with accompanying 95% CI. We stratified analyses by sex, industry and company size. RESULTS: We found no significant change in the overall risk of long-term sickness absence spells after implementing the intervention among young and middle aged workers. Stratified by sex, the intervention resulted in a slight decrease in LSAS risk among female workers (DID OR 0.93 (0.91-0.96)) while the intervention showed no impact among male workers (DID OR 1.01 (0.97-1.06)). We found that companies signing the IA Agreement were large (≥50 employees) and often within the manufacturing and health and social sectors. In large manufacturing companies, we found a reduction in LSAS, among workers both in companies with and without the intervention, resulting in no statistically significant impact of the IA intervention. In large health and social companies, we found an increase in LSAS among workers both in companies with and without the intervention. The increase was smaller among the workers in companies offering the IA intervention compared with workers in companies without, resulting in a positive impact of the IA intervention in the health and social industry. This impact was statistically significant only among female workers. CONCLUSIONS: The results indicate that the impact of the IA Agreement on the risk of long-term sickness absence spells varies considerably depending on sex and industry. These findings suggest that reducing LSAS may warrant industry-specific interventions.

Outpatient mental healthcare service use among women with migrant background in Norway: a national register study.

BACKGROUND: Studies show that migrant women are at greater risk of common mental disorders than the majority population, yet underrepresented in healthcare services. This study investigates the use of outpatient mental healthcare services over a five-year period among migrant and descendant women compared to majority women in Norway. METHODS: Using linked national registry data, we selected all women resident in Norway between 2009 and 2013 (N = 1,834,822). We conducted generalised estimated equations with logistic regression to assess if the odds of using outpatient mental healthcare services differed for migrant and descendant women compared to majority women. We also conducted generalised estimated equations with negative binomial regression to calculate consultation incidence rate ratios for migrant and descendant women relative to majority women among those with a common mental disorder. RESULTS: Both migrant and descendant women had lower odds (OR = 0.47 and OR = 0.60 respectively) of using outpatient mental healthcare services than majority women. Odds of using services increased with length of residency. We also found significant variation by country of origin. Among women with common mental disorders who had used services, migrants, but not descendants, had a lower consultation rate ratio than majority women. Analyses by region of origin revealed that this did not apply to women from EU European countries, North America and Australia and New Zealand. CONCLUSION: Women with migrant background are, overall, underrepresented in OPMH services. Findings indicate that migrant women may not only experience barriers to seeking and accessing care but also in maintaining access to care. This may especially be the case for newly arrived migrant women and women from non-Western countries. Treatment may not be culturally adapted for these groups. Closer investigation of the barriers migrant women experience after using OPMH services is required.

Information bias of social gradients in sickness absence: a comparison of self-report data in the Norwegian Mother and Child Cohort Study (MoBa) and data in national registries.

BACKGROUND: Measurement error in self-report questionnaires is a common source of bias in epidemiologic studies. The study aim was to assess information bias of the educational gradient in sickness absence among participants in the Norwegian Mother and Child Cohort Study (MoBa), comparing self-report data with national register data. METHODS: MoBa is a national prospective cohort study. The present study included 49,637 participants, born 1967-1976, who gave birth 2000-2009. The highest completed education level was recorded in categories and as educational years. Sickness absence was defined as one or more spell lasting more than 16 days between pregnancy weeks 13 and 30. We computed sickness absence risk in mid-pregnancy in strata of education level. Associations between completed educational years and sickness absence were estimated as risk differences in binomial regression and compared between self-report and register data. In additional analyses, we aimed to explain discrepancies between estimates from the two data sources. RESULTS: The overall registry-based sickness absence risk was 0.478 and decreased for increasingly higher education in a consistent fashion, yielding an additive risk difference in association with one additional education year of - 0.032 (95% confidence interval - 0.035 to - 0.030). The self-report risk was lower (0.307) with a corresponding risk difference of only - 0.013 (95% confidence interval - 0.015 to - 0.011). The main explanation of the lower risk difference in the self-report data was a tendency for mothers in low education categories to omit reporting sickness absence in the questionnaire. CONCLUSIONS: A plausible explanation for the biased self-report association is complexity of the sickness absence question and a resulting educational gradient in non-response. As shown for sickness absence in mid-pregnancy in the present study, national registries could be a preferred alternative to self-report questionnaires.

The impact of completing upper secondary education - a multi-state model for work, education and health in young men.

BACKGROUND: Completing upper secondary education is associated with higher work participation and less health-related absence from work. Although these outcomes are closely interrelated, most studies focus on single outcomes, using cross-sectional designs or short follow-up periods. As such, there is limited knowledge of the long-term outcomes, and how paths for completers and non-completers unfold over time. In this paper, we use multi-state models for time-to-event data to assess the long-term effects of completing upper secondary education on employment, tertiary education, sick leave, and disability pension over twelve and a half years for young men. METHODS: Baseline covariates and twelve and a half years of follow-up data on employment, tertiary education, sick leave and disability pension were obtained from national registries for all males born in Norway between 1971 and 1976 (n =184951). The effects of completing upper secondary education (by age 23) were analysed in a multi-state framework, adjusting for both individual and family level confounders. All analyses were done separately for general studies and vocational tracks. RESULTS: Completers do better on a range of outcomes compared to non-completers, for both fields of upper secondary education, but effects of completion change over time. The largest changes are for tertiary education and work, with the probability of work increasing reciprocally to the probability of education. Vocational students are quicker to transfer to the labour market, but tend to have more unemployment, sick leave and disability, and the absolute effects of completion on these outcomes are largest for vocational tracks. However, the relative effects of completion are larger for general studies. CONCLUSION: Completing upper secondary education increases long-term work participation and lowers health-related absence for young men, but effects diminish over time. Studies that have used shorter follow-up periods could be overstating the negative effects of dropout on labour market participation. Multi-state models are well suited to analyse data on work, education and health-related absence, and can be useful in understanding the dynamic aspects of these outcomes.

High birth weight and perinatal mortality among siblings: A register based study in Norway, 1967-2011.

BACKGROUND: Perinatal mortality according to birth weight has an inverse J-pattern. Our aim was to estimate the influence of familial factors on this pattern, applying a cohort sibling design. We focused on excess mortality among macrosomic infants (>2 SD above the mean) and hypothesized that the birth weight-mortality association could be explained by confounding shared family factors. We also estimated how the participant's deviation from mean sibling birth weight influenced the association. METHODS AND FINDINGS: We included 1 925 929 singletons, born term or post-term to mothers with more than one delivery 1967-2011 registered in the Medical Birth Registry of Norway. We examined z-score birth weight and perinatal mortality in random-effects and sibling fixed-effects logistic regression models including measured confounders (e.g. maternal diabetes) as well as unmeasured shared family confounders (through fixed effects models). Birth weight-specific mortality showed an inverse J-pattern, being lowest (2.0 per 1000) at reference weight (z-score +1 to +2) and increasing for higher weights. Mortality in the highest weight category was 15-fold higher than reference. This pattern changed little in multivariable models. Deviance from mean sibling birth weight modified the mortality pattern across the birth weight spectrum: small and medium-sized infants had increased mortality when being smaller than their siblings, and large-sized infants had an increased risk when outweighing their siblings. Maternal diabetes and birth weight acted in a synergistic fashion with mortality among macrosomic infants in diabetic pregnancies in excess of what would be expected for additive effects. CONCLUSIONS: The inverse J-pattern between birth weight and mortality is not explained by measured confounders or unmeasured shared family factors. Infants are at particularly high mortality risk when their birth weight deviates substantially from their siblings. Sensitivity analysis suggests that characteristics related to maternal diabetes could be important in explaining the increased mortality among macrosomic infants.

Adult social position and sick leave: the mediating effect of physical workload.

OBJECTIVE: This study aimed to quantify how much of the adult social gradient in sick leave can be attributed to the mediating role of physical workload while accounting for the role of childhood and adolescent social position and neuroticism. METHODS: Our sample consisted of 2099 women and 1229 men from a Norwegian birth cohort study (born 1967-1976) who participated in the Nord-Trøndelag Health Study (2006-2008) (HUNT3). Data on sick leave (defined as >16 calendar days; 2006-2009) and social position during childhood, adolescence, and adulthood were obtained from national registers. Study outcome was time-to-first sick leave spell. Physical workload and neuroticism were self-reported in HUNT3. Mediating effects through physical workload were estimated using a method based on the additive hazards survival model. RESULTS: A hypothetical change from highest to lowest group in adult social position was, for women, associated with 51.6 [95% confidence interval (95% CI) 24.7-78.5] additional spells per 100,000 person-days at risk, in a model adjusted for childhood and adolescent social position and neuroticism. The corresponding rate increase for men was 41.1 (95% CI 21.4-60.8). Of these additional spells, the proportion mediated through physical workload was 24% (95% CI 10-49) and 30% (95% CI 10-63) for women and men, respectively. CONCLUSIONS: The effect of adult social position on sick leave was partly mediated through physical workload, even while accounting for earlier life course factors. Our findings provide support that interventions aimed at reducing physical workload among those with lower adult social position could reduce sick leave risk.

The gender gap in sickness absence from work and the influence of parental absence on offspring absence 15 years later: register-based cohort of Norwegians born in 1974-1976.

BACKGROUND: Women have shown consistently higher levels of sickness absence from work in comparison to men, but explanations for this gender gap have not been completely understood. Life-course studies suggest that health and health-related social benefits in adult age are influenced by early life experiences. We aimed to estimate intergenerational associations with a 15-year time gap between parents' and offspring sickness absences, pursuing the hypothesis that this parental influence would have a stronger impact for women than for men. METHODS: All persons born alive between 1974 and 1976 in Norway were followed up in several national registries. Employed persons considered to be at risk of sickness absence and also with parents at risk of sickness absence (n = 78,878) were followed in the calendar year of their 33(rd) birthday with respect to spells lasting >16 days. The probability of one or more spells during this year constituted the one-year risk under study. Additive risk differences in association with an exposure (parental sickness absence 15 years earlier) were estimated in a binomial regression analysis. The estimates were adjusted for parental socioeconomic factors. RESULTS: The 1-year sickness absence risk was higher for women (30.4%) than for men (12.3%). The crude risk differences between those exposed and those unexposed to parental sickness absence were similar in percentage points (PP) for women (3.8; 95% confidence interval (CI) 2.6 to 4.9) and men (3.8; 95% CI 2.9 to 4.6). The risk differences were moderately attenuated after adjustment for parental education and father's income to 3.4 PP (2.2 to 4.5) for women and 2.8 PP (2.0 to 3.7) for men. Male absence was more strongly associated with the father's than with the mother's sickness absence, while associations for women were stronger for the same diagnostic groups as their parents. CONCLUSIONS: Parental sickness absence was moderately associated with sickness absence in the next generation. Bias from unmeasured confounders cannot be entirely dismissed. Contrary to our hypothesis, associations were not stronger for women than for men. If parental sickness absence has a long-term causal effect, preventive measures could have an impact over generations.

The association of high birth weight with intelligence in young adulthood: a cohort study of male siblings.

We aimed to explore why, in population studies, the positive association between normal-range birth weight and intelligence becomes negative at the highest birth weights. The study population comprised 217,746 Norwegian male singletons born at term between 1967 and 1976. All had data on birth weight and intelligence quotient (IQ) score at the time of military conscription; 137,574 had data on sibling birth weights; and 62,906 had data on male sibling birth weights. We estimated associations between birth weight and IQ score by ordinary least squares regression for the total study population and by fixed-effects regression for comparisons of brothers. The crude mean IQ score was 1.2 points (95% confidence interval (CI): 0.3, 2.2) lower for those with birth weights of 5,000 g or more compared with the reference group (with birth weights of 4,000-4,499 g). This difference leveled off to 0.0 (95% CI: -0.8, 0.9) in multivariable ordinary least squares regression and reversed to 2.2 points (95% CI: 0.3, 4.2) higher in fixed-effects regression. Results differed mainly because, at a given birth weight, participants who had a sibling with macrosomia had a lower mean IQ score. Nevertheless, within families with 1 or more macrosomic siblings, as in other families, men with higher birth weights tended to have higher IQ scores. Thus, a family-level confounder introduces a cross-level bias that cannot be detected in individual-level studies. We suggest ways in which future studies might elucidate the nature of this confounder.

Impact of aerobic fitness on musculoskeletal sickness absence 5-15 years later: a cohort study of 227,201 male Norwegian employees.

OBJECTIVES: The aim of the study was to estimate associations between aerobic fitness among men at age 18-19 years and work absence due to musculoskeletal sickness 5-15 years later. METHODS: All 321,975 men born between 1967 and 1976 in Norway were identified and followed up in several national registers. Men who completed an aerobic fitness test at military conscription during 1985-1995 (N=227,201) were followed from 2000 through 2003 with respect to a first musculoskeletal absence. Cox regression was conducted to estimate HRs between aerobic fitness (high, medium, poor) and musculoskeletal absence. RESULTS: A total of 26,061 men had a musculoskeletal absence (absolute risk 0.115). Absence was associated with fitness level. Associations were confounded by other conscript characteristics (intellectual capacity, body mass index, musculoskeletal condition) and parental education level and were restricted to non-injury absence. With high fitness as reference, the adjusted non-injury HR estimates were 1.18 (95% CI 1.12 to 1.24) and 1.39 (1.31 to 1.47) for medium and poor fitness, respectively. Poor fitness men were more likely to achieve low educational attainment and employment in high-absence industries and enterprises. The impact of intellectual capacity and parental education level on absence was considerably larger than the effect from fitness. A subset analysis with fitness data of better quality yielded moderately stronger associations. CONCLUSIONS: Aerobic fitness among conscripts was moderately associated with non-injury musculoskeletal absence 5-15 years later. However, the overall impact of intellectual capacity and parental education appears to be greater than that of aerobic fitness.

Adolescent suicide attempts in Bærum, Norway, 1984-2006.

BACKGROUND: There are presently few international studies that examine adolescents' own experience of both triggering and the underlying reasons behind their suicide attempts. AIMS: To present the rates, triggering factors, and underlying reasons for such behavior. METHODS: The 23-year (1984-2006) surveillance study reported includes all general hospital-treated suicide attempters aged between 13 and 19 years (n = 254) living in the municipality of Bærum, a suburb on the outskirts of Oslo, Norway. RESULTS: Suicide attempt rates for both sexes decreased during the period of study. The female suicide attempt rate was on average 3.5 times higher than the male rate. An average of 8.2% of the suicide attempters made a repeat attempt within the following year. Overall, the most commonly reported trigger was a relational conflict (50.2%), and the most commonly reported underlying reason was a dysfunctional family situation (43.6%), followed by mental health problems (22.8%). The main gender difference for both triggers and underlying reasons was that relational conflicts were reported significantly more often by girls than by boys as triggers (55.0% versus 32.7%), and dysfunctional family issues were reported significantly more often by girls than by boys (47.1% versus 30.8%) as underlying reasons for the attempt. Mental health problems were reported less frequently as an underlying reason by girls than boys (21.2% versus 28.8%). CONCLUSIONS: A family-oriented intervention embracing the extended family system seems warranted in a majority of the cases in our study.