Social disadvantage in childhood and all-cause death and cardiovascular

2.2.1. Definition of social disadvantage in childhood

Childhood socioeconomic circumstances have been defined as

father/mother/parental education or occupation, housing conditions in childhood, overcrowding, number of siblings, maternal marital status, illegitimacy, and residence in an orphanage or similar facility. (5) Perhaps the most common way of defining a socially disadvantaged childhood has been the identification through the subjects’ own recollection of the father’s occupational social class. (24; 25; 26; 6; 9; 27; 28; 29)

2.2.2. Prevalence of social disadvantage in childhood in Finland

In 2009, there were 1 450 488 families in Finland of which 584 172 families with children. Of the total population 5 351 427 people the percentage of children is 20,3 %. (30) The rate of poverty is the percentage of people among the total population living below 60 % of the median income of the people in the households. There has been an increase in the number of poor people of the total population during the last ten years according to Statistics Finland. There were 13,1 % poor people of the total population in 2009. (31) The child poverty rate or the rate of poor children of the total population has also been increasing from 11,6% in 2000 to 13,2% in 2009. This risk is highest when the child is preschool - aged. There is also a bigger risk of childhood poverty if the household is single parent household compared to two parent households.

Also the number of siblings in the family increases the risk of child poverty.

The important factor behind child poverty is parents’ position in the work life.

The risk of poverty is high and increasing in the households where parents are unemployed. Also the risk of poverty in the households, where one parent is working, has been increasing in recent years. (32)

In 2010 the unemployment rate was 8,4%. Approximately 30% of the unemployed lived in the household with children. (33) Social welfare support for the families with children was 4 007 million euros in 2000, and 5 687 million euros in 2009. Social welfare for the unemployment was 3373 million euros in 2000, and 4147 million euros in 2009. (33)

2.2.3. Mortality in Finland

In 2009, 49 904 persons died in Finland, of which 25 152 were men and 24 752 women. Working aged people (15-64 years) died 10 653 persons. Cardiovascular diseases (CVD) were the leading cause of death in Finland in 2009 among the total population according to Statistics Finland. 42% of all deaths were attributable to CVD in 2009. Most common CVD is coronary heart disease (CHD), which caused 23% of all deaths. Tumors caused 20% of all deaths, of which lung cancer is the most common cancer in men and breast cancer in women. Also among the working age population, CVD deaths (all CVDs taken into account) were the leading cause of death, although alcohol related causes has been increasing in recent years and CHD deaths decreasing. (34)

For working age men, alcohol-related causes were the leading cause of death in 2009 (1307 deaths) followed by the CHD deaths (1139), suicides (630), lung cancer deaths (401), stroke (285), poisonings (236), respiratory diseases (202), and falls (201). For working aged women the leading cause of death was alcohol-related causes (332), breast cancer (324), suicides (232), lung cancer (192), CHD (186), stroke (155), poisonings (81), and falls (34). (34)

2.2.4. CVD, CHD in Finland and the risk factors

The most common CVDs in Finland are CHD, cardiac insufficiency, stroke, and elevated blood pressure. The prevalence of CVD among population aged ≥45 years was 16% among men and 14% among women in 2000. (35) According to Health 2000-study, 27,7% of working aged men (30-64 years) and 24.3% of working aged women reported having hypertension or elevated blood pressure.

(36) In the end of 2009 there were 508 600 persons who had Social Insurance Institution’s (KELA) special reimbursement because of the medication for hypertension, 191 700 persons because of the medication for CHD, and 46 200 persons because of the medication for cardiac insuffciency. (37) According to Health 2000-study among the working aged population, 1,4% of men and 1,1% of women reported having cardiac insufficiency. Population aged ≥65 there were 14% men and 16% women who reported having cardiac insufficiency, and 10%

of men and 7% of women, who reported having had stroke. (36)

Risk factors for CVD are smoking, obesity, diabetes, elevated serum total and low density lipoprotein (LDL) cholesterol, low serum high density

lipoprotein (HDL) cholesterol level, physical inactivity, elevated blood pressure, and stress. (38) Many of the risk factors can be altered by life-style changes. (39) According to the Barker’s Hypothesis those born small for gestational age are at increased risk of high blood pressure, hyperinsulinemia and obesity in

adulthood leading to increased risk of CVD. (7) CVD is also more common in low socioeconomic class and in the eastern part of Finland. (40)

2.2.5. Social disadvantage in childhood and all-cause mortality and cardiovascular diseases

Adverse socioeconomic conditions in childhood have been associated with mortality in later life. (5; 24; 25; 26) Children from low socioeconomic

circumstances are more likely to be of low birth weight, have poorer diets, to be more exposed to passive smoking and some infectious agents, and to have lower

educational level. (41) Childhood circumstances have been linked with increased risk of stomach cancer, hemorrhagic stroke, external and alcohol-related causes of death. Low childhood and adulthood socioeconomic position have been associated with the increased risk of CHD, lung cancer, and respiratory-related deaths. (5)

Previous studies have found an association between low socioeconomic position (SEP) in childhood and the risk of CVD morbidity and mortality. (24; 26;

27) Frankel et al. found no association to the CVD mortality in the Boyd Orr Cohort study. (42) Also our previous study showed no effect of childhood SEP among participants of the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) study. Analyses were made using recalled data. (28) The general conclusion is that early life socioeconomic position has some persisting influence on ischaemic heart disease (IHD) risk in adult life. (5; 7; 27; 43; 44; 29; 45; 46; 47; 48)

Most life course studies have used retrospective cohorts or a case-control design, relying on participants' recall of early life SEP. There has not been much systematic evaluation of the validity of recalled early life circumstances or of the possibility for recall errors to bias associations. Using recalled information may underestimate the true impact of childhood socioeconomic situation.

Few studies have used data on childhood social status from actual historical records.6,15,17,27 The review by Galobardes et al. showed that studies using objective data on childhood socioeconomic position tended to show stronger associations to mortality than studies using recalled information and using more expansive measures of childhood shows an effect compared to simple measures of recalled fathers occupation. (5)

2.3. ADVERSE CHILDHOOD EXPERIENCES AND BINGE