Health inequality in adolescence. Does stratification occur by familial social background, family affluence, or personal social position?

BACKGROUND: Two new sets of stratification indicators--family's material affluence and adolescent's personal social position- were compared with traditional indicators of familial social position based on parental occupation and education for their ability to detect health inequality among adolescents. METHODS: Survey data were collected in the Adolescent Health and Lifestyle Survey in 2003 from nationally representative samples of 12-, 14- and 16-year-old Finns (number of respondents 5394, response rate 71%). Indicators of the familial social position were father's socio-economic status, parents' education, parents' labour market position. Indicators of material affluence were number of cars, vacation travels, and computers in the family, own room and amount of weekly spending money. Adolescent's personal social position was measured as school performance. Measures of health were long-standing illness, overweight, use of mental health services, poor self-rated health and number of weekly health complaints. Ordinal logistic regression analysis was applied to study the associations between stratification indicators and health variables. RESULTS: All three groups of indicators of social stratification showed inequality in health, but the strongest associations were observed with the adolescent's personal social position. Health inequality was only partly identifiable by the traditional indicators of familial social position. The direction of the inequality was as expected when using the traditional indicators or personal social position: adolescents from higher social positions were healthier than those from lower positions. The indicators of family's material affluence showed mainly weak or no association with health and some of the indicators were inversely associated, although weakly. CONCLUSION: In addition to traditional indicators describing the socio-structural influences on the distribution of health among adolescents, indicators of family's material affluence should be further developed. Adolescents' personal social position should be included in the studies of health inequalities.

The effectiveness of tobacco sales ban to minors: the case of Finland.

OBJECTIVE: To evaluate the effects of the 1977 and 1995 tobacco sales bans on tobacco acquisition of minors. DESIGN: Biennial nationwide postal surveys (adolescent health and lifestyle survey, AHLS) in 1977-2003; annual classroom surveys (school health promotion survey, SHPS) in 1996-2003. SETTING AND PARTICIPANTS: Entire Finland-12, 14, 16, and 18 year olds (AHLS, n = 80 282); eighth and ninth graders (14-16 year olds) (SHPS, n = 226 681). MAIN OUTCOME MEASURES: Purchase of tobacco from commercial sources during the past month, purchase from different commercial (shop, kiosk, other outlet) and social sources, ease of buying tobacco, overall acquisition of tobacco products, daily smoking, tobacco experimenting. RESULTS: Decrease in tobacco purchase from commercial sources was small and short term after 1977 but large and permanent after 1995: purchase rate among 14 year old smokers diminished from 90% to 67% in 2003, 16 year olds from 94% to 62%. Purchases in shops decreased most (14 year olds: from 39% to 14%; 16 year olds: from 76% to 27%); purchases in kiosks less. An increase was observed in obtaining tobacco from other outlets and friends (social sources). Only 2-3% of 14-16 year old smokers used commercial sources exclusively when obtaining tobacco. Daily smoking began to decrease after 2001, following an earlier decrease in those experimenting. No changes were observed among age groups not targeted by the ban. CONCLUSIONS: Legislation appears to have permanently changed tobacco sales practices and decreased purchases from commercial sources. Social sources need to be taken into account when controlling access to tobacco. Sales bans should be accompanied by other health promotion measures.

Health behavior-based selection into educational tracks starts in early adolescence.

Health behaviors and educational tracks of an individual are here presumed to have a strengthening influence on each other during the developmental process, through which individuals gradually reach their adult health and social position. This longitudinal study of a Finnish nationally representative sample of 12 year olds born in 1970 (N = 1009) examined the associations of health behaviors at ages 12 and 14 with educational track at age 16. The dependent variable, educational track, classified the respondents into five successive categories, thought to predict their adult social position. Selection into different educational tracks according to health behaviors was obvious already at age 12, when frequency of tooth brushing, consumption of sweets, coffee drinking and level of participation in physical exercise predicted educational track independently of sociodemographic background. At age 14, the independent predictors were smoking, frequency of tooth brushing and coffee drinking. At both ages, sociodemographic factors had independent associations with educational track. It seems that certain health-related behaviors in early adolescence are indicators of a person's possibilities to benefit from a country's educational supply. Both sociodemographic background and health-related behaviors influence the process of selection into educational tracks leading to social position and health in adulthood.

Health-related lifestyle in adolescence--origin of social class differences in health?

Survey data collected by mail, representing Finnish 16 year olds (N = 2977; response rate 83%), were used to identify which particular aspects of lifestyle are typical of adolescents who select various educational tracks and, thus, have different probabilities of ending up in low or high social positions. The dependent variable, educational track, was formed by classifying the respondents into five successive categories predicting their social position in adulthood. Lifestyle is measured by health behaviours, leisure-time activities and social relations. The probability of belonging to educational tracks with good social prospects in adulthood was high among adolescents who placed much emphasis on health-enhancing behaviours (not smoking, physical exercise, low milk-fat diet, dental hygiene, use of seatbelts, etc.), who did not spend much time watching TV or listening to music and who attended church or other religious meetings weekly. Health-related lifestyle, at the age of 16, is oriented towards the social group the individual is likely to belong to as an adult. The study provides evidence for a strong association between health-related lifestyle and educational track in adolescence.

Social mobility and health related behaviours in young people.

STUDY OBJECTIVE: To assess the influences related to social mobility, particularly health related behaviours, as one potential explanation for the social class variation in health among adults. DESIGN: The study is based on questionnaire data from the Adolescent Health and Lifestyle Surveys of 1985, 1987, and 1989. SETTING: The whole of Finland. PARTICIPANTS: A representative sample of 8355 adolescents. The response rate was 79%. MEASUREMENT AND MAIN RESULTS: The relation between social mobility and health related behaviours among 16 and 18 year old young people was studied. The measure of social mobility was based on a combination of the social class of origin and achieved social position measured by the present educational status, educational attainment, and labour market position. Three mobility groups were constructed: the downwardly mobile, the upwardly mobile and the stable. Health related behaviours in an upwardly or downwardly mobile group were compared with a stable group from the same social class of origin by calculating relative risks (RR). RRs were assessed by calculating age and sex adjusted rate ratios approximating a Mantel-Haenszel estimate. In logistic regression analyses the independent effects of the social class of origin and the achieved social position were investigated. Most of the nine behaviours studied (smoking, alcohol use, heavy intoxication, coffee drinking, tooth brushing, consumption of sweets, lack of physical exercise, choice of bread spread, and consumption of milk) were related to the direction of mobility so that health compromising behaviours were more frequent among downwardly mobile and less frequent among upwardly mobile young people than their stable peers. Achieved social position proved to determine health related behaviours more strongly than class of origin, thus emphasising the way education facilitates both health values and behaviours as well as the future social position. CONCLUSIONS: The close relation between social mobility and health related behaviours is concluded to be a part of an explanation of social class differences in health observed among adults.

Diminishing regional contrasts? The east-west-divide in health behaviour among Finnish adolescents.

We studied whether differences in health behaviour between Eastern and Western Finland have changed between 1977 and 1993 and whether adjusting for socio-economic characteristics changes the relationship between region and health behaviour. The Adolescent Health and Life-style Survey data have been collected biannually by mailed questionnaires from nationally representative samples of 16- and 18-year-olds (n = 27,785). The response rate varied from 79 to 83% by year. According to logistic regression analyses, smoking and physical activity were as prevalent and changes over time similar in both regions. In alcohol, high fat milk and female butter use the East-West-difference persisted over time. Regional differences were mainly explained by socio-economic variation between the two regions.

Urban small area variation in adolescents' health behaviour.

Our previous study indicated that region plays a relatively small role in adolescents' health behaviour. Here, the regional patterning of health behaviour is studied further by shifting the focus to small areas. First, we test whether small area socioeconomic, demographic and housing characteristics correlate with health behaviour. The analysis then turns to the relationship between these characteristics and their individual level correlates. We wish to ascertain if behaviour is related to small area characteristics similarly for both genders and for adolescents' socioeconomic characteristics. The Adolescent Health and Lifestyle Survey data from 1989-1995 (16- and 18-year-olds, n = 1048, response rate 71%) were linked with data describing 33 subareas of Helsinki, the capital of Finland. Smoking, alcohol use, abstention from dietary fat and physical activity were used as lifestyle indicators. Gender apparently influences the extent to which the area plays a role. Logistic regression demonstrated that prolonged unemployment predicted low prevalence of abstention from dietary fat (traditional dietary patterns) among girls and heavy drinking among boys. High total rate of unemployment predicted lower physical activity among girls. Also owner-occupied housing correlated positively with girls' physical activity. Although the individual level socioeconomic characteristics were not as strongly related to health behaviour as the small area factors, a low level of education predicted smoking and alcohol use and, among girls, decreased physical activity. We conclude that small area characteristics, especially the level of unemployment of the area, may be even more strongly related to health behaviour than individual socioeconomic characteristics.

Sixteen-year-old oral contraceptive users in Finland, 1981-1993.

While adolescent fertility and abortion rates continue to decline in Finland, regional variations in teenage pregnancies persist, particularly among 16-17-year-olds. We studied differences in the use of oral contraceptives (OCs) among 16-year-old girls according to sociodemographic variables between 1981 and 1993. Questionnaires were mailed to national samples (N = 462-1594) of 16-year-old girls biannually, giving response rates ranging from 86% to 91% (the Adolescent Health and Lifestyle Survey). The increasing trend in OC use levelled off in 1989 at around 17-19%. OC use was most frequent in the lower socioeconomic groups, least frequent in the rural areas, but did not vary significantly according to region of the country. The pace of adopting OCs did not vary across the socioeconomic groups or regions. The socioeconomic and regional distributions of OC use were consistent with previous studies on teenage sexual activity. The results suggest equal accessibility of family planning services; regional variation in pregnancy rates cannot be explained by unequal distribution of OC use.

Asthma and allergic rhinitis among Finnish adolescents in 1977-1991.

OBJECTIVES: To study whether asthma and allergic rhinitis had increased from 1977 to 1991 and if so, in which subpopulations; to study if structural changes of the society or change in the genetic susceptibility of the population could explain the increase. DESIGN: Cross-sectional surveys with mailed questionnaires in 1977, 1979 and 1991, data from 1977 and 1979 combined; national mortality statistics. SETTING: Finland. SUBJECTS: A nationwide sample of 12-, 14-, 16- and 18- year-olds. Sample sizes were 4335 and 3059, response rates 88% and 77%. Mortality statistics from 1958 to 1990. MAIN OUTCOME MEASURES: Point prevalence rate (%) of self-reported, physician-diagnosed asthma and allergic rhinitis, susceptibility of the population measured by probability of respiratory death. RESULTS: Prevalence of asthma was 1.0% in 1977-1979 and 2.8% in 1991, that of allergic rhinitis 5.0% and 14.9%. Logistic regression analysis showed that the increase did not differ in socio-demographic subgroups or parents' smoking groups and that changes in the distribution of socio-demographic variables did not explain the difference either. Respiratory deaths in ages 0-4 were fewer in the birth cohorts measured in 1991. CONCLUSIONS: Physician-diagnosed asthma and allergic rhinitis increased three-fold among Finnish adolescents in 1977-1991. Factors which explain the increase affected all subgroups similarly. Such factors could be changes in diagnostic practices and indoor air quality. Increased susceptibility could explain only a small part. It is likely that a major part of this considerable increase is real.

Modernization and smoking--regional differences in adolescent smoking in Finland in 1977-1987.

The purpose of the study was to test the applicability of the modernization framework to changes and regional diversity in adolescent smoking. A biannual cross-sectional survey data from the Adolescent Health and Lifestyle Survey was used. A national sample of 14, 16- and 18-year-old Finns answered a mailed questionnaire every other year from 1977. The 1977, 1979 and 1981 data were pooled as were data from 1983 and 1985 (N = 8505, 9777). The 1987 sample was weighted in accordance with the province size (N = 11,374). Modernization trends found in the literature were apparent among adolescent smokers between 1977 and 1987. The use of hand-rolled cigarettes nearly stopped when the use of manufactured cigarettes increased. The use of low-tar cigarettes increased and that of other tobacco types decreased. Regional differences in tobacco types were associated with the structural modernization level of the regions. Snuff use was most prevalent in the most modern and the most traditional regions. The modernization framework proved useful in explaining changes in smoking.

Towards an equal distribution of health? Socioeconomic and regional differences of the secular trend of the age of menarche in Finland from 1979 to 1989.

The purpose of this study was to investigate if a secular trend towards an earlier age of menarche still existed in Finland in the 1980s and if social class and regional differences observed previously in the mean age of menarche had disappeared. Questionnaires were mailed to nationwide representative samples of 16- and 18-year-old girls every other year from 1979 to 1989. At the national level, the secular trend towards an earlier menarche was not observed in the 1980s but the trend was significant among girls living in the North-West and rural areas. Clearly observed regional and urban-rural differences in 1979 disappeared in the 1980s. Social class differences persisted: farmers' daughters had a higher mean age of menarche than those of other occupational groups. Adolescents in the 1980s displayed a more even distribution of health than the cohorts born before them. Improved welfare of the Finnish society and reorganization of the primary health care are probable explanations.

The effects of tobacco sales promotion on initiation of smoking--experiences from Finland and Norway.

Norway and Finland were among the first countries to adopt a total ban on tobacco sales promotion. Such legislation came into force in Norway and Finland in 1975 and 1978 respectively. These two countries are sometimes referred to as illustrations that such legislation has been successfully used as a means to reduce tobacco consumption. Tobacco industry spokesmen seem to interpret available evidence in the opposite way and maintain that the prohibition has not contributed to reducing the use of tobacco. Among the publications referred to and misused by tobacco industry spokesmen are publications from the authors of the present report. The effects of a ban on advertising can only be properly examined after describing a reasonable conceptual model. Such a model has to take into account (i) other social and cultural predictors of smoking, (ii) tobacco sales promotion in the contexts of all other mass communication, (iii) control measures other than a ban, and (iv) the degree of success in implementing the ban on advertising. Like any other kind of mass communication tobacco advertising influences the individual in a rather complex way. Behaviour change may be regarded as the outcome of an interpersonal and intrapersonal process. Social science research on tobacco advertising and the effects of banning such advertising has a short history, most studies having been carried out in the late 1980s. After examining available evidence related to the effects of tobacco advertising on the smoking habits of adolescents we conclude as follows: the few scientifically valid reports available today give both theoretical and empirical evidence for a causal relationship. Tobacco sales promotion seems both to promote and to reinforce smoking among young people. The dynamic tobacco market represented by children and adolescents is probably the main target of tobacco sales promotion. In Finland, there have been few studies explicitly addressing the causal links between tobacco sales promotion and the smoking habits of adolescents. In Norway, no such studies have been carried out. If we examine the changes in the use of tobacco over time, the data available do not lend support to the conclusions drawn by the tobacco industry spokesmen. In Norway the prevalence of daily smokers was higher in 1975, when the ban on tobacco advertising came into force than either before or after. The strongest decrease in the prevalence of daily smokers took place during the first five-year period after the ban was introduced.(ABSTRACT TRUNCATED AT 400 WORDS)

Use of oral contraceptives by adolescents and its consequences in Finland 1981-91.

OBJECTIVES: To study use of oral contraceptives among Finnish teenagers during 1981-91 and how abortions, childbirths, sexually transmitted diseases, and cardiovascular diseases changed during this period. DESIGN: Biannual cross sectional surveys with mailed questionnaires from 1981 onwards and analysis of national statistics. SETTING: Finland. SUBJECTS: A nationwide sample of 14, 16, and 18 year olds. Sample size varied from 1249 to 3887 and response rate from 85% to 94%. MAIN OUTCOME MEASURES: Proportion taking oral contraceptive, fertility and abortion rates, hospital discharge rates, rates of sexually transmitted diseases. RESULTS: The proportion of teenagers taking oral contraceptives increased steadily. In 1991 the percentages among 14, 16, and 18 year olds were 2%, 18%, and 41% compared with 0.2%, 7% and 22% in 1981. Most users had a steady partner (80% of 16 year olds and 85% of 18 year olds). By 1989 rates of abortion had fallen from 12/1000 to 9.3/1000 in 16 year olds and from 25/1000 to 19.2/1000 in 18 year olds; fertility rates had fallen from 4.5/1000 to 2.3/1000 and from 23.5/1000 to 15.3/1000 respectively. Rates in 14 year olds fell only slightly. Gonorrhoea infection fell and HIV infection remained rare. Rates of hospital discharge after thromboembolic venous disease rose slightly. CONCLUSIONS: The increased use of oral contraceptives is the most likely explanation for decreasing abortion and fertility rates among teenagers. Increased reliance on the condom because of the threat of AIDS may increase unwanted pregnancies.

Mortality of doctors: do doctors benefit from their medical knowledge?

Official population and mortality statistics show that overall mortality of male doctors in Finland in 1971-80 was lower than that of all economically active men. Doctors had lower death rates from cardiovascular disease, tumours, other diseases, causes of death amenable to medical interventions, and accidents and violence, but not suicide. Except for tumours, mortality of male doctors was at the same level or higher than that of men in other professions. Risk of suicide was twice as high for male doctors as for other professions. The numbers of women doctors were too small for firm conclusions about their mortality to be drawn. It is concluded either that doctors do not use their professional knowledge and skills in a way that reduces their own mortality risk or that they are exposed to occupational hazards that cancel out such an effect. Possible hazards are more likely to be mental than physical or chemical.

Cancers of affluence: positive social class gradient and rising incidence trend in some cancer forms.

This study shows that, unlike most diseases, some cancer forms are more common in upper social classes. All cancer cases diagnosed in Finland in 1971-75 aged 30-69 and recorded in the Finnish Cancer Registry (n = 36,500) were linked to the file of the 1970 Population Census of Finland with data on socio-economic status and education. Cancers related to both high socio-economic status and high level of education in men were colon, prostate, testis, kidney and melanoma of the skin, and in women colon, breast, and corpus uteri. Since 1953, the incidence of all these cancers had been rising, although that of the testicular cancer had levelled off in the seventies.

Increased risk of respiratory symptoms in young smokers of low tar cigarettes.

The effect of cigarettes yielding less than 10 mg tar was investigated in a representative sample (n = 4729) of 16 and 18 year old Finns. The rate of response was 80%. Cough and phlegm were significantly increased in young people smoking low tar cigarettes. When more than nine cigarettes were smoked daily respiratory symptoms were 2.4-6.2 times more prevalent among those who smoked low tar cigarettes than among those who never smoked. No differences were found between the smokers of low tar and medium tar cigarettes (yielding tar 10-18 mg). These data disagree with the hypothesis that the new low tar brands of cigarettes are less likely to cause respiratory symptoms than the old medium tar brands.