Väestötiede ja kvantitatiivinen sosiaalitutkimus

1. Väestötiede ja kvantitatiivinen sosiaalitutkimus Pekka Martikainen Pekka.Martikainen@helsinki.fi http://blogs.helsinki.fi/pmartika/

2. Laitoksella tehtävästä kvantitatiivisesta tutkimuksesta • Kvantitatiivista tutkimusta tehdään laitoksessa useassa tutkimusryhmässä • Kuolleisuus- ja terveystutkimus • Ikääntyvän väestön tutkimus • Kaupunkitutkimus (aluetutkimus) • Kvantitatiivinen perhetutkimus (Jalovaara) • Namibia/Afrikka-tutkimus (Shemeikka)

3. JOITAIN TUTKIMUSTEEMOJA • Kuolleisuus ja terveys • sosioekonomiset erot ja niiden muutos • koulutus ja tulot • siviilisääty ja perherakenne • elämäntapahtumat • kansainväliset vertailut (hyvinvointivaltio-keskustelu) • alkoholilainsäädännön vaikutukset

4. Alue-vaikutukset • sosioekonominen rakenne, yhteisöllisyys ja koheesio • kuolleisuus, terveys, itsemurha • alueellinen eriytyminen • muuttoliike • pienalueet ja maakunnat/seutukunnat

5. Vanheneva väestö • asuinolot ja köyhyys • perherakenne, yksin eläminen, avoliitto • epävirallinen hoiva ja sukulaissuhteet • elämätapahtumat ja niiden seuraukset • sairastuminen • leskeytyminen • laitostuminen • perhevaikutukset terveydessä

6. Types of data sources • Individual level data on the Finnish population 1970+ • Based on • Censuses from 1970-2005 (every 5-years) • Population registration 1987-2006 (annual) • Linked with data on e.g. • Mortality, hospital discharge and medication • Taxation • Establishment records • Contextual information (eg. area) • Linkage is based on social security numbers • Allows: • Longitudinal analyses • Identify couples/households

7. … continued • 10% sample of the 1950 census • Based on • 1950 Census (household based) • Population census and registration from 1970 onwards • Expanding family study

8. … continued • Surveys data on the employees of the City of Helsinki • Based on questionnaires to employees in 2000 • Re-surveyed in 2007/8 • Linked with data from various registers (STAKES, KELA, City of Helsinki) • Health 2000 Survey • Nationally representative survey of Finns in 2000 • Also medically examined • Päijät-Häme (Ikihyvä) survey in the Area of Lahti • Also medically examined and re-surveyed • All data sets contain information on: • Various health issues • However, also rich in various social, behavioral and attitudinal questions

9. Vanhusten asumismuotojen muutos, laitoshoito ja epävirallinen hoiva

10. Population projection 2003-2040 by age

11. Sources of care • Formal care ~ care from the public sector / paid care from the private sector • care in the community • institutional care • Informal care ~ ’help from family, friends and relatives’

12. Main sources of support and help among 75 year old men and women in Finland (%) living in the community % does not add up 100 as support can be obtained simultaneously from several sources

13. Living arrangements by sex in Finland in 1970-2000 75 years and over

14. Tavallisiin toimiin saatu apu avunantajatahon mukaan puolison kanssa asuvilla, ikävakioidut prosenttiosuudet, 70 vuotta täyttäneet

15. Tavallisiin toimiin saatu apu avunantajatahon mukaan yksin asuvilla, ikävakioidut prosenttiosuudet, 70 vuotta täyttäneet

16. Determinants of entry into long-term care Known to be associated for example with: • poor health and functioning (e.g. dementia) • living arrangements (e.g. living alone) • living conditions (e.g. inadequate housing) • low socioeconomic position (e.g. low income) • Strength of these effects and their relative contribution not well established • How is institutional care distributed over the life-course • Life-events: widowhood • Most results cross-sectional • ‘Pathways’ not well established • Low SES -> poor housing -> poor health -> Institution

17. Sociodemographic factors: Sex, sex Marital status Living arrangements Education Social class Income Housing Partner Region Date/cause of death Use of homecare services An example of datacontent for a study of entry into institutional care STAKES Institutional care: Care episodes Date of entry Date of exit Type of institution STAKES Supply of care: Regional coverage of institutional care Pension institute Health: Medication Hospital discharge STAKES StatisticsFinland STAKES

18. Distribution by gender and living arrangements. Finnish older adults aged 65 and over living in the community

19. Probability of survival without long-term institutionalisation by living arrangements among Finnish older adults living in the community at baseline

20. Figure 1. Relative age-adjusted institutionalization rates in relation to duration of bereavement, Finnish elderly 65+ (Reference = married) Nihtilä and Martikainen, 2006

21. Hazard ratios (women vs. men) of institutionalisation and mode of exit from institution Martikainen, Moustgaard, Murphy, Nihtilä, Koskinen, Martelin, Noro, The Gerontologist 2008

22. = > Adjusted for age: Women stay in care on average 1064 days - if living with spouse at baseline 994 days - if living alone at baseline 1105 days Men stay in care on average 686 days - if living with spouse at baseline 645 days - if living alone at baseline 746 days

23. Kuolleisuus- ja terveyserot

28. Poverty has been suggested as an important cause of socioeconomic inequalities in mortality and morbidity • This possibility is interesting from the scientific point of view, but also from the point of view income redistribution policies • Relatively little empirical data on the effects of income on health is available at present

29. Age-adjusted relative mortality rates by income among men Source: USA: Backlund, Sorlie, Johnson; Ann Epidemiol 6:1, 1996 Finland: Martikainen, Mäkelä, Koskinen, Valkonen; IJE 30, 2001

30. Household equivalent income and self-assessed health (SAH) among men in Finland, Neatherlands and England & Wales

31. SELECTION, CONFOUNDING OR CAUSATION? • Problems of interpreting the association between income and health may be a partial cause of the relative scarcity of research • '... the basic presupposition in studies of socioeconomic differentials in mortality is that socioeconomic status has an effect on mortality. In the case of income differentials, however, this causal pathway is complicated by a reverse path in which the approach of death itself is the cause of decreased income during the years preceding death.' (Kitagawa and Hauser, 1973)

32. FOUR APPROAHES: • Preference for household based measures of income and post-tax income (rarely available) • Adjustment for possible confounders • Analyses of longitudinal data • Analyses of the shape of the relationship between income and health • curvi-linear • linear

33. Age adjusted and fully adjusted hazard ratios of mortality by different measures of income. Women aged 30-64 ---- Adjustedfor age ---- Adjusted for age, educational attainment, occupational social class and economic activity

34. Age adjusted and fully adjusted hazard ratios of mortality by different measures of income. Women aged 65+ ---- Adjustedfor age ---- Adjusted for age, educational attainment, occupational social class and economic activity

37. Women poorest 20% Women richest 60% Women mid 60% Men poorest 20% Men richest 20% Men mid 60%

38. Työttömyys ja kuolleisuus

39. Why are the effects of unemployment on health interesting? • The effects of unemployment are of particular interest in recessionary times • => public health and equity • => policy • These effects are of interest also from a more general research point of view on the etiology of disease • => unemployment as a stressful life-event • Previous evidence clearly indicates that unemployment is strongly associated with ill-health and mortality

40. Why is unemployment related to mortality? • Causal effects of unemployment: Becoming jobless and prolonged redundancy have negative effects on health and increase the risk of premature death. • Increased psychosocial stress • Tobacco and alcohol consumption • Loss of income and material deprivation • Selection: Persons likely to become unemployed, or to have difficulty in re-employment, have pre-existing ill-health and/or "lifestyle" (e.g. tobacco and alcohol consumption, diet), socioeconomic (e.g. social class, housing tenure) or personal characteristics (e.g. age, sex, physical weakness, psychological characteristics, and early life experiences) that increase the risk of future ill-health and mortality.

41. Figure 1. Possible pathways between unemployment, job insecurity and health Martikainen and Ferrie: Encyclopedia of Public Health, 2008

42. Martikainen; BMJ, 1990

43. Natural experiments • ‘Occasionally, under naturally occurring conditions part of the study population is randomly exposed to a an agent or an event. A comparison of the naturally exposed group to a not exposed reference group closely resembles a controlled experiment. Inferences about causality are strong under such conditions’ • ‘Factory closure’ -studies • Most are under-powered (Morris et al.) • Can be deduced from Finnish register data • 1990 recession; unemployment rose from about 4% to 20% in three years • Direct observation of workplace downsizing

44. Figure 2. Mortality by cause and self-inflicted injury leading to hospital admission in 1986-94 following plant closure in New Zealand meat processing workers. Keefe et al. IJE, 2002

45. Unemployment rate by sex Men Women Source: Martikainen&Valkonen 1995

46. Age-adjusted mortality (deaths/100.000)) for selected accidental and violent causes of death 1980-93, 15-64-year-old men and women (two year moving averages) Men Women Suicide Suicide Other accidents Motor vehicle accidents Motor vehicle accidents Other accidents Poisonings Poisonings Source: Martikainen&Valkonen 1995

47. Martikainen, Mäki and Jäntti

48. TO SUMMARIZE • The effects of unemployment on mental well-being are well established in longitudinal studies • The effects of unemployment on mortality and physical health are more difficult to demonstrate and quantify, because the effects of selection are difficult to eliminate. • The effects are typically much smaller in natural experimental designs than in ’traditional’ follow-up studies => the causal effects of unemployment may be easily overestimated • Policy: The effects of mass unemployment and recession on public health are difficult to extrapolate from findings obtained in good economic times.

49. Alkoholin hinnanmuutosten vaikutukset kuolleisuuteen

50. Herttua K, Mäkelä P, Martikainen P. American Journal of Epidemiology 2008