List of publications followed by abstracts from these publications from the Northern Swedish Cohort

Doctoral theses (sorted by year) Hammarström, A. (1986). Youth unemployment and ill-health: results from a two year follow-up study. Solna and Sundbyberg, Karolinska Institute. The main objective of this study was to examine the social and medical consequences of youth unemployment. Therefore, a prospective study was started in 1981 including all 1083 pupils in the last year of compulsory school in the municipality of Luleå. The pupils were followed-up after two years. They were investigated with a comprehensive selfadministered questionnaire, as well as with studies of records and interviews with teachers and school nurses. The total non-participation rate in the study was less than one per cent. The main hypotheses of the study were the following: The most disfavoured socio-medical development was expected among those young people who became unemployed after compulsory school. Similar changes, though less pronounced were expected in a hidden unemployment group, defined as high school who would have who would have preferred to work than to study. The most favourable development was expected among the high school students who were motivated for their studies. The young people in youth Opportunity programmes (YOP) or work were not expected to improve their health because directly after school they were expected to become employed in the “worst” jobs. The following variables were studied: social background, school situation, social activity in clubs, degree of control, satisfaction, signs and symptoms of somatic, psychosomatic and psychological illness, utilization of health care services, absence due to illness and truancy, abuse of alcohol and narcotics, other health deteriorating behaviour and pessimism about the future. Most of the results in the study verified our hypothesis. A multivariate pathway statistical an analysis showed that exposure to unemployment was predictive of ill health and alcohol abuse, even after adjustment for several possible confounding factors. The conclusions of the study are the following: Even as early as in compulsory school, illness is unevenly distributed. On the whole, our theoretical model is verified. Lack of control in compulsory school has a probable causal effect on unemployment and also on certain dependent variables. Unemployment has a probable causal effect on the health symptoms and health deteriorating behaviour. Hidden unemployment has the same effects as unemployment but less pronounced. Our model suits better for girls than for boys. In two important respects our model is rejected: 1. with the tested variables we cannot predict which pupils will become unemployed and which pupils will get YOP or work 2. Girls in YOP improve their health and health behaviour Novo, M. (2000). Young and unemployed does the trade cycle matter for health? : a study of young men and women during times of prosperity and times of recession. Umeå, Umeå University. During the post-war period the Swedish labour market has been characterised by a high intensity of gainful employment in combination with low unemployment rates. At the beginning of the1990s a new trade cycle began, characterised by an economic recession and a sharp increase in unemployment. Young people are especially sensitive to unemployment, since several critical periods for human development occur in this age group. Although unemployment has been proved to cause ill health, recent studies question that these findings are relevant during an economic recession. The objective of this thesis was to analyse if and how the change of trade cycle influenced the health of young unemployed men and women. The population consisted of two groups of all pupils in grade nine in a middle-sized industrial Swedish town. They were surveyed five years later at the age of 21 in 1986 (the boom group, n=1 083), and in 1994 (the recession group, n=898) respectively. All participants were investigated with a comprehensive self-administered questionnaire (with 90 questions about working life, health and health behaviour, family situation and leisure time) as well as with register data. The non-response rate was 2 % in the boom group and 10 % in the recession group. The higher non-response rate in the recession group may have underestimated the alcohol consumption and poor psychological health among men. The experience of all types of unemployment status as well as studies was more frequent in the recession group, while fewer were in employment compared to the boom group. The unemployed men and women had most somatic and psychological symptoms in both the boom and the recession. The levels of ill health did not differ with the trade cycle. However, during the recession poorer health was found among students, as well as among women in work and in labour market programmes, compared to the boom. There was no obvious correlation between the trade cycle and health behaviour among the long-term unemployed either. An association between the length of unemployment and alcohol consumption was found in the boom group and also among women only in the recession group. Unemployment was associated with tobacco consumption, especially among women and during the boom. The decrease in the number of smokers during the recession followed the general decrease of smoking in society as a whole. Stronger selection into the labour market during the boom due to positive individual features was not confirmed. Negative selection, i.e. selection out of the labour market due to individual features was found among both men and women, and during both trade cycles. Lack of control, high demands, financial position, pessimism about the future and low level of education were found as moderating factors which negatively influence the health of young men and women. The gendered division of labour was discussed as a possible cause for the deteriorated health among women during recession. Thus, the trade cycle seemed to have no impact on the health of young unemployed men and women. On the other hand, high levels of unemployment in society correlated negatively with the health of especially women in the population as a whole. Reine, I. (2009). From young to adult : health consequences of unemployment from a gender perspective. Umeå, Umeå university. BACKGROUND: The point of departure in this thesis is that unemployment is a recognised determinant of health, which may vary between different ages and among men and women. Despite governmental policies to tackle unemployment and ease its effects on health, unemployment continues to be a growing public health problem. AIM: The objective of the thesis was to analyse, from a gender perspective, the relationships between ill health and unemployment as well as other unstable labour market positions in the transition from youth to adulthood. The aim of each paper was: I. Does the association between ill health and unemployment differ between young people and adults? II. Is the transition from an unstable labour market position to permanent paid job health-protective? III. Is participation in labour market programmes related to mental health? IV. What is the association between ill health among men and women and how could it be analysed with a gender relations theory? METHODS: The longitudinal study was carried out in Luleå a medium-sized industrial town in the Northern Sweden. The cohort, consisting of all 1083 pupils (506 girls and 577 boys) aged 16 who attended the last year of compulsory school in 1981, was followed up at the ages of 16, 18, 21 and 30. The response rates were high e.g. 96.4% at 14 years follow-up. The cohort was followed with extensive and well-validated questionnaires. Multivariate logistic regression was used in all papers, while propensity score matching was used in Paper III. RESULTS: Paper I. Health effects of long-term unemployment differed between young people and adults. Long-term unemployment was more related to psychological ill health and smoking in young people than in adults. Paper II. The results indicated that after controlling for gender as well as for an indicator of health-related selection, possible confounders and mediators transition from an unstable labour market position to permanent employment could be health-promoting. Paper III. No association was found between participation in active labour market programmes and psychological symptoms. Due to methodological shortages the results have to be interpreted with caution. Adjustment for either all background selection variables or the propensity score in multivariate logistic regression showed similar associations suggesting that propensity score could be used to adjust for background selection variables. Paper IV. A strong association between unemployment and suboptimal selfrated health among women and high alcohol consumption among men was found and a theory of structural relations was used to discuss the gendered patterns for ill health. CONCLUSION: The thesis indicated gendered patterns of relations between unemployment and the health outcomes, in the transition from youth to adulthood. The policy implications of my thesis are that full employment policies should be promoted to reduce the health inequalities associated with unemployment. Novak, M. (2010). Social inequity in health explanation from a life course and gender perspective. Umeå, Umeå university. BACKGROUND: A boy child born in a Gothenburg suburb has a life expectancy that is nine years shorter than that of another child just 23 km away, and among girls the difference is five years. There is no necessary biological reason to this observed difference. In fact, like life length, most diseases follow a social gradient, even in a country like Sweden where many believe there is no class inequity. This social inequity in health tells us that some of us are not achieving our potential in health or in life length compared to our more fortunate fellow citizens. AIM: This thesis attempts to explore the patterns of health inequities and the pathways by which health inequities develop from a life course and gender perspective. In particular focuses on the importance of material, behavioural, health related and psychosocial circumstances from adolescence to adulthood in explaining social inequity in musculoskeletal disorders (MSDs), obesity, smoking, and social mobility. METHOD: All four papers of this thesis were based on quantitative analyses of data from a 14-year follow-up study. The baseline survey was conducted in 1981 in Luleå, Sweden. The survey included all 16-year-old pupils born in 1965. A total of 1081 pupils (575 boys and 506 girls) were surveyed. They were followed up at ages 18, 21 and 30 years with comprehensive selfadministered questionnaires. The response rate was 96.5% throughout the 14-year follow-up. In addition to the questionnaires data, school records, and interviews with nurse and teachers’ were used. RESULTS: There were no class or gender differences in MSDs and in obesity during adolescence, but significantly more girls than boys were smokers. Class and gender differences had emerged when they reached adulthood with more women reporting to have MSDs but more men being overweight and obese. Women continued to be smokers at a higher rate than men through to adulthood. When an intersection between class and gender was considered, a more complex picture emerged. For example, not all women had higher prevalence of MSDs or smoked more than men, rather men with high socioeconomic position (SEP) had lower prevalences of MSDs and smoking than women with high SEP; and these high SEP women had lower prevalences than men with low SEP. The worst-off group was women with low SEP. The obesity pattern was quite the contrary, where women with high SEP had a lower prevalence of obesity than women with low SEP; and these low SEP women had a lower prevalence than men with high SEP. The worstoff group was men with low SEP. Regarding social mobility, health status (other than height in women) and ethnic background were not associated with mobility either for men or women. The results indicated that unequal distribution of material, psychosocial, health and health related behavioural factors during adolescence, young adulthood and adulthood accounted for the observed social gradients and social mobility. However, several factors from adolescence appeared to be more important for women while recent factors were more important for men. Important adolescent factors for social inequity and downward mobility were: unfavourable material circumstances defined as low SEP of parent, unemployed family member, and had no own room during upbringing; unfavourable psychosocial circumstances defined as parental divorce, poor contact with parents, being less liked in school, and low school control; and poor health related behaviour defined as smoking and physical inactivity. Among these factors, being less liked in school showed consistent association with all outcome measures of this thesis. Being less liked by the teachers and students was found to be more common among adolescents whose parents had low SEP. Men and women who were less liked in school during their adolescence were more likely as adults to be smokers, obese (only women), and downwardly mobile. The dominant adult life factor that contributed to class inequity in MSDs for men and women was physical heavy working conditions, which attributed to an estimated 46.9% (women) and 49.5% (men) of the increased risk in MSDs of the lower SEP group. High alcohol consumption among men with low SEP was an additional factor that contributed to class inequities in health and social mobility. CONCLUSION: Social patterning of health in this cohort was gendered and age specific depending on the outcome measures. Unfavourable school environment in early years had long lasting negative influence on later health, health behavior and SEP. The thesis supports the notion of accumulation of risk that social inequities in health occurs due to accumulation of multiple adverse circumstances among the lower SEP group throughout their life course. Schools should be used as a setting for interventions aimed at reducing socioeconomic inequities in health. The detailed policy implications for reduction of social inequities in health among men and women are discussed (page 61). Papers published/in press in international peer-reviewed journals (sorted by year) Hammarström, A., U. Janlert, et al. (1988). Youth unemployment and ill health: results from a 2year follow-up study. Soc Sci Med 26, 1025-1033. A prospective study was started in 1981, including all 1083 pupils in the last year of compulsory school in a municipality in the northern part of Sweden. All pupils were followed up after 2 years. They were investigated with a comprehensive selfadministered questionnaire as well as studies of records and interviews with teachers and school nurses. The total non-participation rate in the study was less than 1%. The main results of the study are the following: unemployment leads to increased psychosomatic and psychological symptoms, decreased social activities in clubs, increased abuse of alcohol and narcotics and increased utilization of health care services. The effects of unemployment are somewhat different among girls and among boys. Girls are more exposed to unemployment and unemployment also leads to more negative effects among them. Hidden unemployment has the same effects as unemployment but the effects are less pronounced. Janlert, U. and A. Hammarström (1992). Alcohol consumption among unemployed youths: results from a prospective study. Br J Addict 87, 703-714. A prospective study, including all 1083 pupils in the final year of compulsory schooling in a municipality in northern Sweden, was performed. Ninety-seven point nine per cent of the pupils were followed up after five years. They completed a comprehensive selfadministered questionnaire including questions on alcohol consumption. Among men a positive correlation between long-standing unemployment (greater than 20 weeks) and alcohol consumption at the beginning and at the end of the study, as well as the change in consumption during the follow-up period was seen. This correlation was still present when earlier alcohol consumption and socioeconomic variables were controlled for. In women there was a positive correlation between unemployment and the level of alcohol consumption, but a negative correlation between unemployment and change in consumption. When controlling for motherhood and alcohol intake at the start of the study the correlation turned positive. Unemployment among women did not seem to affect recruitment to the high consumption group. Our results support the suggestion that unemployment may be a risk indicator for increasing alcohol consumption among young people, particularly in young men. Hammarström, A. (1994). Health consequences of youth unemployment--review from a gender perspective. Soc Sci Med 38, 699-709. Current research is classified into different theoretical approaches, mainly economic deprivation theories, stress-related theories, gender theories and different psychological and sociological theories. The correlations between unemployment and ill-health are explained as a result of both selection and exposure. The societal consequences of youth unemployment have been studied in aggregate studies. The familial consequences is a neglected area, but there is evidence of increased illness as well as battering of wives and children. Almost all research has been focused on the individual and mainly on the psychological consequences. Consistent relationships are found between unemployment and minor psychological disorders. Few studies have included somatic health but the results indicate increased physiological illness, especially among unemployed girls. Increased health care consumption has been documented. There are evidence that unemployment is a risk indicator for both increasing alcohol consumption, particularly in young men. Unemployment is also associated with increased tobacco consumption, increased use of illicit drugs as well as deteriorated health behaviour. The mortality rate is significantly higher among unemployed young men and women, especially in suicides and accidents. Social consequences include increased risk of alienation, lack of financial resources, criminality and future exclusion from the labour market. As mediating factors social support, high employment rate, negative attitudes towards work and high possibility of control have been documented to have a protective effect on health. Research should now be directed towards more qualitative methods, based on theoretical models, in order to search for deeper mechanisms, mediating factors and explanatory theories of the unevenly distributed health in society, in which unemployment has been proved to be one important factor. Hammarström, A. and U. Janlert (1994). Unemployment and change of tobacco habits: a study of young people from 16 to 21 years of age. Addiction 89, 1691-1696. In a cohort study of 1080 pupils who were followed for 5 years from when they left compulsory school (from age 16 to age 21 years), smoking habits were found to correlate with unemployment among both boys and girls. Pupils who were smokers in school had a higher risk of becoming unemployed than non-smokers. Irrespective of early smoking, smoking habits developed more unfavourably among unemployed young people than among those with no unemployment during the period studied. The odds ratio of being a smoker at the age of 21 years when unemployed more than 20 weeks during the observation period, compared with those without or with short unemployment, was 2.44 for men and 3.45 for women. When adjusted for the influence of socio-economic background, education, economy and smoking habits at the start of the period, the odds ratio was 1.7 (95% CI 1.01-2.86) for men and 2.0 (1.13-3.53) for women. The adjusted odds ratio for increasing or starting smoking during the period was 1.5 (95% CI 0.892.56) for men and 2.0 (1.18-3.35) for women. No significant correlation was found between snuffing and unemployment. Thus, it seems that unemployment is a risk factor for development of tobacco smoking in young people, especially among women. Hammarström, A. and U. Janlert (1997). Unemployment and sexual risk-taking among adolescents. Scand J Soc Med 25, 266-270. Sexual risk-taking can lead to serious consequences. This study addressed the question of how sexual risk-taking was influenced by unemployment. A cohort of 1060 adolescents were followed from their last term in compulsory school and five years ahead until the age of 21. Sexual risk-taking, defined as unprotected intercourse without wishing to conceive, was studied with the help of a questionnaire at the beginning and at the end of the period. For men there was a positive correlation between the length of unemployment and increase in risk-taking during the period, but for women there was a (statistically non-significant) negative correlation. In a logistic regression analysis, having children also had a significant effect on increased risk-taking among men. Unemployment thus implies increased sexual risk-taking among adolescent men. Hammarström, A. and U. Janlert (1997). Nervous and depressive symptoms in a longitudinal study of youth unemployment--selection or exposure? J Adolesc 20, 293-305. One thousand and sixty young people were followed for 5 years from the last term of compulsory school. Unemployment correlated positively with changes in nervous complaints and depressive symptoms, even after controlling for initial psychological health and background factors. There were no pronounced gender differences. Qualitative methods were used to study mediating factors between unemployment and mental health, including lack of self-confidence, self-blame, stress, isolation, lack of control and