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SummaryPerceived health during adolescence has not only immediate consequences for individuals and for society, but also long-term. We need to understand better the health development in this period of the lifespan. Empowerment may be one pathway through which social factors and conditions translate into health effects. This study aimed to examine whether empowerment-enabling home and school environments are associated with self-rated health among adolescents, and whether the associations differ between genders, age or majority/minority language groups. Anonymous questionnaire data from respondents aged 11, 13 and 15 years were obtained from the Health Behaviour in School-aged Children study, conducted in Finland in 2014 in Finnish- and Swedish-speaking schools (n = 5925/1877). The proportion rating their health as excellent varied between 33.6 (11-year-olds) and 23.1% (15-year-olds), boys rating their health as excellent more often than girls in all age groups. Findings showed that indicators of both empowerment-enabling home and school environments were independently and positively related to adolescents’ self-rated health. Whereas a respectful, accepting, kind and helpful attitude among classmates and a good home atmosphere were quite consistently associated with excellent health, there were gender and age differences with concern to the other empowerment-enabling indicators. Moreover, there were gender-, age- and language-related differences regarding adolescents’ perceptions of how empowerment enabling their environments were. Home and school environments that create opportunities through encouragement and care, and through strengthening feelings of being secure, accepted and respected are potentially empowerment enabling. This study suggests that such environmental qualities are important for the perceived health of young people.

Background Declining participation rates in health examination surveys may impair the representativeness of surveys and introduce bias into the comparison of results between population groups if participation rates differ between them. Changes in the characteristics of non-participants over time may also limit comparability with earlier surveys. Methods We studied the association of socio-economic position with participation, and its changes over the past 25 years. Occupational class and educational level are used as indicators of socio-economic position. Data from six cross-sectional FINRISK surveys conducted between 1987 and 2012 in Finland were linked to national administrative registers, which allowed investigation of the differences between survey participants and non-participants. Results Our results show that individuals with low occupational class or low level of education were less likely to participate than individuals with high occupational class or high level of education. Participation rates decreased in all subgroups of the population but the decline was fastest among those with low level of education. Conclusions The differences in participation rates must be taken into account to avoid biased estimates because socio-economic position has also been shown to be strongly related to health, health behaviour and biological risk factors. Particular attention should be paid to the recruitment of the less-educated population groups. peerReviewed

The size of a person's social network is linked to health and longevity, but it is unclear whether the number of strong social ties or the number of weak social ties is most influential for health. We examined social network characteristics as predictors of mortality in the Finnish Public Sector Study (n = 7,617) and the Health and Social Support Study (n = 20,816). Social network characteristics were surveyed at baseline in 1998. Information about mortality was obtained from the Finnish National Death Registry. During a mean follow-up period of 16 years, participants with a small social network (≤10 members) were more likely to die than those with a large social network (≥21 members) (adjusted hazard ratio (HR) = 1.23, 95% confidence interval (CI): 1.04, 1.46). Mortality risk was increased among participants with both a small number of strong ties (≤2 members) and a small number of weak ties (≤5 members) (HR = 1.55, 95% CI: 1.26, 1.79) and among participants with both a large number of strong ties and a small number of weak ties (HR = 1.28, 95% CI: 1.08, 1.52), but not among those with a small number of strong ties and a large number of weak ties (HR = 1.04, 95% CI: 0.87, 1.25). These findings suggest that in terms of mortality risk, the number of weak ties may be an important component of social networks.

Sleep apnea is a common problem affecting daily functioning and health. We evaluated associations between sleep apnea and disability pension and mortality in a prospective study of 74,543 cases of sleep apnea (60,125 outpatient; 14,418 inpatient) from the Swedish Patient Register; 2000-2009 inclusive. Cases were matched to five non-cases (n = 371,592) and followed from diagnosis/inclusion via nationwide registers until Dec 31 2010. During a mean (standard deviation) follow-up of 5.1 (2.7) years, 13% men and 21% women with inpatient sleep apnea were disability pensioned. Inpatient sleep apnea was associated with higher total mortality (HR = 1.71; 95% CI: 1.59, 1.84 men; 2.33; 95% CI: 2.04, 2.67 women), with associations strongest for deaths due to ischemic heart disease (HR = 2.27; 95% CI:1.94, 2.65 men; 95% CI: 5.27; 3.78, 7.34 women), respiratory disorders (HR = 3.29; 95% CI: 2.45, 4.42 men; 5.24; 95% CI: 3.52, 7.81 women), and suicide (HR = 1.76; 95% CI: 1.19, 2.60 men; 4.33; 95% CI: 1.96, 9.56 women). There were no associations of inpatient sleep apnea with cancer mortality. Outpatient sleep apnea was associated with higher risk of disability pension, but not higher total mortality. In conclusion, inpatient sleep apnea is related to a higher risk of disability pension and mortality a decade after diagnosis.© The Author 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. Language: en

Background The child-oriented dietary intervention given in the prospective Special Turku Coronary Risk Factor Intervention Project (STRIP) has decreased the intake of saturated fat and lowered serum cholesterol concentration in children from infancy until early adulthood. In this study, we investigated whether the uniquely long-term child-oriented intervention has affected also secondarily parental diet and cardio-metabolic risk factors. Methods The STRIP study is a longitudinal, randomized infancy-onset atherosclerosis prevention trial continued from the child's age of 8 months to 20 years. The main aim was to modify the child's diet towards reduced intake of saturated fat. Parental dietary intake assessed by a one-day food record and cardio-metabolic risk factors were analysed between the child's ages of 9-19 years. Results Saturated fat intake of parents in the intervention group was lower [mothers: 12.0 versus 13.9 daily energy (E%), p 0.0001; fathers: 12.5 versus 13.9 E%, p 0.0001] and polyunsaturated fat intake was higher (mothers: 6.1 versus 5.4 E%, p 0.0001; fathers: 6.3 versus 5.9 E%, p = 0.0003) compared with the control parents. Maternal total and low-density lipoprotein cholesterol concentrations were lower in the intervention compared with the control group (mean ± SE 5.02 ± 0.04 versus 5.14 ± 0.04 mmol/l, p = 0.04 and 3.19 ± 0.04 versus 3.30 ± 0.03 mmol/l, p = 0.03, respectively). Paternal cholesterol values did not differ between the intervention and control groups. Other cardio-metabolic risk factors were similar in the study groups. Conclusions Child-oriented dietary intervention shifted the dietary fat intakes of parents closer to the recommendations and tended to decrease total and low-density lipoprotein cholesterol in the intervention mothers. Dietary intervention directed to children benefits also parents.

Background: Injury prevention is an important issue for police officers, but the effectiveness of prevention initiatives is dependent on officers’ motivation toward, and adherence to, recommended health and safety guidelines. Aims: To understand effects of police officers’ motivation to prevent occupational injury on beliefs about safety and adherence to injury prevention behaviours. Methods: Full-time police officers completed a survey comprising validated psychometric scales to assess autonomous, controlled and amotivated forms of motivation (Treatment Self-Regulation Questionnaire), behavioural adherence (Self-reported Treatment Adherence Scale) and beliefs (Safety Attitude Questionnaire) with respect to injury prevention behaviours. Results: There were 207 participants; response rate was 87%. Hierarchical multiple regression analyses demonstrated that autonomous motivation was positively related to behavioural adherence, commitment to safety and prioritizing injury prevention. Controlled motivation was a positive predictor of safety communication barriers. Amotivation was positively associated with fatalism regarding injury prevention, safety violation and worry. Conclusions: These findings are consistent with the tenets of self-determination theory in that autonomous motivation was a positive predictor of adaptive safety beliefs and adherence to injury prevention behaviours.

We investigated how work-related biomechanical exposure and job strain in midlife separately and jointly predicted back and degenerative musculoskeletal diseases (MSDs). A total of 6,257 employees participated in the Finnish Longitudinal Study on Aging Municipal Employees (FLAME) in 1981 and were followed up for 28 years. Risk ratios and the relative excessive risk due to interaction and 95% confidence intervals were modeled for separate and joint prediction estimates, respectively. After adjustment for confounders, job strain predicted degenerative MSDs among women after 4 and 11 years of follow-up. After 11 years, both exposures predicted both types of MSDs among men. Joint exposure predicted both types of MSDs after 4 years among women (for back MSDs, risk ratio (RR) = 1.58, 95% confidence interval (CI): 1.15, 2.18; for degenerative MSDs, RR = 1.59, 95% CI: 1.21, 2.07) and men (for back MSDs, RR = 1.50, 95% CI: 1.05, 2.15; for degenerative MSDs, RR = 1.61, 95% CI: 1.16, 2.22) and both types of MSDs after 11 years (for back MSDs, RR = 1.72, 95% CI: 1.21, 2.43; for degenerative MSDs, RR = 1.68, 95% CI: 1.25, 2.46) among men only, but the relative excessive risk due to interaction was not significant throughout. However, after 28 years, the separate and joint exposures did not predict MSDs. Workplace interventions should be focused on reducing job strain along with biomechanical exposure for possible prevention of MSDs in working life and around the time of retirement, but there may be other pathways of onset of MSDs in old age.

Study objectives Impaired sleep has been linked to increased risk of cardiovascular disease (CVD), but the underlying mechanisms are still unsettled. We sought to determine how onset of impaired sleep affects the risk of established physiological CVD risk factors (i.e., hypertension, diabetes, and dyslipidemia). Methods In a longitudinal cohort study with 3 survey waves (2000, 2004, 2008) from the Finnish Public Sector study we used repeated information on sleep duration and disturbances to determine onset of impaired sleep. Information on development of CVD risk factors, as indicated by initiation of medication for hypertension, diabetes, and dyslipidemia was derived from electronic medical records within 8 years of follow-up. Data on 45,647 participants was structured as two data-cycles to examine the effect of change in sleep (between two waves) on incident CVD events. We applied strict inclusion and exclusion criteria to determine temporality between changes in sleep and the outcomes. Results While we did not find consistent effects of onset of short or long sleep, we found onset of disturbed sleep to predict subsequent risk of hypertension (hazard ratio = 1.22, 95% CI: 1.04-1.44) and dyslipidemia (HR = 1.17, 95% CI: 1.07-1.29) in fully adjusted analyses. Conclusions Results suggest that onset of sleep disturbances rather than short or long sleep mark an increase in physiological risk factors, which may partly explain the higher risk of CVD observed among impaired sleepers. Commentary A commentary on this paper appears in this issue on page 1629.

Background Health checks in occupational health (OH) care should prevent deterioration of work ability and promote well-being at work. Documentation of health checks should reflect and support continuity of prevention and practice. Aims To analyse how OH nurses (OHNs) undertaking health checks document psychosocial factors at work and use the Work Ability Index (WAI). Methods Analysis of two consecutive OHN health check records and WAI scores with statistical analyses and annotations of 13 psychosocial factors based on a publicly available standard on psychosocial risk management: British Standards Institution specification PAS 1010, part of European Council Directive 89/391/EEC, with a special focus on work-related stress and workplace violence. Results We analysed health check records for 196 employees. The most frequently documented psychosocial risk factors were home-work interface, work environment and equipment, job content, workload and work pace and work schedule. The correlations between the number of documented risk and non-risk factors and WAI scores were significant: OHNs documented more risk factors in employees with lower WAI scores. However, documented psychosocial risk factors were not followed up, and the OHNs' most common response to detected psychosocial risks was an appointment with a physician. Conclusions The number of psychosocial risk factors documented by OHNs correlated with subjects' WAI scores. However, the documentation was not systematic and the interventions were not always relevant. OHNs need a structure to document psychosocial factors and more guidance in how to use the documentation as a tool in their decision making in health checks.

Background: Smoking and physical inactivity are linked to mortality, but it is not known whether the association between smoking and mortality is affected by the amount and intensity of physical activity. We examined the joint associations of smoking and physical activity with mortality, while taking key covariates into account. Methods: We linked survey data, collected in 2000–2002 from among 40–60-year-old employees of the City of Helsinki, Finland, with complete register data on all-cause mortality from Statistics Finland ( n = 6390, 79% women, response rate 67%). Smoking, leisure-time physical activity and covariates (sociodemographic factors, problem drinking, body mass index and self-rated health) were measured at baseline. We fitted Cox regression models (hazard ratios, HR, 95% confidence intervals, CI), and the follow-up continued until the end of 2013. No gender interactions were found. Results: A total of 228 deaths occurred during the follow-up. Smokers were at an increased risk of mortality after full adjustments, but the risk was higher among inactive (HR 3.27, 95% CI 2.05–5.22) and moderately active smokers (HR 2.37, 95% CI 1.49–3.79) than among vigorously active non-smokers. The excess risk for vigorously active smokers, or for inactive or moderately active non-smokers, could not be confirmed. Conclusion : The highest mortality risk was found among physically inactive or moderately active smokers. Prevention of smoking and engaging in vigorous physical inactivity among smokers might prevent mortality during working age.

Objectives Hearing loss is a common health concern in older people, and the prevalence of hearing loss increases with aging. Poor hearing may cause difficulties in everyday life situations and reduce quality of life (QoL). The aim of this study was to assess the associations between different domains of QoL (physical, psychological, social, and environmental), perceived hearing difficulties in various everyday situations, and audiometrically measured hearing level among community-dwelling older adults. Method Cross-sectional analysis of 76- to 91-year-old community-dwelling adults. Data on QoL (WHO Quality of Life Assessment short version) and perceived hearing difficulties were gathered via postal questionnaires (n = 706) and screening pure-tone audiometry was performed at the participants' homes for a random subsample (n = 161). Data were analyzed with linear regression models. Results Factor analysis on the perceived hearing difficulties questionnaire identified three dimensions: speech hearing, socioemotional effects, and spatial hearing. All the perceived hearing difficulty factors, but not the pure-tone audiometry results, were significantly associated with poorer values in all the QoL domains and the total QoL score. Discussion Perceived hearing difficulties in various everyday life situations are more strongly associated with older adults' QoL than audiometrically assessed hearing impairment.

Background Our aim was to study the relationship between objectively measured physical activity and subsequent changes in life-space mobility over 2 years among older people. Life-space mobility refers to the area a person moves through in daily life, taking into account frequency, and need of assistance. Life-space mobility and physical activity correlate, but whether different intensities of objectively assessed physical activity predicts decline in life-space mobility is not known. Methods Prospective cohort study of the "Life-space Mobility in Old Age" (LISPE) project accelerometer substudy. Participants were community-dwelling older people aged 75-90 (n = 164). Life-space mobility was measured with the Life-Space Assessment at baseline face-to-face home interview and telephone follow-up interviews 1 and 2 years after baseline. Physical activity (step count and time spent in moderate activity, low activity, and sedentary behavior) was measured by a tri-axial accelerometer (Hookie "AM20 Activity Meter") for 7 days at baseline. Generalized estimating equations (GEE models) were used to compare changes in life-space mobility between participants categorized according to the baseline physical activity measures. Results Median age of the participants was 79.5 (IQR 6.7) and 64% were women. Over the 2 years, life-space mobility declined significantly among those with lower step counts and less time spent in moderate activity measured at baseline. Time spent in low activity and sedentary behavior did not predict changes in life-space mobility. Conclusions In old age, more time spent walking outdoors and accumulation of moderate-intensity physical activity may help to maintain higher life-space mobility, a correlate of good quality of life.

Background: We investigated the stability and change of leisure-time physical inactivity in adult men and women during a 35-year follow-up. We also analysed the impact of long-term physical inactivity on the development of body mass index (BMI). Methods: In this population-based cohort study, 5254 Finnish twin individuals (59% women) participated in four surveys in 1975, 1981, 1990 and 2011. Mean age at baseline was 23.9 years. Individual long-term leisure-time physical activity (LTPA) was categorized into seven classes varying from 'persistently inactive' to 'persistently active'. We used the multivariate multilevel mixed-effects linear regression model and paired-sample t-test in the analyses. Co-twin control design was used for examining within-pair associations. Results: Of men 11%, and of women 8%, were persistently inactive. Among both sexes, the mean BMI slope trajectories were steeper among the persistently inactive and those who became inactive than among those who were persistently active. Overall, the inactive participants gained 1.4 kg/m(2) [95% confidence interval (CI) 1.2 to 1.7] more in weight than did the active participants from 1975 to 2011. Among twin pairs discordant for LTPA, the corresponding difference was 1.4 kg/m(2) (95% CI 0.83 to 2.0) in dizygotic pairs and 0.68 kg/m(2) (95% CI 0.05 to1.3) in monozygotic pairs. Conclusions: Over a 35-year time span from young adulthood, persistently inactive participants and those who had become inactive had greater weight increases than those who were persistently active. This association was also found in twin-pair analyses, although attenuated in monozygotic pairs. This may support the importance of LTPA in weight management, although further causal inference is required.

Background The aim was to investigate the relationship between self-rated health (SRH) in healthy midlife, mortality, and frailty in old age. Methods In 1974, male volunteers for a primary prevention trial in the Helsinki Businessmen Study (mean age 47 years, n = 1,753) reported SRH using a five-step scale (1 = "very good," n = 124; 2 = "fairly good," n = 862; 3 = "average," n = 706; 4 = "fairly poor," or 5 = "very poor"; in the analyses, 4 and 5 were combined as "poor", n = 61). In 2000 (mean age 73 years), the survivors were assessed using a questionnaire including the RAND-36/SF-36 health-related quality of life instrument. Simplified self-reported criteria were used to define phenotypic prefrailty and frailty. Mortality was retrieved from national registers. Results During the 26-year follow-up, 410 men had died. Frailty status was assessed in 81.0% (n = 1,088) of survivors: 434 (39.9%), 552 (50.7%), and 102 (9.4%) were classified as not frail, prefrail, and frail, respectively. With fairly good SRH as reference, and adjusted for cardiovascular risk in midlife and comorbidity in old age, midlife SRH was related to mortality in a J-shaped fashion: significant increase with both very good and poor SRH. In similar analyses, average SRH in midlife (n = 425) was related to prefrailty (odds ratio: 1.52, 95% confidence interval: 1.14-2.04) and poor SRH (n = 31) both to prefrailty (odds ratio: 3.56, 95% confidence interval: 1.16-10.9) and frailty (odds ratio: 8.38, 95% confidence interval: 2.32-30.3) in old age. Conclusions SRH in clinically healthy midlife among volunteers of a primary prevention trial was related to the development of both prefrailty and frailty in old age, independent of baseline cardiovascular risk and later comorbidity.

INTRODUCTION Socioeconomic differences in smoking over time and across national contexts are poorly understood. We assessed the magnitude of relative and absolute social class differences in smoking in cohorts from Britain, Finland, and Japan over 5-7 years. METHODS The British Whitehall II study (n = 4350), Finnish Helsinki Health Study (n = 6328), and Japanese Civil Servants Study (n = 1993) all included employed men and women aged 35-68 at baseline in 1997-2002. Follow-up was in 2003-2007 (mean follow-up 5.1, 6.5, and 3.6 years, respectively). Occupational social class (managers, professionals and clerical employees) was measured at baseline. Current smoking and covariates (age, marital status, body mass index, and self-rated health) were measured at baseline and follow-up. We assessed relative social class differences using the Relative Index of Inequality and absolute differences using the Slope Index of Inequality. RESULTS Social class differences in smoking were found in Britain and Finland, but not in Japan. Age-adjusted relative differences at baseline ranged from Relative Index of Inequality 3.08 (95% confidence interval 1.99-4.78) among Finnish men to 2.32 (1.24-4.32) among British women, with differences at follow-up greater by 8%-58%. Absolute differences remained stable and varied from Slope Index of Inequality 0.27 (0.15-0.40) among Finnish men to 0.10 (0.03-0.16) among British women. Further adjustment for covariates had modest effects on inequality indices. CONCLUSIONS Large social class differences in smoking persisted among British and Finnish men and women, with widening tendencies in relative differences over time. No differences could be confirmed among Japanese men or women. IMPLICATIONS Changes over time in social class differences in smoking are poorly understood across countries. Our study focused on employees from Britain, Finland and Japan, and found relative and absolute and class differences among British and Finnish men and women. Key covariates had modest effects on the differences. Relative differences tended to widen over the 4- to 7-year follow-up, whereas absolute differences remained stable. In contrast, class differences in smoking among Japanese men or women were not found. Britain and Finland are at the late stage of the smoking epidemic model, whereas Japan may not follow the same model.

Introduction: People with severe mental illness have increased risk for premature mortality and thus a shorter life expectancy. Relative death rates are used to show the excess mortality among patients with mental health disorder but cannot be used for the comparisons by country, region and time. Methods: A population-based register study including all Swedish patients in adult psychiatry admitted to hospital with a main diagnosis of schizophrenia, bipolar or unipolar mood disorder in 1987–2010 (614 035 person-years). Mortality rates adjusted for age, sex and period were calculated using direct standardization methods with the 2010 Swedish population as standard. Data on all residents aged 15 years or older were used as the comparison group. Results: Patients with severe mental health disorders had a 3-fold mortality compared to general population. All-cause mortality decreased by 9% for people with bipolar mood disorder and by 26–27% for people with schizophrenia or unipolar mood disorder, while the decline in the general population was 30%. Also mortality from diseases of the circulatory system declined less for people with severe mental disorder (−35% to − 42%) than for general population (−49%). The pattern was similar for other cardiovascular deaths excluding cerebrovascular deaths for which the rate declined among people with schizophrenia (−30%) and unipolar mood disorder (−41%), unlike for people with bipolar mood disorder (−3%). Conclusions: People with mental health disorder have still elevated mortality. The mortality declined faster for general population than for psychiatric patients. More detailed analysis is needed to reveal causes-of-death with largest possibilities for improvement.

BACKGROUND: Research studies exploring the determinants of disease require sufficient statistical power to detect meaningful effects. Sample size is often increased through centralized pooling of disparately located datasets, though ethical, privacy and data ownership issues can often hamper this process. Methods that facilitate the sharing of research data that are sympathetic with these issues and which allow flexible and detailed statistical analyses are therefore in critical need. We have created a software platform for the Virtual Pooling and Analysis of Research data (ViPAR), which employs free and open source methods to provide researchers with a web-based platform to analyse datasets housed in disparate locations.METHODS: Database federation permits controlled access to remotely located datasets from a central location. The Secure Shell protocol allows data to be securely exchanged between devices over an insecure network. ViPAR combines these free technologies into a solution that facilitates 'virtual pooling' where data can be temporarily pooled into computer memory and made available for analysis without the need for permanent central storage.RESULTS: Within the ViPAR infrastructure, remote sites manage their own harmonized research dataset in a database hosted at their site, while a central server hosts the data federation component and a secure analysis portal. When an analysis is initiated, requested data are retrieved from each remote site and virtually pooled at the central site. The data are then analysed by statistical software and, on completion, results of the analysis are returned to the user and the virtually pooled data are removed from memory.CONCLUSIONS: ViPAR is a secure, flexible and powerful analysis platform built on open source technology that is currently in use by large international consortia, and is made publicly available at [http://bioinformatics.childhealthresearch.org.au/software/vipar/].

Background It has been shown that higher education associates with health outcomes, but the less is known about the specific mechanisms mediating this association. We examined whether higher education would associate with long-term health transitions from childhood to adulthood and whether health behaviors, self-esteem, social support and work-related health hazards could mediate or confound this association. Methods The participants were from a population-based sample of 3596 men and women from the Young Finns study aged 3‐18 years at the beginning of the study in 1980, and who responded to repeated surveys of educational attainment and self-rated health in four study phases from 1997 to 2012. The associations were tested using multistate Markov models for the health-state transition intensities. Results Our results suggested that a 1-year difference in education was related to a 16% higher transition probability from mediocre to good self-rated health over the 5-year follow-up. Depressive symptoms and job strain seemed to partly mediate or confound the association, but self-esteem and social support did not. Conclusions These results suggest that educational attainment is associated with good self-rated health transitions from childhood to adulthood, and multiple processes rather than a single underlying mechanism are likely to drive the educational differences in self-rated health.

BACKGROUND Changes in health-related behaviour may be a key mechanism linking impaired sleep to poor health, but evidence on this is limited. In this study, we analysed observational data to determine whether onset of impaired sleep is followed by changes in health-related behaviours. METHODS We used data from 37,508 adults from the longitudinal Finnish Public Sector Study. In analysis of 59 152 person-observations on duration and quality of sleep and health-related behaviours (alcohol consumption, smoking, physical activity and weight control), data were treated as a series of non-randomized pseudo-trials with strict predefined criteria for data inclusion and temporality. RESULTS Smokers who experienced onset of short sleep were less likely to quit smoking than those with persistent normal sleep [odds ratio (OR) = 0.78, 95% confidence interval (CI): 0.64-0.97]. Onset of short sleep also predicted initiating high-risk alcohol consumption (OR = 1.17, 95% CI: 1.00-1.37). Onset of disturbed sleep was associated with changes in all assessed health-related behaviours: initiation of high-risk alcohol consumption (OR = 1.23, 95% CI: 1.05-1.45), quitting smoking (OR = 0.80, 95% CI: 0.63-1.00), becoming physically inactive (OR = 1.17, 95% CI: 1.06-1.30) and becoming overweight or obese (OR = 1.12, 95% CI: 1.01-1.23). CONCLUSIONS Findings suggest that the onset of short or disturbed sleep are risk factors for adverse changes in health-related behaviours. These findings highlight potential pathways linking impaired sleep to the development of lifestyle-related morbidity and mortality.

Background: Health complaints are a good indicator of an individual’s psychosocial health and well-being. Studies have shown that children and adolescents report health complaints which can cause significant individual burden.Methods:Using data from the international Health Behaviour in School-aged Children study, this article describes trends in multiple recurrent health complaints (MHC) in 35 countries amongN= 237 136 fifteen-year-olds from 1994 to 2010. MHC was defined as the presence of two or more health complaints at least once a week. Logistic regression analysis was performed to evaluate trends across the five survey cycles for each country.Results:Lowest prevalence throughout the period 1994–2010 was 16.9% in 1998 in Austria and highest in 2006 in Israel (54.7%). Overall, six different trend patterns could be identified: No linear or quadratic trend (9 countries), linear decrease (7 countries), linear increase (5 countries), U-shape (4 countries), inverted U-shape (6 countries) and unstable (4 countries).Conclusion: Trend analyses are valuable in providing hints about developments in populations as well as for benchmarking and evaluation purposes. The high variation in health complaints between the countries requires further investigation, but may also reflect the subjective nature of health complaints.

Background: For maintaining good oral health, twice-a-day toothbrushing routine is recommended world-wide. As an association between oral diseases and the main non-communicable diseases is confirmed, the importance of brushing is rising. The aim of this article is to describe trends in more-than-once-a-day toothbrushing frequency in 20 countries/regions participating in five consecutive HBSC Surveys between 1994 and 2010. Methods: Eleven-, 13-, and 15-year-old children, who replied to the questionnaire in any of the five surveys, were included ( N = 474 760). Trends were analysed by logistic regression and multilevel logistic regression modelling. Results: Prevalence of recommended toothbrushing behaviour increased in all countries except in Scandinavia, which had already attained a very high level in 1994. The highest increase (more than + 16%) was observed in Estonia, Russia, Latvia, Finland and in Flemish Belgium. Girls had higher prevalence of toothbrushing than boys (OR = 2.06, 99% CI 2.03–2.10). However, the increasing trend was stronger among boys (OR2010 vs. 1994 for boys 1.60; for girls 1.48), and among the younger adolescents (OR2010 vs. 1994 for 11-year-olds 1.64; for 15-year-olds 1.45). Conclusion: Recommended toothbrushing frequency increased in most of the studied countries/regions and differences between the countries diminished during 2004–2010.

The aim of the study was to assess occupational exposure to bisphenol A in Finland. Five companies took part in the research project: two paint factories (liquid and powder paints), a composite product factory, a thermal paper factory, and a tractor factory. Exposure was assessed by measuring total bisphenol A excretion (free and conjugated) from urine samples, and its concentrations in the air. The results revealed the specific work tasks in two of five companies in which significant occupational exposure to bisphenol A may occur. In the manufacturing of liquid paint hardener, urine samples collected after the working day showed bisphenol A levels of up to 100-170 µg l-1. Workers in thermal paper manufacturing were also exposed to bisphenol A, especially those working in the manufacture of coating material and operating coating machines. Median concentrations of the post-shift urine samples of coating machine workers were in the range of 130-250 µg l-1. The highest bisphenol A concentrations were in the range of 1000-1500 µg l-1. Recommendations for more effective personal protection resulted in decreased exposure, particularly among coating machine operators. In the rest of the companies, urinary bisphenol A levels were typically in the range of those of the general population. Bisphenol A concentrations in air samples were typically low (

Background. The number of diseases and physical functioning difficulties tend to increase with age. The aim of this study was to examine the trajectories of physical functioning across age groups and whether the trajectories differ according to disease status in different population subgroups. Methods. Repeat data from a nationally representative population sample, the Health and Retirement Study, was used. Participants were 10,709 men and 13,477 women aged 60–107 years at baseline with biennial surveys from 1992 to 2010. Average length of follow-up was 10.3 years ranging from 0 to 18 years. Disease status and physical functioning was asked about at all study phases and 10 items were summed to obtain a physical functioning score (0–10). Results. Age modified the relationship between number of chronic diseases and physical functioning with older participants having more physical functioning difficulties with increasing number of diseases. An average 70-year-old participant with no diseases had 0.89 (95% CI: 0.85–0.93) physical functioning difficulties, with one disease 1.72 (95% CI: 1.69–1.76) difficulties, with two diseases 2.57 (95% CI: 2.52–2.62) difficulties, and with three or more diseases 3.82 (95% CI: 3.76–3.88) difficulties. Of the individual diseases memory-related diseases, stroke, pulmonary diseases, and arthritis were associated with significantly higher physical functioning difficulties compared with other diseases. Conclusions. Comorbidity is associated with greater burden of physical functioning difficulties. Of the studied diseases, memory-related diseases, stroke, pulmonary diseases, and arthritis alone or in combination limit most physical functioning.

Background: Mental ill-health, particularly depression and anxiety, is a leading and increasing cause of disability worldwide, especially for women. Methods: We examined the prospective association between physical activity and symptoms of mental ill-health in younger, mid-life and older working women. Participants were 26 913 women from the ongoing cohort Finnish Public Sector Study with complete data at two phases, excluding those who screened positive for mental ill-health at baseline. Mental health was assessed using the 12-item General Health Questionnaire. Self-reported physical activity was expressed in metabolic equivalent task (MET) hours per week. Logistic regression models were used to analyse associations between physical activity levels and subsequent mental health. Results: There was an inverse dose–response relationship between physical activity and future symptoms of mental ill-health. This association is consistent with a protective effect of physical activity and remained after adjustments for socio-demographic, work-related and lifestyle factors, health and body mass index. Furthermore, those mid-life and older women who reported increased physical activity by more than 2 MET hours per week demonstrated a reduced risk of later mental ill-health in comparison with those who did not increase physical activity. This protective effect of increased physical activity did not hold for younger women.Conclusions: This study adds to the evidence for the protective effect of physical activity for later mental health in women. It also suggests that increasing physical activity levels may be beneficial in terms of mental health among mid-life and older women. The alleviation of menopausal symptoms may partly explain age effects but further research is required.

Background: Reductions in maternal smoking can prevent pregnancy complications and adverse effects to foetus. Our objective was to study how the prevalence of maternal smoking differs between Nordic countries, and to identify target groups for smoking-cessation interventions. Methods: Information on maternal smoking and background factors was requested from the Nordic countries (the Danish National Board of Health, the Finnish National Institute for Health and Welfare, the Public Health Institute in Iceland, the Norwegian Institute of Public Health and the Swedish National Board of Health and Welfare). Data on maternal smoking were received from 1991 to 2010 in Denmark, 1987 to 2010 in Finland, 1999 to 2009 in Norway and 1983 to 2008 in Sweden. Trends in smoking were studied by using test for relative proportion. Results: The prevalence of maternal smoking in early pregnancy has declined in the countries during the past 20 years (Denmark: from 30.6 to 12.5%; Norway: 20.6 to 16.5% and Sweden: 31.4 to 6.9%), except in Finland (a steady prevalence at 15%). The highest rates of smoking in early pregnancy were among teenagers (24% in Sweden and 49% in Finland and Norway). Single women were 2–3 times more likely to smoke than married women. The women in the lowest socioeconomic group were 6–7 times more likely to smoke than women in the highest group in Finland and Norway. Conclusion: Maternal smoking and its trends differed between the Nordic countries. The highest smoking rates during pregnancy were observed among teenagers, single women and women with a low socioeconomic position.

Background Long-term predictors of geriatric syndrome of frailty are unclear. Several obesity-related conditions are associated with frailty. This study examines the predictive role of midlife overweight and obesity on development of frailty more than 22 years of follow-up. Methods Data are from 1,119 men and women aged 30 or older without frailty at baseline participating in a population-based Mini-Finland Health Examination Survey (1978-1980) with follow-up measurement in 2000-2001. At baseline (1978-1980), body weight and height were measured. At follow-up (2000-2001), the dependent variable prefrailty was defined as the presence of one or two of five frailty indicators (shrinking, weakness, exhaustion, slowness, and low physical activity) and frailty was defined as three or more indicators. Results The mean age at the baseline was 43.6 (SD 9.7) years, and majority of the participants (95%) were 30-60 years old. Incidence of prefrailty was 5% and frailty 36%. Based on adjusted multinomial logistic regression, persons with overweight (body mass index 25-29.9kg/m(2)) and obesity (body mass index ≥ 30kg/m(2)) at baseline had increased risk of prefrailty (odds ratio 1.45, 95% CI 1.08, 1.96; odds ratio 2.36, 95% CI 1.41, 3.93) and frailty (odds ratio 2.49, 95% CI 1.22, 5.06; odds ratio 5.02, 95% CI 1.89, 13.33) at follow-up in comparison to normal-weight persons after adjusting for age, sex, lifestyle factors and chronic conditions. Conclusions Development of frailty may start already in midlife, and obesity is one of the underlying causes of frailty.

Is underage abortion associated with adverse socioeconomic and health outcomes in early adulthood when compared with underage delivery?Underage abortion was not found to be associated with mental health problems in early adulthood, and socioeconomic outcomes were better among those who experienced abortion compared with those who gave birth.Teenage motherhood has been linked with numerous adverse outcomes in later life, including low educational levels and poor physical and mental health. Whether abortion at a young age predisposes to similar consequences is not clear.This nationwide, retrospective cohort study from Finland, included all women born in 1987 (n = 29 041) and followed until 2012.We analysed socioeconomic, psychiatric and risk-taking-related health outcomes up to 25 years of age after underage (18 years) abortion (n = 1041, 3.6%) and after childbirth (n = 394, 1.4%). Before and after conception analyses within the study groups were performed to further examine the association between abortion and adverse health outcomes. A group with no pregnancies up to 20 years of age (n = 25 312, 88.0%) served as an external reference group.We found no significant differences between the underage abortion and the childbirth group regarding risks of psychiatric disorders (adjusted odds ratio 0.96 [0.67-1.40]) or suffering from intentional or unintentional poisoning by medications or drugs (1.06 [0.57-1.98]). Compared with those who gave birth, girls who underwent abortion were less likely to achieve only a low educational level (0.41 [95% confidence interval 0.31-0.54]) or to be welfare-dependent (0.31 [0.22-0.45]), but more likely to suffer from injuries (1.51 [1.09-2.10]). Compared with the external control group, both pregnancy groups were disadvantaged already prior to the pregnancy. Psychiatric disorders and risk-taking-related health outcomes, including injury, were increased in the abortion group and in the childbirth group similarly on both sides of the pregnancy.The retrospective nature of the study remains a limitation. The identification of study subjects in order to collect additional data was not allowed for ethical reasons. Therefore further confounding factors, such as the intentionality of the pregnancy, could not be checked.Previous studies have found that abortion is not harmful to mental health in the majority of adult women. Our study adds to the current understanding in suggesting that this is also the case concerning underage girls. Furthermore, women with a history of underage abortion had better socioeconomic outcomes compared with those who gave birth. These findings can be generalized to settings of high-quality social and health-care services, where abortion is accessible and affordable to all citizens. Social and health-care professionals who care for and counsel underage girls facing unplanned pregnancy should acknowledge this information.This study was financially supported by the Finnish Cultural Foundation and the Päivikki and Sakari Sohlberg Foundation. The researchers are independent of funders and the funders had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the article for publication. The authors have no competing interests.

Background Homelessness is associated with increased mortality, morbidity and social difficulties and periods of homelessness are sometimes prolonged or repeated. However, there are no long-term follow-up studies focusing upon housing status among homeless people. The aim of this study was to examine morbidity and housing outcomes and to identify factors predicting being independently housed 10 years after shelter use. Methods By combining data from several registers we followed all 552 homeless men who stayed in shelter in Helsinki during 2004 and determined their housing situation and morbidity 10 years later. Their situation was compared with an age-matched control group from the general population (N = 946). Using logistic regression analysis, we assessed the predictive effects of socioeconomic factors and health service use at baseline on becoming independently housed. Results By the end of the follow-up 52.0% of the formerly homeless study group had died, compared with 14.6% of the controls. At 10 years, 6.0% were independently housed, 37.5% lived in supported housing and 4.5% were still or again homeless. Psychiatric disorders, including substance use disorder, were present in 77.5% of the homeless, compared with 16.1% among the controls. Being married (OR 8.3, 95% CI 3.0 to 23.2) and having less than four shelter nights in year 2004 (OR 9.1, 95% CI 2.7 to 30.8) strongly predicted being independently housed 10 years later. Conclusions Homeless staying in shelters have high mortality and morbidity and most of those surviving, are in need of support in their everyday lives even years after the shelter period.

BACKGROUND: This study reports secular trends in medicine use for headache among adolescents in 20 countries from 1986 to 2010.METHODS: The international Health Behaviour in School-aged Children (HBSC) survey includes self-reported data about medicine use for headaches among nationally representative samples of 11-, 13- and 15-year-olds. We included 20 countries with data from at least three data collection waves, with a total of 380 129 participants.RESULTS: The prevalence of medicine use for headaches varied from 16.5% among Hungarian boys in 1994 to 62.9% among girls in Wales in 1998. The prevalence was higher among girls than boys in every country and data collection year. The prevalence of medicine use for headaches increased in 12 of 20 countries, most notably in the Czech Republic, Poland, Russia, Sweden and Wales.CONCLUSION: The prevalence of medicine use for headaches among adolescents is high and increasing in many countries. As some medicines are toxic this may constitute a public health problem.

Modelling data have provided good evidence to support the efficacy of a minimum pricing policy for alcoholic beverages as a means to reduce alcohol consumption and risky and harmful drinking. The aim of the present study was to investigate attitudes and beliefs towards a minimum price policy for alcohol among members of the general public in Western Australia (WA). The study also explored what factors might promote acceptance of the policy. Eleven focus groups, comprising participants from a broad range of backgrounds in WA, were conducted. Using a facilitator-administered semi-structured interview schedule participants discussed their beliefs about the policy and how its acceptability might be promoted. Transcriptions of discussions were analysed using qualitative inductive content analysis for emergent themes. Three major themes emerged: attitudes towards the policy, beliefs about effectiveness and strategies to increase acceptability. Participants expressed negative attitudes towards the policy and thought that it would lead to increased crime, drug use and financial strain. Participants identified the policy as unfair on disadvantaged groups, and suggested that individuals would find a way to procure alcohol regardless of minimum pricing policies. Suggestions to make the policy more acceptable included increasing alcohol education and directing the revenue towards alcohol reduction initiatives. Participants' negative views and perceived lack of effectiveness corroborate research conducted in the UK. Information and education campaigns aimed at reducing misunderstanding of the policy and highlighting its effectiveness may help to promote greater acceptability.

Background: Lower mortality among migrants than in the general population has been found in many, but not in all, previous studies. The mortality of migrants has not been studied in Finland, which has a relatively small and recent migrant population. Methods: People who were born abroad and whose mother tongue is not Finnish were identified from the Finnish Central Population Register ( n = 185 605). A Finnish-born control matched by age, sex and place of residence was identified for each case ( n = 185 605). Information about deaths was collected from the Finnish Causes of Death Register. Cox proportional hazards model was used for assessing the association between migrant status and death in 2011–13. Results: The mortality risk was found to be significantly lower for migrants than for Finnish controls (adjusted hazard ratio 0.77, 95% CI 0.72–0.84), both for migrant men (aHR 0.80, 95% CI 0.73–0.89) and women (aHR 0.78, 95% CI 0.70–0.88). The difference was statistically significant only among people who were not married and among people who were not in employment. There was variation by country of birth, but no migrant group had higher mortality than Finnish controls. No differences in mortality were found by duration of residence in Finland. The higher mortality of Finnish controls was largely explained by alcohol-related conditions and external causes of death. Conclusions: The mortality risk of migrants is lower than of people who were born in Finland. Possible explanations include selection and differences in substance use and other health behaviour.

It is unknown whether or not measuring sleep disturbances repeatedly, rather than at only one point in time, improves prediction of work disability.o examine sleep disturbance patterns over time as a risk marker for diagnosis-specific work disability.Prospective cohort study linking repeatedly measured self-reported sleep disturbances with records of physician-certified work disability (sickness absence) from a national register. Participants responded to surveys in 2000-2002, and 2004, and were followed up for 12 mo.Public sector employees in Finland.25,639 participants (mean age 45.6 yr, 82% female).Incident diagnosis-specific sickness absence of9 days.During a mean follow-up of 323 days, 4,975 employees (19%) had a new episode of sickness absence. In multivariable-adjusted models corrected for multiple testing, stable severe sleep disturbances, in comparison with no sleep disturbances, were associated with an increased risk of sickness absence due to diseases of the musculoskeletal system (hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.45-1.95), and injuries and poisonings (HR 1.64, 95% CI 1.23-2.18). Increases in sleep disturbances predicted subsequent sickness absence due to mental disorders (HR 1.59, 95% CI 1.32-1.91), and diseases of the musculoskeletal system (HR 1.44, 95% CI 1.27-1.64) According to net reclassification improvement analyses, measurement of sleep disturbance patterns rather than the level of sleep disturbances at one point in time improved prediction of all-cause sickness absence by 14%, and diagnosis-specific sickness absences up to 17% (P for improvement0.001).Increasing and severe chronic sleep disturbances mark an increased risk of diagnosis-specific work disability.

Background We examined prospectively the use of all-cause hospital in-patient care among public sector employees by using a 3-year pre- and post-retirement study window. Methods A total of 5269 participants of the Finnish Longitudinal Study of Municipal Employees had retired during January 1984 and July 2000. They had register-based data on retirement (non-disability retirement n = 3411, men 40%, and diagnose-specific disability retirement n = 1858, men 50%) and all-cause hospital in-patient admissions and discharges. Analyses were conducted using Generalized Estimating Equation model. Results The prevalence of hospital care use for non-disability retirees remained stable during the 6-year study window. The rate ratio (RR) for hospital care use increased in the year prior to retirement for men and women who transitioned into disability retirement due to cardiovascular disease and for women with disability due to mental disease. The RRs for hospital care use in the post-retirement year decreased for men who retired due to cardiovascular disease or mental disorders and for women who retired due to cardiovascular or musculoskeletal diseases. Conclusions An increase in hospital care preceding retirement in major diagnosis-specific disability retirement groups was followed by various patterns of decrease in the need of care indicated a beneficial health effect of retirement.