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

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

The Changing Educational Gradient in Marriage: Evidence from Malaysia

The rising age at marriage and non-marriage has been occurring concurrently with the rising educational level in many developing countries. This paper examines the changing relationship between educational attainment and the marriage rate (per cent ever married) and timing (age at marriage) in Malaysia over the past four decades, using multiple waves of Labour Force Survey data. Bivariate analyses show significant educational differentials in the proportion ever married and mean age at marriage for males and females, across ethnic groups and urban-rural locations. The educational effect on the rate and timing of marriage varied over time. Results from binary logistic regression show that controlling for ethnicity, urban-rural location, and age, the negative educational effect on the rate of marriage has turned positive in recent years. The change in the direction of the relationship between education and marriage rate was more pronounced for males than for females. The reduction in the educational gradient and a shift from negative to positive effect means that the conventional hypothesis of the education-marriage nexus needs to be re-assessed. The effects of rising education on the rate and timing of marriage should be considered in the implementation of the National Family Policy.

Double Disadvantage in a Nordic Welfare State: A Demographic Analysis of the Single Parent Employment Gap in Finland, 1987–2018

This study demonstrates how an evolving negative educational gradient of single parenthood can interact with changing labour market conditions to shape labour market inequalities between partnered and single parents. We analysed trends in employment rates among Finnish partnered and single mothers and fathers from 1987 to 2018. In the late 1980s’ Finland, single mothers’ employment was internationally high and on par with that of partnered mothers, and single fathers’ employment rate was just below that of partnered fathers. The gaps between single and partnered parents emerged and increased during the 1990s recession, and after the 2008 economic crisis, it widened further. In 2018, the employment rates of single parents were 11–12 percentage points lower than those of partnered parents. We ask how much of this single parent employment gap could be explained by compositional factors, and the widening educational gradient of single parenthood in particular. We use Chevan and Sutherland’s decomposition technique on register data, which allows us to decompose the single parent employment gap into the composition and rate effects by each category of the background variables. The findings point to an increasing double disadvantage of single parents: the gradually evolving disadvantage in educational backgrounds together with large differences in employment rates between single and partnered parents with low education explain the widening employment gap. Socio-demographic changes in interaction with changes in the labour market can produce inequalities by family structure in a Nordic society known for its extensive support for combining childcare and employment for all parents.

Comparing the educational gradients in three cardiovascular disease-specific health measures

Less-educated persons have worse cardiovascular health. We compare the educational gradients in three disease-specific health measures (biomarkers, self-reported doctors’ diagnoses and cause-specific mortality) in order to compare their relevance in different stages of the disease process. We study 14,102 people aged 50–89 from the US Health Retirement Study (HRS) in the period 2006–17. We use six CVD biomarkers (systolic/ diastolic blood pressure, ratio total/HDL cholesterol, C-reactive protein, body mass index, HbA1c) and two self-reported doctors’ diagnoses (stroke, heart attack). We estimate the gradient in biomarkers using log-binomial regression and the hazard of diagnoses and CVD mortality with Cox survival models.Among those without pre-diagnosed CVD conditions, the educational gradient in mortality is highest (RR 1.97), the gradient for those who receive a CVD diagnosis is in the middle (RR 1.46), and the gradient in biomarkers is lowest (RR 1.32). Among those with recent/ older diagnoses, the biomarker gradient is comparable to levels among the non-diagnosed, while the mortality gradient is much lower (RR 1.35). The gradients in diagnoses and mortality are only slightly explained by differences in biomarkers.The comparison of the three gradients and the mediation analysis suggest that in each of the steps to diagnosis and death there are social factors involved that increase the gradient and go beyond what biomarkers can predict. Having a CVD diagnosis leads to smaller mortality gradients, presumably because of the convergence of educational differences in behaviour and during treatment and monitoring. Our findings support prevention as a strategy against social inequalities in CVD.<br />Key messages<br /><ul><li>The educational gradient is highest for mortality; next highest is diagnoses; lowest is biomarkers.</li><br /><li>The gradients in diagnoses and mortality are only slightly explained by differences in biomarkers.</li><br /><li>CVD progression is subject to social factors that widen the gradient beyond biomarkers’ predictivity.</li><br /><li>Among diagnosed people, changes in behaviour and treatment seem to lower the mortality gradient.</li></ul>

Putting cumulative (dis)advantages in context: Comparing the role of educational inequality in later-life functional health trajectories in England and Germany

Background The cumulative (dis)advantage (CAD) perspective more and more is examined in a comparative way, to highlight the role of context in generating inequality over the life course. This study adds to this field of research by examining trajectories of activities of daily living (ADL) in later life by educational level in a country comparison of England and Germany, emphasizing differing institutional conditions. Method Data used are the English Longitudinal Study of Ageing (ELSA; 11,352 individuals) and the German subsample of the Survey of Health and Retirement in Europe (SHARE; 5,573 individuals). Using population averaged Poisson panel regression models, 12-year trajectories of six birth cohorts are investigated, covering the age range of 50 to 90 years. Results Respondents in England have a higher level of limitations at age 50, and more limited increases over age than in Germany. An educational gradient exists in both countries at age 50. Notably, the educational gradient increases for more recently born cohorts, but declines with increasing age in England, while in Germany educational differences increase for more recently born cohort only. Discussion The current study indicates that CAD processes between educational groups are context sensitive. While England showed convergence of disparities with increasing age, in Germany no differential development was found.

Educational Differences in Risk of All-Cause Mortality After Acute Cardiovascular Events: Examining Cohort and Gender Variations

Acute cardiovascular events are prevalent in older adults. In this study, following a sample of respondents from the 1996–2016 Health and Retirement Study after diagnosis of myocardial infarction or stroke, we used discrete-time event history models to study mortality post diagnosis. We found an educational gradient in mortality following myocardial infarction or stroke with the better educated surviving longer, even as the gradient was weaker for stroke. Cohort variations existed with the educational gradients stronger for more recent cohorts (Silent and Boomer) as compared with the GI cohort. Gender interacted with cohort to shape mortality such that men from the Silent and Boomer cohorts benefited the most from high school and some college education. Mediation analysis showed that the educational differences in mortality are accounted for by spousal educational attainment, wealth, Medicaid coverage, change in health behaviors, and comorbidities.