Pathways to health : Determinants of health, health behaviour and health inequalities in early adulthood

There is increasing evidence that the origins of poor adult health and health inequalities can be traced back to circumstances preceding current socioeconomic position and living conditions. The life-course approach to examining the determinants of health has emphasised that exposure to adverse social and economic circumstances in earlier life or concurrent adverse circumstances due to unfavourable living conditions in earlier life may lead to poor health, health-damaging behaviour, disease or even premature death in adulthood. There is, however, still a lack of knowledge about the contribution of social and economic circumstances in childhood and youth to adult health and health inequalities, and even less is known about how environmental and behavioural factors in adulthood mediate the effects of earlier adverse experiences. The main purpose of this study was to deepen our understanding of the development of poor health, health-damaging behaviours and health inequalities during the life-course. Its aim was to find out which factors in earlier and current circumstances determine health, the most detrimental indicators of health behaviour (smoking, heavy drinking and obesity as a proxy for the balance between nutrition and exercise), and educational health differences in young adults in Finland. Following the ideas of the social pathway theory, it was assumed that childhood environment affects adult health and its proximal determinants via different pathways, including educational, work and family careers. Early adulthood was studied as a significant phase of life when many behavioural patterns and living conditions relevant to health are established. In addition, socioeconomic health inequalities seem to emerge rapidly when moving into adulthood; they are very small or non-existent in childhood and adolescence, but very marked by early middle age. The data of this study were collected in 2000 2001 as part of the Health 2000 Survey (N = 9,922), a cross-sectional and nationally representative health interview and examination survey. The main subset of data used in this thesis was the one comprising the age group 18 29 years (N = 1,894), which included information collected by standardised structured computer-aided interviews and self-administered questionnaires. The survey had a very high participation rate at almost 90% for the core questions. According to the results of this study, childhood circumstances predict the health of young adults. Almost all the childhood adversities studied were found to be associated with poor self-rated health and psychological distress in early adulthood, although fewer associations were found with the somatic morbidity typical of young adults. These effects seemed to be more or less independent of the young adult s own education. Childhood circumstances also had a strong effect on smoking and heavy drinking, although current circumstances and education in particular, played a role in mediating this effect. Parental smoking and alcohol abuse had an influence on the corresponding behaviours of offspring. Childhood circumstances had a role in the development of obesity and, to a lesser extent, overweight, particularly in women. The findings support the notion that parental education has a strong effect on early adult obesity, even independently of the young adult s own educational level. There were marked educational differences in self-rated health in early adulthood: those in the lowest educational category were most likely to have average or poorer health. Childhood social circumstances seemed to explain a substantial part of these educational differences. In addition, daily smoking and heavy drinking contributed substantially to educational health differences. However, the contribution of childhood circumstances was largely shared with health behaviours adopted by early adulthood. Employment also shared the effects of childhood circumstances on educational health differences. The results indicate that childhood circumstances are important in determining health, health behaviour and health inequalities in early adulthood. Early recognition of childhood adversities followed by relevant support measures may play an important role in preventing the unfortunate pathways leading to the development of poor health, health-damaging behaviour and health inequalities. It is crucially important to recognise the needs of children living in adverse circumstances as well as children of substance abusing parents. In addition, single-parent families would benefit from support. Differences in health and health behaviours between different sub-groups of the population mean that we can expect to see ever greater health differences when today s generation of young adults grows older. This presents a formidable challenge to national health and social policy as well as health promotion. Young adults with no more than primary level education are at greatest risk of poor health. Preventive policies should emphasise the role of low educational level as a key determinant of health-damaging behaviours and poor health. Keywords: health, health behaviour, health inequalities, life-course, socioeconomic position, education, childhood circumstances, self-rated health, psychological distress, somatic morbidity, smoking, heavy drinking, BMI, early adulthood

Worksite Fitness Policy in an Intellectual Capital Framework

In a framework of Intellectual Capital (IC), the effects and interactions of a Worksite Fitness Program (WFP) policy was studied with a multidisciplinary approach. In a preliminary study, indicators for physical activity (PAI), physical fitness (PFI), activity in WFP on a regular (WFPI) and on a events basis (WFPE) were created in line with positive findings regarding the associations between physical activity and fitness patterns and sick leave, perceived health, and self-assessed work ability. The intensity of physical activity was found to be the most important variable to predict positive associations with the above mentioned wellness parameters. In four case study follow-up settings, the effects and interactions of physical activity and fitness patterns and the company’s WFP-policy on different elements of IC were studied. Qualitative methods were applied in constructing indicators and a descriptive IC measure for each case company. In cross-sectional and follow-up settings, several findings with respect to IC were found regarding physical activity in general and activity in WFP in particular. Findings were relatively strong in health and wellness related indicators in Human Capital, where, as also in Structural Capital indicators such as the company climate and employee-superior relationship, revealed positive associations. Physical activity patterns were found to act in minor role in Relational Capital. Overall, WFP was seen to be an integrated part of Structural Capital. From the viewpoint of Worksite Fitness Program as a phenomenon, this study positioned WFP as an active element of Intellectual Capital. The literature in the field of WFP emphasizes the role of WFP as an instrument to activate employees in physical activity, and thus promote their health and wellbeing. With the wider perspective the active and long range WFP policy can support a company’s Structural and Relational Capital in line with the fundamental role it has on Human Capital.

Psychological resources, their social antecedents, and association with well-being and health behaviour in early adulthood

The success of entering work life, young people s psychological resources and self-reported well-being were studied in a longitudinal setting from a life-span developmental-contextual perspective in early adulthood. The aim was to analyse how psychosocial characteristics in early childhood and adolescence predict successful entrance into work life, how this is associated with well-being, and to assess the level of psychological resources such as dispositional optimism, personal meaning of work and coping in early adulthood. The role of these and social support, in the relationship between regional factors (such as place of residence and migration), self-reported health and life satisfaction was studied. The association between a specific coping strategy, i.e. eating and drinking in a stressful situation and eating habits, was studied to demonstrate how coping is associated with health behaviour. Multivariate methods, including binary logistic regression analyses and ANOVA, were used for statistical analyses. The subjects were members of the Northern Finland 1966 Birth Cohort, which consists of all women and men born in 1966 in the two northernmost provinces of Finland (n= 12,058). The most recent follow-up, at the age of 31 years when 11,637 subjects were alive, took place in 1997-1998. The results show, first, that social resources in the childhood family and adolescence school achievement predict entrance into the labour market. Secondly, psychosocial resources were found to mediate the relationship between migration from rural to urban areas, and subjective well-being. Thirdly, psychological resources at entrance into the labour market were found to develop from early infancy on. They are, however, influenced later by work history. Fourthly, stress-related eating and drinking, as a way of coping, was found to be directly associated with unhealthy eating habits and alcohol use. Gender differences were found in psychosocial resources predicting, and being associated with success in entering the labour market. For men, the role of attitudinal and psychological factors seems to be especially important in entrance into work life and in the development of psychological resources. For women, academic attainment was more important for successfully entering work life, and lack of emotional social support was a risk factor for stress-related eating only among women. Stress-related eating and drinking habits were predicted by a long history of unemployment as well as a low level of education among both genders, but not excluding an academic degree among men. The results emphasize the role of childhood psychosocial factors in preventing long-term unemployment and in enhancing psychological well-being in early adulthood. Success in entering work life, in terms of continuous work history, plays a crucial role for well-being and the amount of psychological resources in early adulthood. The results emphasize the crucial role of enhancing psychological resources for promoting positive health behaviour and diminishing regional differences in subjective well-being.

Impact of dental insurance on adults’ oral health care in Tehran, Iran.

The aim of the present study was to determine relationships between insurance status and utilization of oral health care and its characteristics and to identify factors related to insured patients’ selection of dental clinic or dentist. The study was based on cross-sectional data obtained through phone interviews. The target population included adults in the city of Tehran. Using a two-stage stratified random technique, 3,200 seven-digit numbers resembling real phone numbers were drawn; when calling, 1,669 numbers were unavailable (busy, no answer, fax, line blocked). Of the 1,531 subjects who answered the phone call, 224 were outside the target age (under 18), and 221 refused to respond, leaving 1,086 subjects in the final sample. The interviews were carried out using a structured questionnaire and covered characteristics of dental visits, the respondent’s reason for selecting a particular dentist or clinic and demographic and socio-economic background (gender, age, level of education, income, and insurance status). Data analysis included the Chi-square test, ANOVA, and logistic regression and the corresponding odds ratios (OR). Of all the 1,086 respondents, 57% were women, 62% were under age 35, 46% had a medium and 34% a high level of education, 13% were under the poverty line, and 70% had insurance coverage; 64% with the public, and 6% with a commercial insurance. Having insurance coverage was more likely for women (OR=1.5), for those in the oldest age group (OR=2.0), and for those with a high level of education (OR=2.5). Of those with dental insurance, 54% reported having had a dental visit within the past 12 months ; more often by those with commercial insurance in comparison with public (65% vs. 53% p<0.001). Check-up as the reason for the most recent visit occurred most frequently among those with commercial insurance (28%) compared with those having public insurance (16%) or being non-insured (13%) (p<0.001). Having had two or more dental visits within the past 12 months was most common among insured respondents, when compared with the non-insured (31% vs. 22% p=0.01). The non-insured respondents reported tooth extractions almost twice as frequently as did the insured ones (p<0.001). Of the 726 insured subjects, 60% selected fully out-of-pocket-paid services (FOP), and 53% were unaware of their insurance benefits. Of those who selected FOP, good interpersonal aspects (OR=4.6), being unaware of dental insurance benefits (OR=4.6), and good technical aspects (OR=2.3) as a reason had greater odds of selecting FOP. The present study revealed that dental insurance was positively related to demand for oral health care as well as to utilization of services, but to the latter with a minor extent. Among insured respondents, despite their opportunity to use fully or highly subsidized oral health care services, good interpersonal relationship and high quality of services were the most important factors when an insured patient selected a dentist or a clinic. The present findings indicate a clear need to modify dental insurance systems in Iran to facilitate optimal use of oral health care services to maximize the oral health of the population. A special emphasis in the insurance schemes should be focused on preventive care.

The Macroeconomic Effects of Fiscal Policy in a Small Open Economy under a Flexible Exchange Rate Regime

This licentiate's thesis analyzes the macroeconomic effects of fiscal policy in a small open economy under a flexible exchange rate regime, assuming that the government spends exclusively on domestically produced goods. The motivation for this research comes from the observation that the literature on the new open economy macroeconomics (NOEM) has focused almost exclusively on two-country global models and the analyses of the effects of fiscal policy on small economies are almost completely ignored. This thesis aims at filling in the gap in the NOEM literature and illustrates how the macroeconomic effects of fiscal policy in a small open economy depend on the specification of preferences. The research method is to present two theoretical model that are extensions to the model contained in the Appendix to Obstfeld and Rogoff (1995). The first model analyzes the macroeconomic effects of fiscal policy, making use of a model that exploits the idea of modelling private and government consumption as substitutes in private utility. The model offers intuitive predictions on how the effects of fiscal policy depend on the marginal rate of substitution between private and government consumption. The findings illustrate that the higher the substitutability between private and government consumption, (i) the bigger is the crowding out effect on private consumption (ii) and the smaller is the positive effect on output. The welfare analysis shows that the less fiscal policy decreases welfare the higher is the marginal rate of substitution between private and government consumption. The second model of this thesis studies how the macroeconomic effects of fiscal policy depend on the elasticity of substitution between traded and nontraded goods. This model reveals that this elasticity a key variable to explain the exchange rate, current account and output response to a permanent rise in government spending. Finally, the model demonstrates that temporary changes in government spending are an effective stabilization tool when used wisely and timely in response to undesired fluctuations in output. Undesired fluctuations in output can be perfectly offset by an opposite change in government spending without causing any side-effects.

Essays on Platforms: Business Strategies, Regulation and Policy in Telecommunications, Media and Technology Industries

The growth of the information economy has been stellar in the last decade. General-purpose technologies such as the computer and the Internet have promoted productivity growth in a large number of industries. The effect on telecommunications, media and technology industries has been particularly strong. These industries include mobile telecommunications, printing and publishing, broadcasting, software, hardware and Internet services. There have been large structural changes, which have led to new questions on business strategies, regulation and policy. This thesis focuses on four such questions and answers them by extending the theoretical literature on platforms. The questions (with short answers) are: (i) Do we need to regulate how Internet service providers discriminate between content providers? (Yes.) (ii) What are the welfare effects of allowing consumers to pay to remove advertisements from advertisement-supported products?(Ambiguous, but those watching ads are worse off.) (iii) Why are some markets characterized by open platforms, extendable by third parties, and some by closed platforms, which are not extendable? (It is a trade-off between intensified competition for consumers and benefits from third parties) (iv) Do private platform providers allow third parties to access their platform when it is socially desirable? (No.)

The role of policy in forest resource development.

XVIII IUFRO World Congress, Ljubljana 1986.