The education-health gradient: Revisiting the role of socio-emotional skills.

Is the education-health gradient inflated because both education and health are associated with unobserved socio-emotional skills? We find that the gradient in health behaviors and outcomes is reduced by about 15 to 50% from accounting for fine-grained personality facets and up to another 50% from Locus of Control. Traditional aggregated Big-Five scales, however, have a much smaller contribution to the gradient. We use sibling-fixed effects to net out the contribution from genes and shared childhood environment, decomposing the gradient into its components with an order-invariant method. We rely on a large survey (N = 28,261) linked to high-quality Danish administrative registers with information on parental background and objectively measured diagnoses and care use. Accounting for Locus of Control yields the strongest gradient reduction in self-rated health status and objective diagnoses (30%-50%), and in health behaviors the most important factor is Extraversion, a skill that has been shown to be malleable in interventions.

Family wellbeing in general practice: a study protocol for a cluster-randomised trial of the web-based resilience programme on early child development.

BACKGROUND: Social, emotional and behavioural problems in early childhood are associated with increased risk for a wide range of poor outcomes associated with substantial cost and impact on society as a whole. Some of these problems are rooted in the early mother-infant relationship and might be prevented. In Denmark, primary health care has a central role in preventive care during pregnancy and the first years of the child's life and general practice provides opportunities to promote a healthy mother-infant relationship in early parenthood. OBJECTIVE: In the context of standardised antenatal and child development assessments focused on psychosocial wellbeing, we examine the impact of a complex intervention designed to improve maternal mentalisation skills, involving training of general practice clinicians and signposting towards a web-based resource. Joint main outcomes are child socio-emotional and language development at age 30 months measured by parentally reported questionnaires (Communicative Development Inventory and Strengths and Difficulties Questionnaire). METHODS: The study is a cluster-randomised controlled trial based in general practices in the Capital Region and the Zealand Region of Denmark. Seventy practices were included. Practices were randomised by a computer algorithm in a ratio of 1:1 to intervention or control groups. Each practice was asked to recruit up to 30 women consecutively at their first scheduled antenatal assessment. Clinicians in both groups received one day of training in preventive antenatal and child development consultations with added focus on parental psychosocial well-being, social support, and parent-child interaction. These preventive consultations delivered in both trial arms require enhanced data recording about psychosocial factors. In intervention clinics, clinicians were asked to signpost a web page at three scheduled antenatal consultations and at four scheduled consultations when the child is 5 weeks, 5 months, 1 and 2 years. DISCUSSION: We hypothesise that the intervention will increase mothers' ability to be sensitive to their child's mental state to an extent that improves the child's language and mental state at 30 months of age measured by parent-reported questionnaires. TRIAL REGISTRATION: ClinicalTrials.gov NCT04129359. Registered on Oct 16 2019.

Trading off fiscal budget adherence and child protection.

Many countries delegate a substantial part of social service decisions to local administrative levels, while federal laws provide the overall framework for service levels. Strict regulations to reduce budget overruns may however leave local governments with a potential trade-off between adhering to fiscal budgets and supplying critical welfare services as e.g. programs to protect vulnerable children. We investigate if budgetary constraints influence child protection decisions using high-quality register data. We show that the introduction of fiscal sanctions to improve budget adherence contributed to a sharp decline in budget overruns on child protective services by reducing the number of children in out-of-home care. Our results further show that monthly variation in budget adherence within a fiscal year affects the probability of a placement in out-of-home care for children in need of help towards the end of a fiscal year. We estimate that a budget overrun of 10 percentage points by mid-year leads to a 1.2 percent reduction in the number of children in care over the remaining part of the fiscal year. Municipalities reduced child protection expenditure by choosing cheaper types of care and ending placement for children in out-of-home care, particularly for children turning 18. Our paper contributes to the literature on fiscal federalism by documenting the trade-off between managing public expenditure and providing safety and equal opportunity for vulnerable children. We thus highlight that enforcing strict budget adherence may be in conflict with social policy goals. Our results raise an important discussion about centralization versus delegation of critical public services.

Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries.

Importance: The average health outcomes in the US are not as good as the average health outcomes in other developed countries. However, whether high-income US citizens have better health outcomes than average individuals in other developed countries is unknown. Objective: To assess whether the health outcomes of White US citizens living in the 1% and 5% richest counties (hereafter referred to as privileged White US citizens) are better than the health outcomes of average residents in other developed countries. Design, Setting, and Participants: This comparative effectiveness study, conducted from January 1, 2013, to December 31, 2015, identified White US citizens living in the 1% (n = 32) and 5% (n = 157) highest-income counties in the US and measured the following 6 health outcomes associated with health care interventions: infant and maternal mortality, colon and breast cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction. The study used Organisation for Economic Co-operation and Development data, CONCORD-3 cancer data, and Medicare data to compare their outcomes with all residents in 12 other developed countries: Australia, Austria, Canada, Denmark, Finland, France, Germany, Japan, the Netherlands, Norway, Sweden, and Switzerland. Statistical analysis took place from July 25, 2017, to August 29, 2020. Main Outcomes and Measures: Infant mortality; maternal mortality; 5-year survival of patients with colon cancer, breast cancer, or childhood acute lymphocytic leukemia; and 30-day age-standardized case fatality after acute myocardial infarction. Results: The infant mortality rate among White US citizens in the 5% highest-income counties was 4.01 per 1000, and the maternal mortality rate among White US citizens in the 5% highest-income counties was 10.85 per 100 000, both higher than the mean rates for any of the 12 comparison countries. (The infant mortality rate for the top 1% counties was 3.54 per 1000, and the maternal mortality rate was 10.05 per 100 000.) The 5-year survival rate for White US citizens in the 5% highest-income counties was 67.2% (95% CI, 66.7%-67.7%) for colon cancer, higher than that of average US citizens (64.9% [95% CI, 64.7%-65.1%]) and average citizens in 6 countries, comparable with that of average citizens in 4 countries, and lower than that of average citizens for 2 countries. The 5-year survival rate for breast cancer among White US women in the 5% highest-income US counties was 92.0% (95% CI, 91.6%-92.4%), higher than in all 12 comparison countries. The 5-year survival rate for White children with acute lymphocytic leukemia in the 5% highest-income US counties was 92.6% (95% CI, 90.7%-94.2%), exceeding the mean survival rate for only 1 country and comparable with the mean survival rates in 11 countries. The adjusted 30-day acute myocardial infarction case-fatality rate for White US citizens in the 5% highest-income US counties was 8% below the rate for all US citizens and was 5% below the rate for all US citizens in the 1% highest-income US counties; these estimates were similar to the median outcome of other high-income countries. Conclusions and Relevance: This study suggests that privileged White US citizens have better health outcomes than average US citizens for 6 health outcomes but often fare worse than the mean measure of health outcomes of 12 other developed countries. These findings imply that even if all US citizens experienced the same health outcomes enjoyed by privileged White US citizens, US health indicators would still lag behind those in many other countries.

The Wealth of Parents: Trends Over Time in Assortative Mating Based on Parental Wealth.

This article describes trends in parental wealth homogamy among union cohorts formed between 1987 and 2013 in Denmark. Using high-quality register data on the wealth of parents during the year of partnering, we show that the correlation between partners' levels of parental wealth is considerably lower compared with estimates from research on other countries. Nonetheless, parental wealth homogamy is high at the very top of the parental wealth distribution, and individuals from wealthy families are relatively unlikely to partner with individuals from families with low wealth. Parental wealth correlations among partners are higher when only parental assets rather than net wealth are examined, implying that the former might be a better measure for studying many social stratification processes. Most specifications indicate that homogamy increased in the 2000s relative to the 1990s, but trends can vary depending on methodological choices. The increasing levels of parental wealth homogamy raise concerns that over time, partnering behavior has become more consequential for wealth inequality between couples.

The contagious nature of a vaccine scare: How the introduction of HPV vaccination lifted and eroded MMR vaccination in Denmark.

BACKGROUND: Human papillomavirus (HPV) vaccine coverage was high in Denmark until it plunged following negative media coverage. We examined whether the decline in HPV vaccination undermined uptake of another adolescent vaccine, measles, mumps and rubella (MMR). METHODS: The Danish national health register provided data on uptake of MMR vaccine dose 2 (at age 13) for children born from 1991 to 2003 (n = 827,716). The primary exposure variable comprised three time periods: before HPV vaccine introduction, during high HPV vaccine coverage, and after the drop in HPV vaccine coverage. To examine the effect of HPV vaccination on MMR2 uptake, we estimated MMR2 uptake by age 13 using logistic regression, controlling for gender, birth month, birth year, and maternal education. FINDINGS: MMR2 vaccination coverage was high for both girls and boys (86% and 85%) in 2009. Following the introduction of HPV vaccine for girls in 2009, MMR2 coverage increased for girls even as it decreased for boys (gender gap 4·6 percentage points, 95% CI 4·3 to 4·8). Coverage with MMR2 for girls continued to be high over the following four years, and almost all girls (91%) who received MMR2 vaccination also received HPV1 vaccination within the same week. When negative media coverage led to a decline in HPV vaccination, MMR2 uptake for girls also declined. By 2015, MMR2 coverage for girls and boys had become similar again (80% and 79%). Families with the highest level of maternal education showed the strongest decline in MMR2 coverage for girls. INTERPRETATION: Concomitant vaccine provision can increase overall vaccine uptake. However, reduced demand for one vaccine may reduce concomitant vaccination and undermine resiliency of a country's vaccination program. FUNDING: Drs. Gørtz and Ejrnæs appreciate generous funding from the Novo Nordisk Foundation (grant no. NNF17OC0026542) and from the Danish National Research Foundation through its grant (DNRF-134) to the Center for Economic Behavior and Inequality (CEBI) at the University of Copenhagen.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

Employment effects of active labor market programs for sick-listed workers.

We use register data of 88,948 sick-listed workers in Denmark over the period 2008-2011 to investigate the effect of active labor market programs on the duration until returning to non-subsidized employment and the duration of this employment. To identify causal treatment effects, we exploit over-time variation in the use of active labor market programs in 98 job centers and time-to- event. We find that ordinary education and subsidized job training have significant positive employment effects. Subsidized job training has a large, positive effect on the transition into employment but no effect on the subsequent employment duration. In contrast, ordinary education has a positive effect on employment duration but no effect on the transition into employment. The latter effect is the result of two opposing effects, a large positive effect of having completed education and a large negative lock-in effect, with low re-employment chances during program participation.

Child-to-teacher ratio and day care teacher sickness absenteeism.

The literature on occupational health points to work pressure as a trigger of sickness absence. However, reliable, objective measures of work pressure are in short supply. This paper uses Danish day care teachers as an ideal case for analysing whether work pressure measured by the child-to-teacher ratio, that is, the number of children per teacher in an institution, affects teacher sickness absenteeism. We control for individual teacher characteristics, workplace characteristics, and family background characteristics of the children in the day care institutions. We perform estimations for two time periods, 2002-2003 and 2005-2006, by using generalized method of moments with lagged levels of the child-to-teacher ratio as instrument. Our estimation results are somewhat mixed. Generally, the results indicate that the child-to-teacher ratio is positively related to short-term sickness absence for nursery care teachers, but not for preschool teachers.

Early retirement in the day-care sector: the role of working conditions and health.

This article studies the role of working conditions and health for elderly female day-care teachers' decision to enter early retirement. Entry into retirement is analysed in a duration framework that allows for unobserved heterogeneity in the baseline hazard. Data are from a Danish longitudinal data set based on administrative register records for 1997-2006. Working conditions are measured by four indicators. First, work pressure is measured by the child-to-teacher ratio, which varies across municipalities and over time. Second, working conditions are measured by the proportion of children with a problematic social background. Third, the share of trained teachers is considered an indicator of working conditions. And fourth, the size of the institution is assessed as an indicator of working conditions. Regressions in a duration model framework show that there is no significant relationship between the child-to-teacher ratio or the size of the institution and early retirement. However, working conditions measured by the social background of the children and the share of trained day-care teachers have a significant effect on the probability of early retirement. Finally, a poor health condition is associated with a higher propensity to enter early retirement.