Fatherhood timing and men's midlife earnings: A within-family study of Finnish cohorts born in 1938-50.

Fathers tend to achieve higher earnings than childless men, but there is limited evidence on the associations between fatherhood timing and men's later earnings. Using a longitudinal census-based sample of Finnish men, including a subsample of brothers, we investigated fatherhood timing and men's midlife earnings using both between- and within-family models. Earnings around age 50 were lower among adolescent and young fathers than for men who became fathers at ages 25-29 or later, but these associations became negligible after accounting for measured confounders and unobserved familial confounding. Overall, our findings highlight the important roles of selection into early childbearing and into childlessness. At the population level, early fatherhood was associated with clear negative distributional shifts in fathers' midlife earnings. However, among all men, any influence of fatherhood timing on men's midlife earnings distribution paled in comparison with that of childlessness.

Does having siblings really protect against childhood atopic diseases? A total population and within-family analysis.

The association between having older siblings and decreased risk for atopic symptoms is well-established. This has been interpreted as evidence for the microbiota hypothesis, i.e. that increased early-childhood microbial exposure caused by siblings protects from immune hypersensitivities. However, possible confounders of the association have received little attention. We used register data on Finnish cohorts born in 1995-2004 (N = 559,077) to assess medication purchases for atopic diseases: antihistamines, eczema medication, asthma medication and Epinephrine. We modelled the probability of atopic medication purchases at ages 0-15 by birth order controlling for important observed confounders and all unobserved genetic and environmental characteristics shared by siblings in a within-family fixed effects model. We further studied medication purchases among first-borns according to the age difference with younger siblings to assess whether having younger siblings in early childhood is beneficial. Having older siblings was associated with a lower probability of atopic medication purchases. Compared to first-borns, the probability was 10-20% lower among second-borns, 20-40% lower among third-borns, and 30-70% lower among subsequent children, depending on medication type. Confounding accounted for up to 75% of these differences, particularly for asthma and eczema medication, but significant differences by birth order remained across all medication types. Among first-borns, a smaller age difference with younger siblings was related to a lower likelihood of atopic medication use. Our results, based on designs that account for unobserved confounding, show that exposure to siblings in early childhood, protects from atopic diseases, and thus strongly support the microbiota hypothesis.

Excess winter mortality in Finland, 1971-2019: a register-based study on long-term trends and effect modification by sociodemographic characteristics and pre-existing health conditions.

OBJECTIVES: Excess winter mortality is a well-established phenomenon across the developed world. However, whether individual-level factors increase vulnerability to the effects of winter remains inadequately examined. Our aim was to assess long-term trends in excess winter mortality in Finland and estimate the modifying effect of sociodemographic and health characteristics on the risk of winter death. DESIGN: Nationwide register study. SETTING: Finland. PARTICIPANTS: Population aged 60 years and over, resident in Finland, 1971-2019. OUTCOME MEASURES: Age-adjusted winter and non-winter death rates, and winter-to-non-winter rate ratios and relative risks (multiplicative interaction effects between winter and modifying characteristics). RESULTS: We found a decreasing trend in the relative winter excess mortality over five decades and a drop in the series around 2000. During 2000-2019, winter mortality rates for men and women were 11% and 14% higher than expected based on non-winter rates. The relative risk of winter death increased with age but did not vary by income. Compared with those living with at least one other person, individuals in institutions had a higher relative risk (1.07, 95% CI 1.05 to 1.08). Most pre-existing health conditions did not predict winter death, but persons with dementia emerged at greater relative risk (1.06, 95% CI 1.04 to 1.07). CONCLUSIONS: Although winter mortality seems to affect frail people more strongly-those of advanced age, living in institutions and with dementia-there is an increased risk even beyond the more vulnerable groups. Protection of high-risk groups should be complemented with population-level preventive measures.

Grandparental support and maternal depression: Do grandparents' characteristics matter more for separating mothers?

Grandparental support may protect mothers from depression, particularly mothers who separate and enter single parenthood. Using longitudinal Finnish register data on 116,917 separating and 371,703 non-separating mothers with young children, we examined differences in mothers' antidepressant purchases by grandparental characteristics related to provision of support. Grandparents' younger age (<70 years), employment, and lack of severe health problems predicted a lower probability of maternal depression. Depression was also less common if grandparents lived close to the mother and if the maternal grandparents' union was intact. Differences in maternal depression by grandparental characteristics were larger among separating than among non-separating mothers, particularly during the years before separation. Overall, maternal grandmothers' characteristics appeared to matter most, while the role of paternal grandparents was smaller. The findings suggest that grandparental characteristics associated with increased potential for providing support and decreased need of receiving support predict a lower likelihood of maternal depression, particularly among separating mothers.

Contribution of causes of death to changing inequalities in life expectancy by income in Finland, 1997-2020.

BACKGROUND: Socioeconomic inequalities in mortality originate from different causes of death. Alcohol-related and smoking-related deaths are major drivers of mortality inequalities across Europe. In Finland, the turn from widening to narrowing mortality disparities by income in the early 2010s was largely attributable to these causes of death. However, little is known about recent inequalities in life expectancy (LE) and lifespan variation. METHODS: We used individual-level total population register-based data with annual information on disposable household income and cause-specific mortality for ages 30-95+, and assessed the contribution of smoking on mortality using the Preston-Glei-Wilmoth method. We calculated trends in LE at age 30 and SD in lifespan by income quintile in 1997-2020 and conducted age and cause-of-death decompositions of changes in LE. RESULTS: Disparity in LE and lifespan variation by income increased in 2015-2020, largely attributable to the stagnation of both measures in the lowest income quintile. The LE gap between the extreme quintiles in 2018-2020 was 11.2 (men) and 5.9 (women) years, of which roughly 40% was attributable to alcohol and smoking. However, the recent widening of the gap and the stagnation in LE in the lowest quintile over time were not driven by any specific cause-of-death group. CONCLUSIONS: After a decade of narrowing inequalities in LE and lifespan variation in Finland, the gaps between income groups are growing again. Increasing LE disparity and stagnating mortality on the lowest income levels are no longer attributable to smoking and alcohol-related deaths but are more comprehensive, originating from most cause-of-death groups.

Maternal psychiatric and somatic illness, and the risk of unintentional injuries in children: variation by type of maternal illness, type of injury and child age.

BACKGROUND: Maternal mental illness appears to increase the risk of unintentional childhood injuries, which are a common cause of morbidity and mortality in early childhood. However, little is known about the variations in this association by type of injury and child's age, and studies on the effects of maternal somatic illness on children's injury risk are scarce. METHODS: We used Finnish total population register data from 2000 to 2017 to link 1 369 325 children to their biological mothers and followed them for maternal illness and childhood injuries until the children's sixth birthday. Cox regression models were used to examine the associations between maternal illness and children's injuries by type of illness (neurological, psychiatric and cancer), type of injury (transport injuries, falls, burns, drowning or suffocations, poisonings, exposure to inanimate and animate mechanical forces) and child's age (<1 year-olds, 1-2 year-olds, 3-5 year-olds). RESULTS: After adjustment for family structure, maternal age at birth, maternal education, income, child's gender, native language and region of residence, children of unwell mothers showed a higher risk of injuries (HR: 1.21, 95% CI: 1.19 to 1.23). This association was clear for maternal neurological (HR: 1.31, 95% CI: 1.26 to 1.36) and psychiatric illnesses (HR: 1.20, 95% CI: 1.18 to 1.23) but inconsistent for cancer. Maternal illness predicted an increased risk of injury across all age groups. CONCLUSIONS: Maternal mental and somatic illness may both increase children's injury risk. Adequate social and parenting support for families with maternal illness may reduce childhood injury.

Socioeconomic differences in children's victimization to maternal and paternal violence: a register-based study.

AIMS: To explore the potential of administrative data in assessment of the association between parental socioeconomic position (SEP) and children's violent victimization by biological parents. METHODS: A longitudinal register-linkage study based on child-mother and child-father data, including all children born in Finland between 1991 and 2017. The data included 1,535,428 children, 796,335 biological mothers, and 775,966 fathers. We used logistic regression with person-years as observations and cluster-robust standard errors to predict children's violent victimization in 2009-2018 and assessed effect modification by child's age and gender. RESULTS: For the SEP indicators, lower maternal education (adjusted odds ratio (OR) 2.90, secondary education OR 1.99) and lower paternal education (OR 2.24, secondary education OR 1.59) were risk factors for violent victimization. Parental social assistance receipt (OR 2.4) and non-employment (OR 1.8-1.9) increased the risk of victimization to maternal and paternal violence. Income was associated with victimization in a gradient-like manner, with ORs ranging from 1.14 to 1.98 among mothers and from 1.29 to 2.56 among fathers. Children with low parental SEP were at the highest risk of parental violence, particularly paternal violence, at ages 3-8 years. CONCLUSIONS: All indicators of low SEP increased the risk of children experiencing both maternal and paternal physical violence, especially at ages 3-8 years. Longitudinal register data-because of large samples, no nonresponse or self-report bias, and the possibility to analyze violence committed by mother and father and age-groups separately-have great potential for comprehensive research on the risk factors of parental violence that are difficult to reliably assess with other types of data.

Partnership trajectories preceding medically assisted reproduction.

The number of people who undergo medically assisted reproduction (MAR) to conceive has increased considerably in recent decades. However, existing research into the demographics and the partnership histories of this growing subgroup is limited. Using unique data from Finnish population registers on nulliparous women born in Finland in 1971-77 (n = 21,129; ∼10 per cent of all women) who had undergone MAR treatment, we created longitudinal partnership histories from age 16 until first MAR treatment. We identified six typical partnership trajectories and used relative frequency sequence plots to investigate heterogeneity in partnership transitions within and between these groups. The majority of women (60.7 per cent) underwent MAR with their first partner, followed by women who underwent MAR in a second (21.5 per cent) or higher-order partnership (7.1 per cent), while 10.7 per cent underwent MAR without a partner. On average, women undergoing MAR were relatively young (with around half starting treatment before age 30) and were highly educated with high incomes.

Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reform.

BACKGROUND: Minimum legal drinking age (MLDA) is an effective policy tool in preventing youth drinking and short-term alcohol-attributable harm, but studies concerning long-term associations are scarce. METHODS: In this register-based, national cohort study, we assessed alcohol-attributable morbidity and mortality of cohorts born in 1944-54 in Finland. Data were from the 1970 census, the Care Register for Healthcare (maintained by the Finnish Institute of Health and Welfare), and the Cause-of-Death Register (maintained by Statistics Finland). As MLDA was lowered from 21 years to 18 years in 1969, these cohorts were effectively allowed to buy alcohol from different ages (18-21 years). We used survival analysis to compare their alcohol-attributable mortality and hospitalisations with a 36-year follow-up. FINDINGS: Compared with the first cohort (1951) allowed to buy alcohol from age 18, the hazard ratios (HRs) for alcohol-attributable morbidity and mortality were lower in cohorts who could not buy alcohol until age 20 or 21 years. For alcohol-attributable morbidity in those aged 21 years when the reform took place, HR was 0·89 (95% CI 0·86-0·93) for men and 0·87 (0·81-0·94) for women versus those aged 17 years. For alcohol-attributable mortality, HR was 0·86 (0·79-0·93) for men and 0·78 (0·66-0·92) for women aged 21 years when the reform took place. The outcomes of the later-born 1952-54 cohorts did not differ from the 1951 cohort. INTERPRETATION: Earlier cohorts had consistently lower alcohol-attributable mortality and morbidity; however, other simultaneous increases in alcohol availability probably contributed to increased alcohol-related harm among the younger cohorts. Overall, differences between cohorts born only a few years apart highlight late adolescence as a crucial period for the establishment of lifelong patterns of alcohol use and suggest that higher MLDA could be protective for health beyond young adulthood. FUNDING: Yrjö Jahnsson Foundation, Foundation for Economic Education, Emil Aaltonen Foundation, Academy of Finland, European Research Council, and NordForsk.

Moderating role of sociodemographic factors in parental psychiatric treatment before and after offspring severe self-harm.

BACKGROUND: Parental psychiatric disorders are known risk factors for adolescent self-harm. Although this association is likely to have a bidirectional element, evidence on changes in parental psychiatric treatment following offspring self-harm is scarce. METHODS: Finnish children born in 1987-1996 with a hospital-treated episode of self-harm between the ages 13 and 19 years (N = 3636) were identified using administrative register data, and their biological mothers (N = 3432) and fathers (N = 3167) were followed two years before and after the episode. Data on purchases of psychotropic medication, specialized psychiatric treatment and psychiatric sickness allowances were used to examine psychiatric treatment among parents. Differences by parental education, employment and living arrangements were assessed, and offspring self-harm was compared with offspring accidental poisonings and traffic accidents. RESULTS: Psychiatric treatment peaked among mothers during the three-month period after offspring self-harm, after which the treatment prevalence decreased but remained slightly elevated relative to the time preceding offspring self-harm. Higher levels of education and being employed increased the likelihood of treatment right after the episode. Among fathers, changes in treatment were negligible. Treatment trajectories around the comparison events of accidents were similar in shape but more muted than among the parents whose children had self-harmed. LIMITATIONS: General practitioner visits or other data from primary health care were not available. CONCLUSION: Mothers receive increased psychiatric treatment after stressful offspring events. Our results indicate that prevention of self-harm and accidents would be beneficial not only for those directly concerned but also for their family members.

The association of lowered alcohol prices with birth outcomes and abortions: A population-based natural experiment.

BACKGROUND AND AIMS: Alcohol use during pregnancy remains an important risk factor for adverse birth outcomes, but little is known regarding how alcohol prices affect pregnancy outcomes on the population level. We assess the associations between decreased alcohol prices with birth outcomes and abortions. DESIGN: Using national registers, we used interrupted time-series modelling to compare outcomes of pregnancies conceived before and after a tax cut, resulting in 33% mean decrease of off-premise alcohol prices on 1 March 2004. We also addressed possible heterogeneity of the associations by maternal age and household income. SETTING: Finland. PARTICIPANTS: All registered pregnancies starting 2 years before and 1 year after the alcohol price cut (analysis sample consisted of 169 735 live births and 32 441 abortions). MEASUREMENTS: The outcomes were birth weight, gestational age, the probability of low birth weight (< 2500 g at birth), preterm birth (< 37 weeks of gestation), any congenital malformations and share of registered abortions of pregnancies. FINDINGS: On the population level, lowered alcohol prices were associated with an increase in abortions immediately after the price cut [+0.84 percentage points; 95% confidence interval (CI) = 0.2, 1.4]. For birth outcomes, negative associations were observed among women in the lowest income quintile; for example, increased probabilities of low birth weight (+1.5 percentage points; 95% CI = 0.4, 2.6) and preterm birth (+1.98 percentage points; 95% CI = 0.8, 3.2). All changes were strongest immediately after the price cut and attenuated during the course of the following year. CONCLUSIONS: Lowered alcohol prices in Finland were associated with a short-term increase in adverse birth outcomes among low-income mothers and an overall increase in abortions.

Income differences in partial life expectancy between ages 35 and 64 from 1988 to 2017: the contribution of living arrangements.

BACKGROUND: Socioeconomic differences in mortality among the working-age population have increased in several high-income countries. The aim of this study was to assess whether changes in the living arrangement composition of income groups have contributed to changing income differences in life expectancy during the past 30 years. METHODS: We used Finnish register data covering the total population to calculate partial life expectancies between ages 35 and 64 by income quartile in 1988-2017. The contribution of living arrangements to these differences was assessed by direct standardization. Decomposition methods were used to determine the extent of life expectancy differences due to external (accidental, violent and alcohol-related) causes of death. RESULTS: The life expectancy gap between the highest and lowest income quartile increased until 2003-07, but decreased thereafter. The contribution of living arrangements to these differences remained mostly stable: 36-39% among men and 15-23% among women. Those living without children consistently showed the greatest life expectancy differences by income. External causes of death significantly contributed to income differences in life expectancy. CONCLUSIONS: The living arrangement composition of income groups explained part of the differences in life expectancy, but not their changes. Our results on the contribution of external causes of death imply that both the persistent income gradient in mortality as well as the mortality disparities by living arrangements are at least partially related to similar selection or causal mechanisms.

Medically assisted reproduction and mental health: a 24-year longitudinal analysis using Finnish register data.

BACKGROUND: Medically assisted reproduction can negatively affect women's mental health, particularly when the treatments do not result in a live birth. Although the number of women relying on medically assisted reproduction to conceive has grown rapidly, our knowledge about the mental health effects before, during, and after treatment is limited. OBJECTIVE: This study aimed to understand the long-term association between medically assisted reproduction and mental health outcomes for women before, during, and after their treatments, and according to whether the treatment resulted in a live birth. STUDY DESIGN: Using Finnish register data for the period from 1995 to 2018, we estimated the probability of psychotropic purchases (antidepressants, anxiolytics, hypnotics, and sedatives) for 3 groups of women who: (1) gave birth after natural conception, (2) gave birth after medically assisted reproduction treatments, or (3) underwent medically assisted reproduction but remained childless. We followed up women for up to 12 years before and 12 years after the reference date, which corresponded to the conception date for women who had a first live birth either after a natural or a medically assisted conception, or the date of the last medically assisted reproduction treatment for women with no live birth by the end of 2017. We estimated linear probability models before and after adjustment for sociodemographic characteristics. RESULTS: The results show that women who did not have a live birth after undergoing medically assisted reproduction treatments purchased more psychotropics than women who gave birth after conceiving naturally or through medically assisted reproduction, and that these differences did not attenuate over time. Twelve years after the reference date, 17.73% (95% confidence interval, 16.82-18.63) of women who underwent medically assisted reproduction but remained childless purchased psychotropics vs 11.11% of women who gave birth after natural conception (95% confidence interval, 10.98-11.26) and 12.17% (95% confidence interval, 11.65-12.69) of women who gave birth after medically assisted reproduction treatments. In addition, women who conceived naturally and through medically assisted reproduction had very similar psychotropic use patterns from 3 years before conception to 4 years after, and over the long term. Adjustment for women's sociodemographic characteristics did not change the results. CONCLUSION: The similarities in psychotropic purchases of women who had a live birth, whether naturally or through medically assisted reproduction, suggest that the higher psychotropic use among women who remained childless after undergoing medically assisted reproduction were likely driven more by involuntary childlessness than by treatment-related stress. The results highlight the importance of counseling for women undergoing medically assisted reproduction treatments, especially if their attempts to conceive are unsuccessful.

Labor epidural analgesia and subsequent risk of offspring autism spectrum disorder and attention-deficit/hyperactivity disorder: a cross-national cohort study of 4.5 million individuals and their siblings.

BACKGROUND: A recent study has suggested that labor epidural analgesia may be associated with increased rates of offspring autism spectrum disorder. Subsequent replication attempts have lacked sufficient power to confidently exclude the possibility of a small effect, and the causal nature of this association remains unknown. OBJECTIVE: This study aimed to investigate the extent to which exposure to labor epidural analgesia is associated with offspring autism spectrum disorder and attention-deficit/hyperactivity disorder following adjustments for unmeasured familial confounding. STUDY DESIGN: We identified 4,498,462 singletons and their parents using the Medical Birth Registers in Finland (cohorts born from 1987-2005), Norway (1999-2015), and Sweden (1987-2011) linked with population and patient registries. These cohorts were followed from birth until they either had the outcomes of interest, emigrated, died, or reached the end of the follow-up (at mean ages 13.6-16.8 years), whichever occurred first. Cox regression models were used to estimate country-specific associations between labor epidural analgesia recorded at birth and outcomes (eg, at least 1 secondary care diagnosis of autism spectrum disorder and attention-deficit/hyperactivity disorder or at least 1 dispensed prescription of medication used for the treatment of attention-deficit/hyperactivity disorder). The models were adjusted for sex, birth year, birth order, and unmeasured familial confounders via sibling comparisons. Pooled estimates across all the 3 countries were estimated using inverse variance weighted fixed-effects meta-analysis models. RESULTS: A total of 4,498,462 individuals (48.7% female) were included, 1,091,846 (24.3%) of which were exposed to labor epidural analgesia. Of these, 1.2% were diagnosed with autism spectrum disorder and 4.0% with attention-deficit/hyperactivity disorder. On the population level, pooled estimates showed that labor epidural analgesia was associated with increased risk of offspring autism spectrum disorder (adjusted hazard ratio, 1.12; 95% confidence interval, 1.10-1.14, absolute risks, 1.20% vs 1.07%) and attention-deficit/hyperactivity disorder (adjusted hazard ratio, 1.20; 95% confidence interval, 1.19-1.21; absolute risks, 3.95% vs 3.32%). However, when comparing full siblings who were differentially exposed to labor epidural analgesia, the associations were fully attenuated for both conditions with narrow confidence intervals (adjusted hazard ratio [autism spectrum disorder], 0.98; 95% confidence interval, 0.93-1.03; adjusted hazard ratio attention-deficit/hyperactivity disorder, 0.99; 95% confidence interval, 0.96-1.02). CONCLUSION: In this large cross-national study, we found no support for the hypothesis that exposure to labor epidural analgesia causes either offspring autism spectrum disorder or attention-deficit/hyperactivity disorder.

Perinatal health among migrant women: A longitudinal register study in Finland 2000-17.

Migrants often have better health than the native-born population ('healthy immigrant effect'), although the effect tends to attenuate over time since migration. However, following the weathering hypothesis, migrants may have worse health due to a combination of discrimination and poorer financial conditions faced by many of them. Yet, little is known about interactions between migrant origin and individual socioeconomic status or the time spent in the host country in relation to reproductive health. We use Finnish register data of 491,532 women and 948,616 births spanning years 2000-17 to longitudinally study the association between the country of birth and perinatal outcomes (preterm birth, unplanned C-section, episiotomy and spontaneous vaginal birth); the interaction of country of birth with household income; and the effect of time since migration using random intercept logistic regression models. We show that a 'healthy immigrant effect' largely does not exist for perinatal outcomes apart from migrants from a few high-income countries. Instead, in particular women from poorer countries tended to fare worse than native women. Often, the effect of the country of birth did not differ by household income, or the patterns were not clear. The impact of time since immigration was complex and dependent on country of birth and the outcome studied, but showed an increase in risk of preterm birth among migrants from low- and lower-middle-income countries compared to those born in Finland. Discrimination, language barriers in seeking care or refugee experiences are among some of the possible mechanisms explaining the worse perinatal health of migrants from poorer countries. The inequalities observed in a global scale in countries' economic outcomes may reproduce themselves as reproductive health inequalities among migrants living in wealthy countries.

The Well-Being of Adolescents Conceived Through Medically Assisted Reproduction: A Population-Level and Within-Family Analysis.

Medically assisted reproduction (MAR) plays an increasingly important role in the realization of fertility intentions in advanced societies, yet the evidence regarding MAR-conceived children's longer-term well-being remains inconclusive. Using register data on all Finnish children born in 1995-2000, we compared a range of social and mental health outcomes among MAR- and naturally conceived adolescents in population-averaged estimates, and within families who have conceived both through MAR and naturally. In baseline models, MAR-conceived adolescents had better school performance and the likelihood of school dropout, not being in education or employment, and early home-leaving were lower than among naturally conceived adolescents. No major differences were found in mental health and high-risk health behaviours. Adjustment for family sociodemographic characteristics attenuated MAR adolescents' advantage in social outcomes, while increasing the risk of mental disorders. The higher probability of mental disorders persisted when comparing MAR adolescents to their naturally conceived siblings. On average, MAR adolescents had similar or better outcomes than naturally conceived adolescents, largely due to their more advantaged family backgrounds, which underscores the importance of integrating a sociodemographic perspective in studies of MAR and its consequences.

Income differences in COVID-19 incidence and severity in Finland among people with foreign and native background: A population-based cohort study of individuals nested within households.

BACKGROUND: Although intrahousehold transmission is a key source of Coronavirus Disease 2019 (COVID-19) infections, studies to date have not analysed socioeconomic risk factors on the household level or household clustering of severe COVID-19. We quantify household income differences and household clustering of COVID-19 incidence and severity. METHODS AND FINDINGS: We used register-based cohort data with individual-level linkage across various administrative registers for the total Finnish population living in working-age private households (N = 4,315,342). Incident COVID-19 cases (N = 38,467) were identified from the National Infectious Diseases Register from 1 July 2020 to 22 February 2021. Severe cases (N = 625) were defined as having at least 3 consecutive days of inpatient care with a COVID-19 diagnosis and identified from the Care Register for Health Care between 1 July 2020 and 31 December 2020. We used 2-level logistic regression with individuals nested within households to estimate COVID-19 incidence and case severity among those infected. Adjusted for age, sex, and regional characteristics, the incidence of COVID-19 was higher (odds ratio [OR] 1.67, 95% CI 1.58 to 1.77, p < 0.001, 28.4% of infections) among individuals in the lowest household income quintile than among those in the highest quintile (18.9%). The difference attenuated (OR 1.23, 1.16 to 1.30, p < 0.001) when controlling for foreign background but not when controlling for other household-level risk factors. In fact, we found a clear income gradient in incidence only among people with foreign background but none among those with native background. The odds of severe illness among those infected were also higher in the lowest income quintile (OR 1.97, 1.52 to 2.56, p < 0.001, 28.0% versus 21.6% in the highest quintile), but this difference was fully attenuated (OR 1.08, 0.77 to 1.52, p = 0.64) when controlling for other individual-level risk factors-comorbidities, occupational status, and foreign background. Both incidence and severity were strongly clustered within households: Around 77% of the variation in incidence and 20% in severity were attributable to differences between households. The main limitation of our study was that the test uptake for COVID-19 may have differed between population subgroups. CONCLUSIONS: Low household income appears to be a strong risk factor for both COVID-19 incidence and case severity, but the income differences are largely driven by having foreign background. The strong household clustering of incidence and severity highlights the importance of household context in the prevention and mitigation of COVID-19 outcomes.

Changes in parents' psychotropic medication use following child's cancer diagnosis: A fixed-effects register-study in Finland.

BACKGROUND: Symptoms of depression and anxiety are elevated among parents of children with cancer. However, knowledge of parents' psychotropic medication use following child's cancer diagnosis is scarce. METHODS: We use longitudinal Finnish register data on 3266 mothers and 2687 fathers whose child (aged 0-19) was diagnosed with cancer during 2000-2016. We record mothers' and fathers' psychotropic medication use (at least one annual purchase of anxiolytics, hypnotics, sedatives, or antidepressants) 5 years before and after the child's diagnosis and assess within-individual changes in medication use by time since diagnosis, cancer type, child's age, presence of siblings, and parent's living arrangements and education using linear probability models with the individual fixed-effects estimator. The fixed-effects models compare each parent's annual probability of psychotropic medication use after diagnosis to their annual probability of medication use during the 5-year period before the diagnosis. RESULTS: Psychotropic medication use was more common among mothers than fathers already before the child's diagnosis, 11.2% versus 7.3%. Immediately after diagnosis, psychotropic medication use increased by 6.0 (95% CI 4.8-7.2) percentage points among mothers and by 3.2 (CI 2.1-4.2) percentage points among fathers. Among fathers, medication use returned to pre-diagnosis level by the second year, except among those whose child was diagnosed with acute lymphoblastic leukemia or lymphoblastic lymphoma. Among mothers of children with a central nervous system cancer, medication use remained persistently elevated during the 5-year follow-up. For mothers with other under-aged children or whose diagnosed child was younger than 10 years, the return to pre-diagnosis level was also slow. CONCLUSIONS: Having a child with cancer clearly increases parents' psychotropic medication use. The increase is smaller and more short-lived among fathers, but among mothers its duration depends on both cancer type and family characteristics. Our results suggest that an increased care burden poses particular strain to the long-term mental well-being of mothers.

Socioeconomic differences in psychiatric treatment before and after self-harm: an observational study of 4,280 adolescents and young adults.

BACKGROUND: Individuals in higher socioeconomic positions tend to utilise more mental health care, especially specialist services, than those in lower positions. Whether these disparities in treatment exist among adolescents and young adults who self-harm is currently unknown. METHODS: The study is based on Finnish administrative register data on all individuals born 1986-1994. Adolescents and young adults with an episode of self-harm treated in specialised healthcare at ages 16-21 in 2002-2015 (n=4280, 64% female) were identified and followed 2 years before and after the episode. Probabilities of specialised psychiatric inpatient admissions and outpatient visits and purchases of psychotropic medication at different time points relative to self-harm were estimated using generalised estimation equations, multinomial models and cumulative averages. Socioeconomic differences were assessed based on parental education, controlling for income. RESULTS: An educational gradient in specialised treatment and prescription medication was observed, with the highest probabilities of treatment among the adolescents and young adults with the highest educated parents and lowest probabilities among those whose parents had basic education. These differences emerged mostly after self-harm. The probability to not receive any treatment, either in specialised healthcare or psychotropic medication, was highest among youth whose parents had a basic level of education (before self-harm 0.39, 95% CI 0.34-0.43, and after 0.29, 95% CI 0.25-0.33 after) and lowest among youth with higher tertiary educated parents (before self-harm: 0.22, 95% CI 0.18-0.26, and after 0.18, 95% CI 0.14-0.22). The largest differences were observed in inpatient care. CONCLUSIONS: The results suggest that specialised psychiatric care and psychotropic medication use are common among youth who self-harm, but a considerable proportion have no prior or subsequent specialised treatment. The children of parents with lower levels of education are likely to benefit from additional support in initiating and adhering to treatment after an episode of self-harm. Further research on the mechanisms underlying the educational gradient in psychiatric treatment is needed.