Journal of Physical Activity and Health, 2015, 12, 193 -199 http://dx.doi.org/10.1123/jpah.2013-0245 © 2015 Human Kinetics, Inc.
Official Journal of ISPAH www.JPAH-Journal.com ORIGINAL RESEARCH
Childhood Adversities and Socioeconomic Position as Predictors of Leisure-Time Physical Inactivity in Early Adulthood Laura Kestilä, Tomi Mäki-Opas, Anton E Kunst, Katja Borodulin, Ossi Rahkonen, and Ritva Prättälä Background: Limited knowledge exists on how childhood social, health-related and economic circumstances predict adult physical inactivity. Our aim was a) to examine how various childhood adversities and living conditions predict leisure-time physical inactivity in early adulthood and b) to find out whether these associations are mediated through the respondent’s own education. Methods: Young adults aged 18–29 were used from the Health 2000 Study of the Finnish. The cross-sectional data were based on interviews and questionnaires including retrospective information on childhood circumstances. The analyses were carried out on 68% of the original sample (N = 1894). The outcome measure was leisure-time physical inactivity. Results: Only a few of the 11 childhood adversities were related with physical activity in early adulthood. Having been bullied at school was associated with physical inactivity independently of the other childhood circumstances and the respondent’s own education. Low parental education predicted leisure-time physical inactivity in men and the association was mediated by the respondent´s own education. Respondents with only primary or vocational education were more likely to be physically inactive during leisure-time compared with those with secondary or higher education. Conclusions: There is some evidence that few specific childhood adversities, especially bullying at school, have long-lasting effects on physical activity levels. Keywords: young adults, life course, education, Finland Physical inactivity is considered to be a risk factor for health and well-being;1 there is a concern about its potential effect on current as well as on later psychological and physiological health. Physical activity provides important health benefits for young people and later in adulthood. However, the information on the effects of various childhood social, economic and health-related factors on physical activity in early adulthood is scarce. In adolescence, according to earlier Finnish studies, low parental socioeconomic position (SEP) has been suggested to associate with low physical activity2 and high parental education with high physical activity.3 There is also some evidence that parental SEP is associated with leisure-time physical activity in early adulthood4 and that childhood socioeconomic circumstances explain partly the educational differences in leisure-time physical activity later in adulthood.5 Several European studies have reported that parental SEP is associated with physical inactivity and sedentary behaviors in adolescence6,7 and even in adulthood.8,9 In addition, physical inactivity in youth is also associated with several emotional and behavioral problems.10,11 Although the factors determining physical activity have been studied earlier,12–20 very few studies have been able to examine different aspects of childhood living conditions and problems. Moreover, little is known about the relative importance of past and present socioeconomic circumstances on physical activity. In previous studies from the same data,21–23 it was found that several childhood circumstances predicted other health behaviors such
as smoking and heavy drinking, as well as obesity. The effects were partly independent and partly mediated by later early adult circumstances. In this study, our main objective was to explore the associations between various indicators of economic, social and health-related problems in childhood and leisure time physical inactivity in early adulthood. In more detail, the aims of the study were a) to examine how various childhood living conditions and adversities predict leisure-time physical inactivity in early adulthood and b) to find out whether these associations are mediated through the respondent’s education.
Data and Methods Participants This study is based on a sample of 1894 young adults aged 18 to 29 in Finland. The two-stage cluster sample was representative of the entire country. The data were collected in 2000–2001 as part of the Health 2000 Survey.24 The information was obtained with standardized computer-aided interviews (CAPI) and self-administered questionnaires. The participation rate among young adults was relatively high; 68% returned the self-administered questionnaire that included the questions concerning childhood adversities and leisure-time physical activity.
Measures Kestilä is with the Dept of Social and Health Care Systems, National Institute for Health and Welfare (THL), Helsinki, Finland. Mäki-Opas (tomi. [email protected]), Borodulin, and Prättälä are with the Dept of Health, National Institute for Health and Welfare (THL), Helsinki, Finland. Kunst is with the Academic Medical Centre (AMC), University of Amsterdam, the Netherlands. Rahkonen is with the Dept of Public Health, Hjelt Institute, University of Helsinki, Finland.
Outcome Measures. The physical activity was assessed by a
question “How much do you exercise and strain yourself physically in your leisure time?” with 4 response alternatives: 1) In my leisure time I read, watch TV, and do other activities in which I do not move much and which do not strain me physically; 2) In my leisure time I walk, cycle, and move in other ways at least 4 hours per week; 3) In my leisure time I exercise at least 3 hours per week; and 4) In my leisure 193
194 Kestilä et al
time I practice regularly several times per week for competition (choose this also if you spend most of your time in competitive sports). The first response alternative was used as describing the leisure-time physical inactivity and was analyzed against the other alternatives, which were combined to the same category. Parental Educational Level and Childhood Living Conditions.
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Parental education was based on the participant’s response concerning his/her mother’s and father’s basic and vocational education. The parent with the higher education was chosen to indicate parental education. Family structure was based on the question “When starting school (ie, when you were about 7 years old), did you live . . . ?” with 4 possible response alternatives: “at home with both your parents,” “with only one parent,” “with relatives such as grandparents,” and “in an orphanage or other institution,” and it was categorized into 2 groups (“two parents” and “single-parent or other”). Childhood Adversities. Childhood adversities were based on the question “When you think about your growth years, ie, before you were aged 16, did you experience any of the following?” The respondents were able to select the following answers: “No,” “Yes,” and “Can’t say.” Eleven adversities were described: 1) long-term financial problems, 2) parental regular unemployment, 3) parental serious disease or disability, 4) paternal alcohol problems, 5) maternal alcohol problems, 6) paternal mental health problems, 7) maternal mental health problems, 8) serious conflicts within the family, 9) parental divorce, 10) own serious chronic illness, and 11) being bullied at school. In general, the pairwise correlations between different childhood adversities were below 0.4. The childhood adversities were analyzed with dichotomous variables: “Yes” or “No,” where the option “Can’t say” was combined with the option “No.” The Respondent’s Own Educational Level. Respondent’s own education was based on the highest completed degree. Because many persons were still studying (21%), the measure for students was based on the expected level of education assuming the person to complete the ongoing studies. Three categories were constructed: “only primary school,” “vocational school,” and “secondary school graduate or higher.”
Statistical Analysis First, we present the distribution of leisure-time physical activity by its volume in men and women (Table 1). We also present the prevalence of different childhood living conditions and current living conditions by gender as well as the prevalence of physical inactivity in different sub-groups (Table 2). The significance of the difference between genders is presented for all variables (chi-square). Second, the associations between leisure-time physical inactivity and childhood as well as current determinants, were analyzed (Tables 3 and 4). The significance of the interactions between gender and all explanatory factors were first tested. Since significant interactions were found, we stratified the further analyses by gender. To assess pathways between the predictors, the variables were added to the logistic regression model sequentially, starting with the factors concerning early childhood (around age 7), followed by variables describing the living conditions at a later phase (before age 16). At the next stage, the models were adjusted for the effect of the respondent´s own educational level. Results are presented as prevalence and odds ratios (ORs) with 95% confidence intervals (CI). The sampling design and nonresponse were accounted for by using poststratification weights25 constructed specifically for the dataset and analyzed by SAS software program, version 9.2.26
Results Characteristics of the Study Population In general, leisure time physical activity was more common in men compared with women. However, women were more often moderately physically active during leisure time. The prevalence of being physically inactive during leisure time was almost the same among both genders (Table 1). Childhood adversities included paternal alcohol problem, long-term financial problems in the family, parents’ divorce, serious conflicts within the family, parents’ serious illness, or disability and bullying at school (13% to 29%; Table 2). Less frequently (2% to 8%) reported adversities were parental mental
Table 1 Leisure-Time Physical Activity by its Volume in Men and Women Aged 18–29 years, %; The Health 2000 Study, Finland Leisure-time physical activity
Men
Women
All
Inactivity (in my leisure time I read, watch TV, and do other activities in which I do not move much and which do not strain me physically)
26.7
26.3
26.4
Moderate activity (in my leisure time I walk, cycle, and move in other ways at least 4 hours per week)
36.7
53.4
45.6
High activity (in my leisure time I exercise at least 3 hours per week)
27.3
16.8
21.7
Competitive sports (in my leisure time I practice regularly several times per week for competition; choose this also if you spend most of your time in competitive sports)
9.3
3.6
6.3
< 0.01
P (significance of the difference between genders) N
589
674
1263
Childhood Predictors of Physical Inactivity 195
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Table 2 Parental Education, Childhood Adversities, Childhood Family Structure, the Respondents Own Educational Level and Leisure-Time Physical Inactivity (Inactivity %) in Men and Women Aged 18–29 Years, %; The Health 2000 Study, Finland
Parental education Primary level education only Primary level and some vocational Middle level education Secondary school graduate Family structure Two parents Single-parent family or other Childhood adversities (reported adversity) Long-term financial problems Parental regular unemployment Parental serious disease/disability Paternal alcohol problems Maternal alcohol problems Paternal mental health problem Maternal mental health problem Serious conflicts within the family Parental divorce Own serious chronic illness Bullied at school The respondent’s own educational level Primary school only
Vocational school Secondary school graduate Lower-degree level tertiary Higher-degree level tertiary or higher
Men
% Women
All
P
Men
Inactivity (%) Women
All
21.3 30.3 23.2 25.2
17.2 31.0 26.3 25.5
19.1 30.7 24.8 25.4
0.3
26.2 37.7 21.2 17.9
29.7 25.7 25.4 25.2
27.9 31.3 23.6 21.8
93.7 6.3
90.7 9.3
92.1 7.9
0.0
26.1 34.2
25.3 34.9
25.7 34.7
14.7 10.7 12.2 13.8 3.4 2.5 2.7 18.8 19.1 3.0 21.8
19.3 11.8 14.4 19.7 7.3 4.9 5.6 28.9 21.1 4.1 27.0
17.1 11.3 13.4 16.9 5.4 3.8 4.2 24.1 20.2 3.6 24.6
0.0 0.5 0.3 0.0 0.0 0.0 0.0 < 0.01 0.4 0.3 0.0
28.2 33.9 27.1 21.0 25.0 26.7 6.3 24.3 26.8 43.8 32.3
39.1 37.2 33.3 32.3 29.2 34.4 18.9 29.9 29.3 40.7 38.5
34.7 35.7 30.7 28.0 27.9 31.9 15.1 27.9 28.2 41.9 35.9
8.7 38.3 13.2 24.7 15.2
6.5 25.8 12.1 33.9 21.7
7.5 31.7 12.6 29.6 18.6
< 0.01
47.1 32.1 20.5 20.7 16.7
32.6 35.5 22.2 22.7 21.1
40.4 33.6 21.4 21.9 19.4
Note. P = significance of the difference between genders.
health problems, maternal alcohol problem and the respondent’s own serious or chronic illness. In general, women reported childhood adversities more often than men.
The Association of Parental SEP and Childhood Adversities With Leisure-Time Physical Inactivity in Early Adulthood Among women, parental education was not associated with leisuretime physical inactivity (Table 3). However, men whose parents belonged to the 2 lowest categories significantly differed statistically from those whose parents belonged to the highest educational category (OR 1.7, 95% CI 1.0–2.9 for the primary level education and OR 2.8, 95% CI 1.7–4.9 for the primary level education with some vocational education; Table 4, Model 0). These associations remained rather unchanged despite of the adjustment for other childhood factors. However, adjusting for the respondent’s own education attenuated the associations (OR 1.2, 95% CI 0.6–2.1 and OR 2.0, 95% CI 1.2–3.6; Table 4, Model III). Of the most often reported childhood adversities, having been bullied at school was associated with leisure-time physical inactiv-
ity among both genders (women OR 2.1, 95% CI 1.4–3.1 and men OR 1.5, 95% CI 1.0–2.3; Tables 3 and 4, Model 0). The association remained statistically significant after adjusting for parental education, childhood family structure, other childhood adversities, and the respondent´s own education (Models I–III, Tables 3 and 4). Moreover, long-term financial problems (OR 1.6, 95% CI 1.1–2.5) were associated with leisure time physical inactivity among women (Table 3, Model 0). The association remained statistically significant after adjusting for parental education, childhood family structure, childhood adversities, and the respondent’s own educational level (Models I–III). We also tested whether adjusting for early adult chronic conditions had an influence on the significance of the associations between childhood adversities and leisure-time physical activity, but this did not change the results (results not shown). Respondent’s own educational level was associated with leisure time physical inactivity in early adulthood (Tables 3 and 4, Model 0). In men, leisure time physical inactivity was the most common among those with only primary level education (OR 3.8, 95% CI 2.1–6.9) compared to the highest educational category; Table 4, Model 0). The association attenuated slightly after controlling for the childhood conditions, but remained statistically significant (OR
Table 3 Leisure-Time Physical Inactivity by Parental Education, Childhood’s Family Structure, Childhood Adversities, and Respondent’s Own Educational Level in Women Aged 18–29 Years; Sequential Logistic Regression Model, Odds Ratios, and Their 95% Confidence Intervall (OR [95% CI]); The Health 2000 Study, Finland
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Parental education (PE) Primary level education only Primary level and some vocational Middle level education Secondary school graduate Childhood’s family structure (FS) Single-parent family or other Two parents Childhood adversities (CA) Long-term financial problems Parental regular unemployment Own serious chronic illness Bullied at school Respondent’s own educational level (OE) Primary only Vocational school Secondary school graduate, lower-degree or higher-degree level tertiary or higher
Model 0 Univariate
Model I PE+FS
Model II +CA (all)
Model III +OE
1.4 [0.8–2.5] 1.1 [0.7–1.8] 1.1 [0.6–1.7] 1
1.4 [0.8–2.4] 1.1 [0.7–1.8] 1.0 [0.6–1.7] 1
1.2 [0.7–2.1] 1.0 [0.6–1.6] 0.9 [0.5–1.5] 1
0.9 [0.5–1.6] 0.8 [0.5–1.3] 0.8 [0.5–1.3] 1
1.5 [0.9–2.6] 1
1.5 [0.8–2.6] 1
1.3 [0.7–2.3] 1
1.3 [0.7–2.3] 1
1.5 [1.0–2.4] 1.4 [0.8–2.5] 1.5 [0.6–3.4] 2.0 [1.3–3.0]
1.5 [1.0–2.4] 1.3 [0.8–2.3] 1.5 [0.6–3.4] 1.9 [1.3–2.9]
1.6 [1.1–2.5] 1.4 [0.8–2.4] 1.5 [0.6–3.4] 2.1 [1.4–3.1] 1.8 [0.9–3.6] 2.0 [1.3–2.9] 1
1.5 [0.7–3.4] 1.96 [1.3–3.0] 1
Table 4 Leisure-Time Physical Inactivity by Parental Education, Childhood’s Family Structure, Childhood Adversities, and Respondent’s Own Education Level in Men Aged 18–29 Years; Sequential Logistic Regression Model, Odds Ratios, and Their 95% Confidence Intervals (OR [95% CI]); The Health 2000 Study, Finland
Parental education (PE) Primary level education only Primary level and some vocational Middle level education Secondary school graduate Childhood’s family structure (FS) Single-parent family or other Two parents Childhood adversities (CA) Long-term financial problems Parental regular unemployment Own serious chronic illness Bullied at school Respondent’s own educational level (OE) Primary only Vocational school Secondary school graduate, lower-degree or higher-degree level tertiary or higher
196
Model 0 Univariate
Model I PE+FS
Model II +CA (all)
Model III +OE
1.7 [1.0–2.9] 2.8 [1.7–4.9] 1.1 [0.7–1.9] 1
1.6 [0.9–2.9] 2.8 [1.6–4.8] 1.1 [0.6–1.9] 1
1.6 [0.9–2.8] 2.8 [1.6–4.9] 1.1 [0.6–1.8] 1
1.2 [0.6–2.1] 2.0 [1.2–3.6] 0.9 [0.5–1.6] 1
1.6 [0.8–3.3] 1
1.4 [0.6–2.9] 1
1.3 [0.5–3.0] 1
1.2 [0.5–2.7] 1
1.0 [0.5–1.9] 1.4 [0.7–3.1] 2.4 [0.8–7.2] 1.6 [1.0–2.5]
1.0 [0.5–1.8] 1.4 [0.7–3.1] 2.6 [0.8–8.4] 1.6 [1.0–2.6]
1.0 [0.5–1.7] 1.6 [0.8–3.3] 2.1 [0.8–5.8] 1.5 [1.0–2.3] 3.8 [2.1–6.9] 2.1 [1.3–3.2] 1
3.0 [1.4–6.5] 1.8 [1.1–2.8] 1
Childhood Predictors of Physical Inactivity 197
3.0, 95% CI 1.4–6.5; Model III). In addition, those with secondary education were more often physically inactive than those from the highest educational category among men (OR 2.1, 95% CI 1.3–3.2). The association remained statistically significant after controlling for the childhood adversities (Model III). In women, those with vocational education had higher risk of being physically inactive (OR 2.0, 95% CI 1.3–2.9 compared with the highest educational category; Table 3, Model 0).
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Discussion In this study, we examined how parental SEP and various childhood adversities were associated with leisure-time physical inactivity in early adulthood, and whether these associations were mediated through the respondent’s own education. Having been bullied at school was associated with physical inactivity independently of the other childhood circumstances and the respondent’s own education. Low parental education was associated with leisure-time physical inactivity only in men and the association was mediated through the respondent´s own education. However, respondent’s own education had the strongest association with leisure-time physical inactivity in early adulthood; those with only primary or vocational education were more likely to be physically inactive during leisure-time than those with secondary or higher education. According to our results, bullying at school was associated with leisure-time physical inactivity in early adulthood among both genders. A previous study based on the same data21 showed that overweight young adults reported often that they have been bullied at school. In addition, a study from Canada shows that obese children are more likely to be bullied at school.27 It may be that young adults who are physically inactive during leisure-time, have been obese and have also been bullied at school. Both obesity and physical inactivity lead to physical inactivity behaviors in later life. According to our study, the contribution of childhood SEP to leisure-time physical inactivity was not similar among men and women. Among men, low parental education and among women long-term financial problems, were associated with leisure-time physical inactivity in early adulthood. Our interpretation for this is that parental support, social or financial, is critical for being physically active in childhood, and without support an individual might continue to be physically inactive in later life. Our finding is in agreement with our previous studies where poor childhood circumstances were associated with smoking, heavy alcohol consumption and obesity in early adulthood.21–23 We also found that poor childhood circumstances have effects even on adulthood leisure-time physical inactivity, either through adult SEP or through adulthood health behaviors.28 It is also possible that some other factors, such as peer group, youth cultures, and school context, play important roles in the formation of physical activity behaviors.29–34 These factors may have an independent effect on physical activity or interact with other childhood circumstances. Unfortunately, we were not able to examine these factors in this study. The respondent’s own education had the strongest association with leisure-time physical inactivity in early adulthood. Education is one of the key indicators of SEP and it may present the cognitive resources, more favorable living and working conditions, higher income as well as more positive social environment, which all may encourage for physical activity. It has been well documented that lower SEP is associated with physical inactivity and sedentary behaviors.2–4,6–9,13 It has been even suggested that physical activity in adolescence and high parental socioeconomic position are
associated with higher academic performance and future plans for higher education.10 It also might be that unemployment status influences leisure time physical activity, as young people who are not employed have more leisure-time compared with those who are already working. Thus, we adjusted for the respondent´s main economic activity (results not shown), but the observed association between education and leisure-time physical inactivity remained statistically significant. To conclude, both obesity and physical inactivity as well as their interrelationships with bullying in childhood might contribute to physical inactivity behaviors later in life. Moreover, own education career remains to be the strongest predictor of leisuretime physical inactivity in early adulthood. To plan successful physical activity promotion programs for young people, it is essential take into account the unfortunate educational trajectories which may already begin from the childhood circumstances and adversities.
Methodological Considerations Some methodological considerations should be taken into account when interpreting the results. First, physical activity was based on self-reported information and is prone to the recall bias.35 However, it has been shown that self-reported physical activity is very close to objectively measured physical activity and that no remarkable gender or socioeconomic differences exist in self-reported and objectively measured physical activity.12,36,37 Recently, our physical activity questionnaire has been validated against objective physical activity measurement.38 Second, the information on childhood circumstances was based on retrospective reports, and should be interpreted with caution.39–41 For example, respondents may have used different criteria in assessing childhood circumstances. We have, however, no reason to expect that this would be systematic in our data. One weakness of this study is that we did not have any information on individual’s physical activity or other health behaviors in childhood, or information of these within the family. Third, the respondent’s own education did not take into account those who may have temporarily “finished” their education. However, those who later continue their education may resemble in health behaviors to those who already have a higher level of education. We may, therefore, assume that the effect of education on physical activity would be even stronger that what we observed. Fourth, the size of our data only allowed us to report strong associations. The cross-sectional and retrospective nature of the data raises some methodological issues that have been discussed earlier.21–23,42,43 However, the strength of our data was that we were able to include a wide selection of indicators of childhood living conditions, and to study their concordance with adult characteristics. Finally, nonresponse may have influenced our results. However, if those in the nonresponse were more likely to have poorer circumstances than the respondents, our results would be even more pronounced. Acknowledgments The authors would like to acknowledge the contribution of the Department of Health, Functional Capacity and Wellbeing in the National Institute for Health and Welfare (formerly National Institute for Public Health) for collecting and preparing the Health 2000 –data. This work was supported by the Research Program of the Future of Work and Wellbeing, Academy of Finland, the Ministry of Education and Culture, and the Finnish Youth Research Network.
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Int J Behav Nutr Phys Act. 2010;7:79. PubMed doi:10.1186/14795868-7-79 17. Dumith SC, Gigante DP, Domingues MR, Kohl HW, 3rd. Physical activity change during adolescence: a systematic review and a pooled analysis. Int J Epidemiol. 2011;40(3):685–698. PubMed doi:10.1093/ ije/dyq272 18. Gebremariam MK, H Bergh I, F Andersen L, Ommundsen Y, Bjelland M, Lien N. Stability and change in potential correlates of physical activity and association with pubertal status among Norwegian children in the transition between childhood and adolescence. Int J Behav Nutr Phys Act. 2012;9:56. PubMed doi:10.1186/1479-5868-9-56 19. Graham DJ, Bauer KW, Friend S, Barr-Anderson DJ, NuemarkSztainer D. Personal, behavioral, and socio-environmental correlates of physical activity among adolescent girls: cross-sectional and longitudinal associations. J Phys Act Health. 2014;11(1):51–61. PubMed 20. Young D, Saksvig BI, Wu TT, et al. Multilevel correlates of physical activity for early, mid, and late adolescent girls. J Phys Act Health. 2014;11(5):950–60. PubMed 21. Kestilä L, Rahkonen O, Martelin T, Lahti-Koski M, Koskinen S. Do childhood social circumstances affect overweight and obesity in early adulthood? Scand J Public Health. 2009;37(2):206–219. PubMed doi:10.1177/1403494808100827 22. Kestilä L, Koskinen S, Martelin T, et al. Influence of parental education, childhood adversities, and current living conditions on daily smoking in early adulthood. Eur J Public Health. 2006;16(6):617–626. PubMed doi:10.1093/eurpub/ckl054 23. Kestilä L, Martelin T, Rahkonen O, et al. Childhood and current determinants of heavy drinking in early adulthood. Alcohol. 2008;43(4):460–469. PubMed doi:10.1093/alcalc/agn018 24. Aromaa A, Koskinen S, eds. Health and Functional Capacity in Finland. Baseline Results of the Health 2000 Health Examination Survey. Helsinki, Finland: Hakapaino Oy; 2004. Publications of the National Public Health Institute (KTL). 25. Lehtonen R, Pahkinen EJ. Practical methods for design and analysis of complex surveys. 2nd ed. Chichester, England: John Wiley & Sons, Ltd.; 1994. 26. SAS Institute Inc. SAS/STAT 9.2 User’s Guide. 2008. 27. Janssen I, Craig WM, Boyce WF, Pickett W. Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics. 2004;113(5):1187–1194. PubMed doi:10.1542/ peds.113.5.1187 28. Mäkinen T, Kestilä L, Borodulin K, Martelin T, Rahkonen O, Prättälä R. Effects of childhood socio-economic conditions on educational differences in leisure-time physical activity. Eur J Public Health. 2010;20(3):346–353. PubMed doi:10.1093/eurpub/ckp187 29. Bahr SJ, Marcos AC, Maughan SL. Family, educational and peer influences on the alcohol use of female and male adolescents. J Stud Alcohol. 1995;56(4):457–469. PubMed 30. Bonomo Y. Early onset of drinking increases alcohol use in adulthood. Evid Based Ment Health. 2005;8(4):98. PubMed doi:10.1136/ ebmh.8.4.98 31. D’Amico EJ, Ellickson PL, Collins RL, Martino S, Klein DJ. Processes linking adolescent problems to substance-use problems in late young adulthood. J Stud Alcohol. 2005;66(6):766–775. PubMed 32. Holman TB, Jensen L, Capell M, Woodard F. Predicting alcohol use among young adults. Addict Behav. 1993;18(1):41–49. PubMed doi:10.1016/0306-4603(93)90007-V 33. Jones-Webb R, Short B, Wagenaar A, et al. Environmental predictors of drinking and drinking-related problems in young adults. J Drug Educ. 1997;27(1):67–82. PubMed doi:10.2190/RJYG-D5C3-H2F0-GJ0L 34. Pitkänen T, Lyyra AL, Pulkkinen L. Age of onset of drinking and the use of alcohol in adulthood: a follow-up study from age 8-42
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Childhood Predictors of Physical Inactivity 199 for females and males. Addiction. 2005;100(5):652–661. PubMed doi:10.1111/j.1360-0443.2005.01053.x 35. Lissner L, Potischman N, Troiano R, Bengtsson C. Recall of physical activity in the distant past: the 32-year follow-up of the Prospective Population Study of Women in Goteborg, Sweden. Am J Epidemiol. 2004;159(3):304–307. PubMed doi:10.1093/aje/kwh048 36. Pettee KK, Storti KL, Ainsworth BE, Kriska AM. Measurement of Physical Activity and Inactivity in Epidemiologic Studies. In: Lee IM, Blair SN, Manson JE, Paffenbarger RS, eds. Epidemiologic methods in physical acivity studies. New York: Oxford University Press; 2009:15–33. 37. Slootmaker SM, Schuit AJ, Chinapaw MJ, Seidell JC, van Mechelen W. Disagreement in physical activity assessed by accelerometer and self-report in subgroups of age, gender, education and weight status. Int J Behav Nutr Phys Act. 2009;6:17. PubMed doi:10.1186/14795868-6-17 38. Fagt S, Andersen LF, Anderssen SA, et al. Nordic monitoring of diet, physical activity and overweight. Validation of indicators. Denmark: Kailow Express ApS; 2011. 39. Dube SR, Williamson DF, Thompson T, Felitti VJ, Anda RF. Assessing the reliability of retrospective reports of adverse childhood experi-
ences among adult HMO members attending a primary care clinic. Child Abuse Negl. 2004;28(7):729–737. PubMed doi:10.1016/j. chiabu.2003.08.009 40. Hardt J, Rutter M. Validity of adult retrospective reports of adverse childhood experiences: review of the evidence. J Child Psychol Psychiatry. 2004;45(2):260–273. PubMed doi:10.1111/j.14697610.2004.00218.x 41. O’Malley SS, Carey KB, Maisto SA. Validity of young adults’ reports of parental drinking practices. J Stud Alcohol. 1986;47(5):433–435. PubMed 42. Kestilä L, Koskinen S, Martelin T, et al. Determinants of health in early adulthood: what is the role of parental education, childhood adversities and own education? Eur J Public Health. 2006;16(3):306–315. PubMed doi:10.1093/eurpub/cki164 43. Pirkola S, Isometsa E, Aro H, et al. Childhood adversities as risk factors for adult mental disorders: results from the Health 2000 study. Soc Psychiatry Psychiatr Epidemiol. 2005;40(10):769–777. PubMed doi:10.1007/s00127-005-0950-x
Official Journal of ISPAH www.JPAH-Journal.com ORIGINAL RESEARCH
Childhood Adversities and Socioeconomic Position as Predictors of Leisure-Time Physical Inactivity in Early Adulthood Laura Kestilä, Tomi Mäki-Opas, Anton E Kunst, Katja Borodulin, Ossi Rahkonen, and Ritva Prättälä Background: Limited knowledge exists on how childhood social, health-related and economic circumstances predict adult physical inactivity. Our aim was a) to examine how various childhood adversities and living conditions predict leisure-time physical inactivity in early adulthood and b) to find out whether these associations are mediated through the respondent’s own education. Methods: Young adults aged 18–29 were used from the Health 2000 Study of the Finnish. The cross-sectional data were based on interviews and questionnaires including retrospective information on childhood circumstances. The analyses were carried out on 68% of the original sample (N = 1894). The outcome measure was leisure-time physical inactivity. Results: Only a few of the 11 childhood adversities were related with physical activity in early adulthood. Having been bullied at school was associated with physical inactivity independently of the other childhood circumstances and the respondent’s own education. Low parental education predicted leisure-time physical inactivity in men and the association was mediated by the respondent´s own education. Respondents with only primary or vocational education were more likely to be physically inactive during leisure-time compared with those with secondary or higher education. Conclusions: There is some evidence that few specific childhood adversities, especially bullying at school, have long-lasting effects on physical activity levels. Keywords: young adults, life course, education, Finland Physical inactivity is considered to be a risk factor for health and well-being;1 there is a concern about its potential effect on current as well as on later psychological and physiological health. Physical activity provides important health benefits for young people and later in adulthood. However, the information on the effects of various childhood social, economic and health-related factors on physical activity in early adulthood is scarce. In adolescence, according to earlier Finnish studies, low parental socioeconomic position (SEP) has been suggested to associate with low physical activity2 and high parental education with high physical activity.3 There is also some evidence that parental SEP is associated with leisure-time physical activity in early adulthood4 and that childhood socioeconomic circumstances explain partly the educational differences in leisure-time physical activity later in adulthood.5 Several European studies have reported that parental SEP is associated with physical inactivity and sedentary behaviors in adolescence6,7 and even in adulthood.8,9 In addition, physical inactivity in youth is also associated with several emotional and behavioral problems.10,11 Although the factors determining physical activity have been studied earlier,12–20 very few studies have been able to examine different aspects of childhood living conditions and problems. Moreover, little is known about the relative importance of past and present socioeconomic circumstances on physical activity. In previous studies from the same data,21–23 it was found that several childhood circumstances predicted other health behaviors such
as smoking and heavy drinking, as well as obesity. The effects were partly independent and partly mediated by later early adult circumstances. In this study, our main objective was to explore the associations between various indicators of economic, social and health-related problems in childhood and leisure time physical inactivity in early adulthood. In more detail, the aims of the study were a) to examine how various childhood living conditions and adversities predict leisure-time physical inactivity in early adulthood and b) to find out whether these associations are mediated through the respondent’s education.
Data and Methods Participants This study is based on a sample of 1894 young adults aged 18 to 29 in Finland. The two-stage cluster sample was representative of the entire country. The data were collected in 2000–2001 as part of the Health 2000 Survey.24 The information was obtained with standardized computer-aided interviews (CAPI) and self-administered questionnaires. The participation rate among young adults was relatively high; 68% returned the self-administered questionnaire that included the questions concerning childhood adversities and leisure-time physical activity.
Measures Kestilä is with the Dept of Social and Health Care Systems, National Institute for Health and Welfare (THL), Helsinki, Finland. Mäki-Opas (tomi. [email protected]), Borodulin, and Prättälä are with the Dept of Health, National Institute for Health and Welfare (THL), Helsinki, Finland. Kunst is with the Academic Medical Centre (AMC), University of Amsterdam, the Netherlands. Rahkonen is with the Dept of Public Health, Hjelt Institute, University of Helsinki, Finland.
Outcome Measures. The physical activity was assessed by a
question “How much do you exercise and strain yourself physically in your leisure time?” with 4 response alternatives: 1) In my leisure time I read, watch TV, and do other activities in which I do not move much and which do not strain me physically; 2) In my leisure time I walk, cycle, and move in other ways at least 4 hours per week; 3) In my leisure time I exercise at least 3 hours per week; and 4) In my leisure 193
194 Kestilä et al
time I practice regularly several times per week for competition (choose this also if you spend most of your time in competitive sports). The first response alternative was used as describing the leisure-time physical inactivity and was analyzed against the other alternatives, which were combined to the same category. Parental Educational Level and Childhood Living Conditions.
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Parental education was based on the participant’s response concerning his/her mother’s and father’s basic and vocational education. The parent with the higher education was chosen to indicate parental education. Family structure was based on the question “When starting school (ie, when you were about 7 years old), did you live . . . ?” with 4 possible response alternatives: “at home with both your parents,” “with only one parent,” “with relatives such as grandparents,” and “in an orphanage or other institution,” and it was categorized into 2 groups (“two parents” and “single-parent or other”). Childhood Adversities. Childhood adversities were based on the question “When you think about your growth years, ie, before you were aged 16, did you experience any of the following?” The respondents were able to select the following answers: “No,” “Yes,” and “Can’t say.” Eleven adversities were described: 1) long-term financial problems, 2) parental regular unemployment, 3) parental serious disease or disability, 4) paternal alcohol problems, 5) maternal alcohol problems, 6) paternal mental health problems, 7) maternal mental health problems, 8) serious conflicts within the family, 9) parental divorce, 10) own serious chronic illness, and 11) being bullied at school. In general, the pairwise correlations between different childhood adversities were below 0.4. The childhood adversities were analyzed with dichotomous variables: “Yes” or “No,” where the option “Can’t say” was combined with the option “No.” The Respondent’s Own Educational Level. Respondent’s own education was based on the highest completed degree. Because many persons were still studying (21%), the measure for students was based on the expected level of education assuming the person to complete the ongoing studies. Three categories were constructed: “only primary school,” “vocational school,” and “secondary school graduate or higher.”
Statistical Analysis First, we present the distribution of leisure-time physical activity by its volume in men and women (Table 1). We also present the prevalence of different childhood living conditions and current living conditions by gender as well as the prevalence of physical inactivity in different sub-groups (Table 2). The significance of the difference between genders is presented for all variables (chi-square). Second, the associations between leisure-time physical inactivity and childhood as well as current determinants, were analyzed (Tables 3 and 4). The significance of the interactions between gender and all explanatory factors were first tested. Since significant interactions were found, we stratified the further analyses by gender. To assess pathways between the predictors, the variables were added to the logistic regression model sequentially, starting with the factors concerning early childhood (around age 7), followed by variables describing the living conditions at a later phase (before age 16). At the next stage, the models were adjusted for the effect of the respondent´s own educational level. Results are presented as prevalence and odds ratios (ORs) with 95% confidence intervals (CI). The sampling design and nonresponse were accounted for by using poststratification weights25 constructed specifically for the dataset and analyzed by SAS software program, version 9.2.26
Results Characteristics of the Study Population In general, leisure time physical activity was more common in men compared with women. However, women were more often moderately physically active during leisure time. The prevalence of being physically inactive during leisure time was almost the same among both genders (Table 1). Childhood adversities included paternal alcohol problem, long-term financial problems in the family, parents’ divorce, serious conflicts within the family, parents’ serious illness, or disability and bullying at school (13% to 29%; Table 2). Less frequently (2% to 8%) reported adversities were parental mental
Table 1 Leisure-Time Physical Activity by its Volume in Men and Women Aged 18–29 years, %; The Health 2000 Study, Finland Leisure-time physical activity
Men
Women
All
Inactivity (in my leisure time I read, watch TV, and do other activities in which I do not move much and which do not strain me physically)
26.7
26.3
26.4
Moderate activity (in my leisure time I walk, cycle, and move in other ways at least 4 hours per week)
36.7
53.4
45.6
High activity (in my leisure time I exercise at least 3 hours per week)
27.3
16.8
21.7
Competitive sports (in my leisure time I practice regularly several times per week for competition; choose this also if you spend most of your time in competitive sports)
9.3
3.6
6.3
< 0.01
P (significance of the difference between genders) N
589
674
1263
Childhood Predictors of Physical Inactivity 195
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Table 2 Parental Education, Childhood Adversities, Childhood Family Structure, the Respondents Own Educational Level and Leisure-Time Physical Inactivity (Inactivity %) in Men and Women Aged 18–29 Years, %; The Health 2000 Study, Finland
Parental education Primary level education only Primary level and some vocational Middle level education Secondary school graduate Family structure Two parents Single-parent family or other Childhood adversities (reported adversity) Long-term financial problems Parental regular unemployment Parental serious disease/disability Paternal alcohol problems Maternal alcohol problems Paternal mental health problem Maternal mental health problem Serious conflicts within the family Parental divorce Own serious chronic illness Bullied at school The respondent’s own educational level Primary school only
Vocational school Secondary school graduate Lower-degree level tertiary Higher-degree level tertiary or higher
Men
% Women
All
P
Men
Inactivity (%) Women
All
21.3 30.3 23.2 25.2
17.2 31.0 26.3 25.5
19.1 30.7 24.8 25.4
0.3
26.2 37.7 21.2 17.9
29.7 25.7 25.4 25.2
27.9 31.3 23.6 21.8
93.7 6.3
90.7 9.3
92.1 7.9
0.0
26.1 34.2
25.3 34.9
25.7 34.7
14.7 10.7 12.2 13.8 3.4 2.5 2.7 18.8 19.1 3.0 21.8
19.3 11.8 14.4 19.7 7.3 4.9 5.6 28.9 21.1 4.1 27.0
17.1 11.3 13.4 16.9 5.4 3.8 4.2 24.1 20.2 3.6 24.6
0.0 0.5 0.3 0.0 0.0 0.0 0.0 < 0.01 0.4 0.3 0.0
28.2 33.9 27.1 21.0 25.0 26.7 6.3 24.3 26.8 43.8 32.3
39.1 37.2 33.3 32.3 29.2 34.4 18.9 29.9 29.3 40.7 38.5
34.7 35.7 30.7 28.0 27.9 31.9 15.1 27.9 28.2 41.9 35.9
8.7 38.3 13.2 24.7 15.2
6.5 25.8 12.1 33.9 21.7
7.5 31.7 12.6 29.6 18.6
< 0.01
47.1 32.1 20.5 20.7 16.7
32.6 35.5 22.2 22.7 21.1
40.4 33.6 21.4 21.9 19.4
Note. P = significance of the difference between genders.
health problems, maternal alcohol problem and the respondent’s own serious or chronic illness. In general, women reported childhood adversities more often than men.
The Association of Parental SEP and Childhood Adversities With Leisure-Time Physical Inactivity in Early Adulthood Among women, parental education was not associated with leisuretime physical inactivity (Table 3). However, men whose parents belonged to the 2 lowest categories significantly differed statistically from those whose parents belonged to the highest educational category (OR 1.7, 95% CI 1.0–2.9 for the primary level education and OR 2.8, 95% CI 1.7–4.9 for the primary level education with some vocational education; Table 4, Model 0). These associations remained rather unchanged despite of the adjustment for other childhood factors. However, adjusting for the respondent’s own education attenuated the associations (OR 1.2, 95% CI 0.6–2.1 and OR 2.0, 95% CI 1.2–3.6; Table 4, Model III). Of the most often reported childhood adversities, having been bullied at school was associated with leisure-time physical inactiv-
ity among both genders (women OR 2.1, 95% CI 1.4–3.1 and men OR 1.5, 95% CI 1.0–2.3; Tables 3 and 4, Model 0). The association remained statistically significant after adjusting for parental education, childhood family structure, other childhood adversities, and the respondent´s own education (Models I–III, Tables 3 and 4). Moreover, long-term financial problems (OR 1.6, 95% CI 1.1–2.5) were associated with leisure time physical inactivity among women (Table 3, Model 0). The association remained statistically significant after adjusting for parental education, childhood family structure, childhood adversities, and the respondent’s own educational level (Models I–III). We also tested whether adjusting for early adult chronic conditions had an influence on the significance of the associations between childhood adversities and leisure-time physical activity, but this did not change the results (results not shown). Respondent’s own educational level was associated with leisure time physical inactivity in early adulthood (Tables 3 and 4, Model 0). In men, leisure time physical inactivity was the most common among those with only primary level education (OR 3.8, 95% CI 2.1–6.9) compared to the highest educational category; Table 4, Model 0). The association attenuated slightly after controlling for the childhood conditions, but remained statistically significant (OR
Table 3 Leisure-Time Physical Inactivity by Parental Education, Childhood’s Family Structure, Childhood Adversities, and Respondent’s Own Educational Level in Women Aged 18–29 Years; Sequential Logistic Regression Model, Odds Ratios, and Their 95% Confidence Intervall (OR [95% CI]); The Health 2000 Study, Finland
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Parental education (PE) Primary level education only Primary level and some vocational Middle level education Secondary school graduate Childhood’s family structure (FS) Single-parent family or other Two parents Childhood adversities (CA) Long-term financial problems Parental regular unemployment Own serious chronic illness Bullied at school Respondent’s own educational level (OE) Primary only Vocational school Secondary school graduate, lower-degree or higher-degree level tertiary or higher
Model 0 Univariate
Model I PE+FS
Model II +CA (all)
Model III +OE
1.4 [0.8–2.5] 1.1 [0.7–1.8] 1.1 [0.6–1.7] 1
1.4 [0.8–2.4] 1.1 [0.7–1.8] 1.0 [0.6–1.7] 1
1.2 [0.7–2.1] 1.0 [0.6–1.6] 0.9 [0.5–1.5] 1
0.9 [0.5–1.6] 0.8 [0.5–1.3] 0.8 [0.5–1.3] 1
1.5 [0.9–2.6] 1
1.5 [0.8–2.6] 1
1.3 [0.7–2.3] 1
1.3 [0.7–2.3] 1
1.5 [1.0–2.4] 1.4 [0.8–2.5] 1.5 [0.6–3.4] 2.0 [1.3–3.0]
1.5 [1.0–2.4] 1.3 [0.8–2.3] 1.5 [0.6–3.4] 1.9 [1.3–2.9]
1.6 [1.1–2.5] 1.4 [0.8–2.4] 1.5 [0.6–3.4] 2.1 [1.4–3.1] 1.8 [0.9–3.6] 2.0 [1.3–2.9] 1
1.5 [0.7–3.4] 1.96 [1.3–3.0] 1
Table 4 Leisure-Time Physical Inactivity by Parental Education, Childhood’s Family Structure, Childhood Adversities, and Respondent’s Own Education Level in Men Aged 18–29 Years; Sequential Logistic Regression Model, Odds Ratios, and Their 95% Confidence Intervals (OR [95% CI]); The Health 2000 Study, Finland
Parental education (PE) Primary level education only Primary level and some vocational Middle level education Secondary school graduate Childhood’s family structure (FS) Single-parent family or other Two parents Childhood adversities (CA) Long-term financial problems Parental regular unemployment Own serious chronic illness Bullied at school Respondent’s own educational level (OE) Primary only Vocational school Secondary school graduate, lower-degree or higher-degree level tertiary or higher
196
Model 0 Univariate
Model I PE+FS
Model II +CA (all)
Model III +OE
1.7 [1.0–2.9] 2.8 [1.7–4.9] 1.1 [0.7–1.9] 1
1.6 [0.9–2.9] 2.8 [1.6–4.8] 1.1 [0.6–1.9] 1
1.6 [0.9–2.8] 2.8 [1.6–4.9] 1.1 [0.6–1.8] 1
1.2 [0.6–2.1] 2.0 [1.2–3.6] 0.9 [0.5–1.6] 1
1.6 [0.8–3.3] 1
1.4 [0.6–2.9] 1
1.3 [0.5–3.0] 1
1.2 [0.5–2.7] 1
1.0 [0.5–1.9] 1.4 [0.7–3.1] 2.4 [0.8–7.2] 1.6 [1.0–2.5]
1.0 [0.5–1.8] 1.4 [0.7–3.1] 2.6 [0.8–8.4] 1.6 [1.0–2.6]
1.0 [0.5–1.7] 1.6 [0.8–3.3] 2.1 [0.8–5.8] 1.5 [1.0–2.3] 3.8 [2.1–6.9] 2.1 [1.3–3.2] 1
3.0 [1.4–6.5] 1.8 [1.1–2.8] 1
Childhood Predictors of Physical Inactivity 197
3.0, 95% CI 1.4–6.5; Model III). In addition, those with secondary education were more often physically inactive than those from the highest educational category among men (OR 2.1, 95% CI 1.3–3.2). The association remained statistically significant after controlling for the childhood adversities (Model III). In women, those with vocational education had higher risk of being physically inactive (OR 2.0, 95% CI 1.3–2.9 compared with the highest educational category; Table 3, Model 0).
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Discussion In this study, we examined how parental SEP and various childhood adversities were associated with leisure-time physical inactivity in early adulthood, and whether these associations were mediated through the respondent’s own education. Having been bullied at school was associated with physical inactivity independently of the other childhood circumstances and the respondent’s own education. Low parental education was associated with leisure-time physical inactivity only in men and the association was mediated through the respondent´s own education. However, respondent’s own education had the strongest association with leisure-time physical inactivity in early adulthood; those with only primary or vocational education were more likely to be physically inactive during leisure-time than those with secondary or higher education. According to our results, bullying at school was associated with leisure-time physical inactivity in early adulthood among both genders. A previous study based on the same data21 showed that overweight young adults reported often that they have been bullied at school. In addition, a study from Canada shows that obese children are more likely to be bullied at school.27 It may be that young adults who are physically inactive during leisure-time, have been obese and have also been bullied at school. Both obesity and physical inactivity lead to physical inactivity behaviors in later life. According to our study, the contribution of childhood SEP to leisure-time physical inactivity was not similar among men and women. Among men, low parental education and among women long-term financial problems, were associated with leisure-time physical inactivity in early adulthood. Our interpretation for this is that parental support, social or financial, is critical for being physically active in childhood, and without support an individual might continue to be physically inactive in later life. Our finding is in agreement with our previous studies where poor childhood circumstances were associated with smoking, heavy alcohol consumption and obesity in early adulthood.21–23 We also found that poor childhood circumstances have effects even on adulthood leisure-time physical inactivity, either through adult SEP or through adulthood health behaviors.28 It is also possible that some other factors, such as peer group, youth cultures, and school context, play important roles in the formation of physical activity behaviors.29–34 These factors may have an independent effect on physical activity or interact with other childhood circumstances. Unfortunately, we were not able to examine these factors in this study. The respondent’s own education had the strongest association with leisure-time physical inactivity in early adulthood. Education is one of the key indicators of SEP and it may present the cognitive resources, more favorable living and working conditions, higher income as well as more positive social environment, which all may encourage for physical activity. It has been well documented that lower SEP is associated with physical inactivity and sedentary behaviors.2–4,6–9,13 It has been even suggested that physical activity in adolescence and high parental socioeconomic position are
associated with higher academic performance and future plans for higher education.10 It also might be that unemployment status influences leisure time physical activity, as young people who are not employed have more leisure-time compared with those who are already working. Thus, we adjusted for the respondent´s main economic activity (results not shown), but the observed association between education and leisure-time physical inactivity remained statistically significant. To conclude, both obesity and physical inactivity as well as their interrelationships with bullying in childhood might contribute to physical inactivity behaviors later in life. Moreover, own education career remains to be the strongest predictor of leisuretime physical inactivity in early adulthood. To plan successful physical activity promotion programs for young people, it is essential take into account the unfortunate educational trajectories which may already begin from the childhood circumstances and adversities.
Methodological Considerations Some methodological considerations should be taken into account when interpreting the results. First, physical activity was based on self-reported information and is prone to the recall bias.35 However, it has been shown that self-reported physical activity is very close to objectively measured physical activity and that no remarkable gender or socioeconomic differences exist in self-reported and objectively measured physical activity.12,36,37 Recently, our physical activity questionnaire has been validated against objective physical activity measurement.38 Second, the information on childhood circumstances was based on retrospective reports, and should be interpreted with caution.39–41 For example, respondents may have used different criteria in assessing childhood circumstances. We have, however, no reason to expect that this would be systematic in our data. One weakness of this study is that we did not have any information on individual’s physical activity or other health behaviors in childhood, or information of these within the family. Third, the respondent’s own education did not take into account those who may have temporarily “finished” their education. However, those who later continue their education may resemble in health behaviors to those who already have a higher level of education. We may, therefore, assume that the effect of education on physical activity would be even stronger that what we observed. Fourth, the size of our data only allowed us to report strong associations. The cross-sectional and retrospective nature of the data raises some methodological issues that have been discussed earlier.21–23,42,43 However, the strength of our data was that we were able to include a wide selection of indicators of childhood living conditions, and to study their concordance with adult characteristics. Finally, nonresponse may have influenced our results. However, if those in the nonresponse were more likely to have poorer circumstances than the respondents, our results would be even more pronounced. Acknowledgments The authors would like to acknowledge the contribution of the Department of Health, Functional Capacity and Wellbeing in the National Institute for Health and Welfare (formerly National Institute for Public Health) for collecting and preparing the Health 2000 –data. This work was supported by the Research Program of the Future of Work and Wellbeing, Academy of Finland, the Ministry of Education and Culture, and the Finnish Youth Research Network.
198 Kestilä et al
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