Changes in Chlamydia trachomatis risk before and after union formation and separation among women of reproductive age.

BACKGROUND: Not having an established relationship is associated with an elevated risk of Chlamydia trachomatis (CT) infection, but this might reflect selection into and out of unions. Although union formation and union separation are common events in reproductive age, little is known about changes in CT risk before and after these transitions. METHODS: We linked Finnish Population Register data to the National Register of Infectious Diseases and used fixed-effects linear probability models that account for all time-invariant confounders to examine changes in women's 6-month CT risk 3 years before and 3 years after entry into first cohabitation (n = 293 554), non-marital separation (n = 201 647) or marital separation (n = 92 232) during 2005-14. RESULTS: From 3 years to 1 year before first union formation, the 6-month risk of CT increased slightly, peaking at 1.27% immediately prior to union formation (95% confidence interval 1.22-1.31). It declined sharply following union formation, being only 0.40% (0.34-0.46) 6-12 months after union formation with little changes thereafter. Among women separating from non-marital unions, the risk increased from 0.50% (0.42-0.57) to 1.45% (1.40-1.49) around the time of separation and decreased following separation. The pattern of findings was relatively similar for marital separation, although the observed risks and changes were smaller in magnitude. CONCLUSIONS: Our results based on longitudinal data and individual fixed-effects models indicate that the period immediately after separation may be causally associated with an elevated risk of CT. This suggests that recently separated women should be identified as a high-risk group for CT.

Fatherhood timing and men's midlife earnings: A within-family study of Finnish cohorts born in 1938-50.

Fathers tend to achieve higher earnings than childless men, but there is limited evidence on the associations between fatherhood timing and men's later earnings. Using a longitudinal census-based sample of Finnish men, including a subsample of brothers, we investigated fatherhood timing and men's midlife earnings using both between- and within-family models. Earnings around age 50 were lower among adolescent and young fathers than for men who became fathers at ages 25-29 or later, but these associations became negligible after accounting for measured confounders and unobserved familial confounding. Overall, our findings highlight the important roles of selection into early childbearing and into childlessness. At the population level, early fatherhood was associated with clear negative distributional shifts in fathers' midlife earnings. However, among all men, any influence of fatherhood timing on men's midlife earnings distribution paled in comparison with that of childlessness.

Neurological conditions and subsequent divorce risk in the Nordic countries: the importance of gender and both spouses' education.

BACKGROUND: Prior studies suggest that poor physical health, accompanied by functional disability, is associated with increased divorce risk. However, this association may depend on gender, the socioeconomic resources of the couple, as well as the social policy and social (in)equality context in which the illness is experienced. This study focuses on neurological conditions, which often have substantial functional consequences. METHODS: We used longitudinal population-wide register data from the years 2007-2016 (Denmark, Sweden) or 2008-2017 (Finland, Norway) to follow 2 809 209 married couples aged 30-64 for neurological conditions, identified using information on specialised healthcare for diseases of the nervous system and subsequent divorce. Cox regression models were estimated in each country, and meta-analysis used to calculate across-country estimates. RESULTS: During the 10-year follow-up period, 22.2% of couples experienced neurological conditions and 12.0% of marriages ended in divorce. In all countries, divorce risk was elevated among couples where at least one spouse had a neurological condition, and especially so if both spouses were ill. The divorce risk was either larger or similar for husband's illness, compared with wife's illness, in all educational categories. For the countries pooled, the weighted average HR was 1.21 (95% CI 1.20 to 1.23) for wives' illness, 1.27 (95% CI 1.25 to 1.29) for husbands' illness and 1.38 (95% CI 1.34 to 1.42) for couples where both spouses were ill. CONCLUSIONS: Despite some variation by educational resources and country context, the results suggest that the social consequences of illness are noticeable even in Nordic welfare states, with the husband's illness being at least as important as the wife's.

Partner violence surrounding divorce: A record-linkage study of wives and their husbands.

Objective: This study analyzes the victimization trajectories of partner violence against women surrounding divorce, depending on whether the couple has children together. Background: Prior studies have found that partner violence is associated with an increased risk of divorce. No study has assessed the victimization trajectories surrounding divorce for women with and without children, although women with children may remain at higher risk of violence following divorce. Method: Using Finnish record-linkage data of 22,468 divorced and 333,542 continuously married women and their husbands, we used repeated-measures logistic regression analyses to assess changes in victimization for partner violence before and after divorce. The outcomes considered were police-reported crimes committed by husbands against their wives and hospital-treated assault injuries recorded for wives. Results: The risk of crime victimization for partner assault was already elevated from 2 to 3 years before divorce, peaked in the year prior to divorce, and then mainly leveled off 1-2 years after divorce. Hospital data show that the time of the greatest risk was from 6 to 12 months before divorce, when divorce is usually filed for. Women with younger children experienced elevated risks of physical violence shortly before divorce and remained at higher risk of menace than women without children for a year after divorce. Conclusion: Divorcing women committed assaults against their husbands, but these were mostly accompanied by victimization, suggesting that resistant violence was common for women as perpetrators. Women with a history of victimization need support, especially at the starts of their divorce processes.

Childhood socio-economic circumstances and dementia: prospective register-based cohort study of adulthood socio-economic and cardiovascular health mediators.

BACKGROUND: This study analysed the association between childhood socio-economic circumstances and the risk of dementia, and investigated the mediating role of potentially modifiable risk factors including adulthood socio-economic position and cardiovascular health. METHODS: We used a 10% sample of the 1950 Finnish population census linked with subsequent population and health registers (n = 95 381). Information of socio-economic characteristics, family structure and housing conditions at the age of 0-15 years was obtained from the 1950 census. We identified cohort members who developed dementia in 2000-2018 using national hospital, medication and death registers. Discrete time survival analysis using logistic regression and mediation analysis applying the Karlson-Holm-Breen (KHB) method were employed. RESULTS: An excess risk of dementia was observed for household crowding [odds ratio (OR) = 1.10; 95% CI 1.02-1.18 for 3 to <4 persons per heated room; OR = 1.19; 95% CI 1.11-1.27 for ≥4 persons], single-father family (OR = 1.27; 95% CI 1.07-1.51) and eastern and northern region of residence (OR = 1.19; 95% CI 1.10-1.28). The effects of single-father family and region of residence were mostly direct with adulthood characteristics mediating 14% and 29% of the total effect, respectively. The largest indirect effect was observed for household crowding mediated through adulthood socio-economic position (47-65%). CONCLUSIONS: The study shows that childhood socio-economic circumstances are associated with dementia, and that the underlying mechanisms only partly relate to adulthood socio-economic position and cardiovascular health. Socio-economic and health interventions targeted at families with children may carry long-term benefits by contributing to a lower dementia risk in later life.

Does the suddenness matter? Antidepressant use before and after a spouse dies suddenly or expectedly of stroke.

Aims: Changes in mental health at the time of widowhood may depend on the expectedness of spousal death, but scant evidence is available for spousal deaths attributable to stroke. Methods: Using register-linkage data for Finland, we assessed changes in antidepressant use before and after spousal death for those whose spouses died suddenly of stroke between 1998 and 2003 (N=1820) and for those whose spouses died expectedly of stroke, with prior hospitalisation for cerebrovascular disease (N=1636). We used both population-averaged logit models and individual fixed-effects linear probability models. The latter models control for unobserved time-invariant heterogeneity between the individuals. Results: Our study indicates that the suddenness of a spouse's death from stroke plays a role in the well-being of the surviving spouse. Increases in antidepressant use appeared larger following widowhood for those whose spouses died suddenly of stroke relative to those whose spouses had a medical history of cerebrovascular disease. Conclusions: The suddenness of a spouse's death from stroke plays a role for the surviving spouse. The results suggest multifaceted timings of distress surrounding spousal death, depending on the suddenness of a spouse's death from stroke.

Association between a history of clinical depression and dementia, and the role of sociodemographic factors: population-based cohort study.

BACKGROUND: Depression is associated with an increased dementia risk, but the nature of the association in the long-term remains unresolved, and the role of sociodemographic factors mainly unexplored. AIMS: To assess whether a history of clinical depression is associated with dementia in later life, controlling for observed sociodemographic factors and unobserved factors shared by siblings, and to test whether gender, educational level and marital status modify the association. METHOD: We conducted a national cohort study of 1 616 321 individuals aged 65 years or older between 2001 and 2018 using administrative healthcare data. A history of depression was ascertained from the national hospital register in the period 15-30 years prior to dementia follow-up. We used conventional and sibling fixed-effects Cox regression models to analyse the association between a history of depression, sociodemographic factors and dementia. RESULTS: A history of depression was related to an adjusted hazard ratio of 1.27 (95% CI 1.23-1.31) for dementia in the conventional Cox model and of 1.55 (95% CI 1.09-2.20) in the sibling fixed-effects model. Depression was related to an elevated dementia risk similarly across all levels of education (test for interaction, P = 0.84), but the association was weaker for the widowed than for the married (P = 0.003), and stronger for men than women (P = 0.006). The excess risk among men attenuated following covariate adjustment (P = 0.10). DISCUSSION: This study shows that a history of depression is consistently associated with later-life dementia risk. The results support the hypothesis that depression is an aetiological risk factor for dementia.

Seasonal variation in seeking help for domestic violence based on Google search data and Finnish police calls in 2017.

Aims: Domestic violence is a major health concern and a largely hidden crime. It is estimated that authorities receive information in only a minority of cases. This study investigated seasonal patterns in seeking help for domestic violence by employing Google data. Methods: We utilised monthly Google search data and police calls made in Finland in 2017 to analyse seasonal variation in seeking help for domestic violence. We calculated rate ratios for selected Google terms based on observed search volumes (O) and those expected without seasonal variation (E). These rate ratios (O/E) were compared with the corresponding police call statistics registered as domestic violence. Results: The findings on Google search data showed increased search volumes for domestic violence in November, January and March. The rate ratio (O/E) for searches for shelters is 1.30 in November [95% confidence interval (CI): 1.27-1.33], 1.17 in January (95% CI: 1.14-1.20), and 1.16 in March (95% CI: 1.13-1.29). These peaks in search volumes occur within the same months as those observed in the corresponding police calls categorised as domestic violence. Police data also showed somewhat higher volumes in April. Conclusions: The study suggests that Google search volumes can be used to study the highest peaks in seeking help for domestic violence in countries with a high level of Internet usage and no available police data.

Physical health conditions and subsequent union separation: a couple-level register study on neurological conditions, heart and lung disease, and cancer.

BACKGROUND: Studies that assess the role of physical health conditions on separation risk are scarce and mostly lack health information on both partners. It is unclear how the association between physical illness and separation risk varies by type of illness, gender of the ill spouse and age of the couple. METHODS: We used Finnish register data on 127 313 couples to examine how neurological conditions, heart and lung disease, and cancer are associated with separation risk. The data included information on medication, hospitalisations, separations and sociodemographic characteristics. Marital and non-marital cohabiting couples aged 40-70 years were followed from 1998 to 2003 for the onset of health conditions and subsequent separation, and Cox regression was used to examine the associations. RESULTS: Compared with healthy couples, the HR of separation was elevated by 43% for couples in which both spouses had a physical health condition, by 22% for couples in which only the male spouse had fallen ill, and by 11% for couples in which only the female had fallen ill. Among older couples, the associations between physical illness and separation risk were even clearer. The association with separation risk was strongest for neurological conditions, and after incidence of these conditions among males, separation risk increased over time. Adjustment for sociodemographic characteristics had little effect. CONCLUSIONS: Our findings suggest that poor health may largely strain relationships through disability and associated burden of spousal care, and this should be taken into consideration when planning support services for couples with physical health conditions.

Is impending or actual death of a spouse with dementia bad for mental health? Antidepressant use surrounding widowhood.

BACKGROUND: Previous studies have shown that the risk of death is elevated after the death of a spouse. Limited evidence is available on changes in mental health before and after bereavement among individuals whose spouse dies of dementia. METHODS: We analyzed changes in the 3-month prevalence of antidepressant use for 5 years before and 3 years after widowhood for individuals whose spouses died of either dementia or other causes. The study used data of 41 855 widowed individuals and repeated-measures logistic regression analyses. Antidepressant use was based on the prescription register of Finland in 1995-2007. RESULTS: Five years before widowhood, the 3-month prevalence for antidepressant use was 4% among widowing men and 6-7% among widowing women, regardless of whether the spouse died of dementia or other causes. Further changes in antidepressant use depended on a spouse's cause of death. Women whose spouses died of dementia experienced large increase in antidepressant use starting from 3 to 4 years prior to widowhood, whereas other widows did not experience large increase until after widowhood. The trajectories for men were similar. Antidepressant use following the death of a spouse with dementia stayed at a new heightened level after widowhood. CONCLUSIONS: The trajectories of antidepressant use indicate that the process of losing a spouse to dementia is bad for mental health, already a few years prior to widowhood. There are no clear improvements in mental health after the death of a spouse with dementia. Support services for individuals whose spouses' dementia progresses are needed.

Men's age at first birth and alcohol-related morbidity and mortality among siblings.

BACKGROUND: Men's age at first birth may negatively or positively affect alcohol-related morbidity and mortality, although little evidence is available. METHODS: We used register data of over 22,000 brothers to analyze the associations between age at first birth and alcohol-related morbidity and mortality from the age of 35 until the age of 60 or 72. We employed conventional Cox models and inter-sibling models, which allowed adjustment for unobserved social and genetic characteristics shared by brothers. RESULTS: The findings show that men's age at first birth was inversely associated with alcohol-related morbidity and mortality, independent of unobserved characteristics shared by brothers and of observed demographic confounders. Men who had their first child late at 35-45 years experienced lower alcohol-related morbidity and mortality (hazard ratio (HR) = 0.57, 95 % confidence interval (CI) = 0.43, 0.75) than men who had their first child at 25-29. Men who had their first child before age 20 had the highest morbidity and mortality among all fathers (HR = 1.36, 95 % CI = 1.09, 1.69), followed by men who had their child at 20-24 (HR = 1.12, 95 % CI = 1.00, 1.25). CONCLUSIONS: The results imply that the inverse association between men's age at first birth and alcohol-related morbidity and mortality is not driven by familial characteristics.

Midlife socioeconomic position and old-age dementia mortality: a large prospective register-based study from Finland.

OBJECTIVES: To assess the association between multiple indicators of socioeconomic position and dementia-related death, and to estimate the contribution of dementia to socioeconomic differences in overall mortality at older ages. DESIGN: Prospective population-based register study. SETTING: Finland. PARTICIPANTS: 11% random sample of the population aged 70-87 years resident in Finland at the end of year 2000 (n=54 964). MAIN OUTCOME MEASURE: Incidence rates, Kaplan-Meier survival probabilities and Cox regression HRs of dementia mortality in 2001-2016 by midlife education, occupational social class and household income measured at ages 53-57 years. RESULTS: During the 528 387 person-years at risk, 11 395 individuals died from dementia (215.7 per 10 000 person-years). Lower midlife education, occupational social class and household income were associated with higher dementia mortality, and the differences persisted to the oldest old ages. Compared with mortality from all other causes, however, the socioeconomic differences emerged later. Dementia accounted for 28% of the difference between low and high education groups in overall mortality at age 70+ years, and for 21% of the difference between lowest and highest household income quintiles. All indicators of socioeconomic position were independently associated with dementia mortality, low household income being the strongest independent predictor (HR=1.24, 95% CI 1.16 to 1.32), followed by basic education (HR=1.14, 1.06 to 1.23). Manual occupational social class was related to a 6% higher hazard (HR=1.06, 1.01 to 1.11) compared with non-manual social class. Adjustment for midlife economic activity, baseline marital status and chronic health conditions attenuated the excess hazard of low midlife household income, although significant effects remained. CONCLUSION: Several indicators of socioeconomic position predict dementia mortality independently and socioeconomic inequalities persist into the oldest old ages. The results demonstrate that dementia is among the most important contributors to socioeconomic inequalities in overall mortality at older ages.

Is the relationship between men's age at first birth and midlife health changing? Evidence from two British cohorts.

Becoming a father, particularly for the first time, is a central transition in men's lives, and whether this transition takes place early or later in life may have important ramifications on the whole later life course. Previous research has shown that men who father their first child early in life have poorer later-life health than men who postpone having children. However, it is not known how selection by cognitive ability and other childhood characteristics confound the association between the timing of fatherhood and later-life health, or how the association is changing over time as parenthood is postponed to an older age. We investigate the association between men's age at the birth of their first child and midlife self-rated health in two British cohorts born in 1958 and 1970. The study employs logit models. Relative to men who had their first child when they were between 25 and 29 years old, men who had their first child before the age of 20 have the poorest health, followed by men who had a child when they were 20-24 years old. This result was observed in both cohorts. Childhood cognitive ability, which previous research has not analyzed, strongly contributed to this association, and to a greater extent than other childhood characteristics. For the 1970 cohort, those who became fathers at age 35 or older had the best health. This advantage was not found for the 1958 cohort. These findings suggest that the relationship between young age at fatherhood and midlife health is strongly confounded by cognitive ability, and that in recent cohorts a new pattern of advantage among older fathers has emerged.

Risk of Hospitalization for Cancer, Musculoskeletal Disorders, Injuries, or Poisonings Surrounding Widowhood.

Psychological distress has been indicated to affect the risk of death from cardiovascular disease, cancer, and external causes. Mortality from these major causes of death is also known to be elevated after widowhood when distress is at a heightened level. Surprisingly little is known about changes in health other than mental and cardiac health shortly before widowhood. We used longitudinal data on widowed (n = 19,185) and continuously married (n = 105,939) individuals in Finland (1996-2002) to assess the risk of hospitalization for cancer and for external and musculoskeletal causes surrounding widowhood or random dates. We fitted population-averaged logit models using longitudinal data of older adults aged 65 years or over. The results show that hospitalization for injuries had already increased prior to widowhood and clearly peaked after it. The increases were largely related to falls. A similar increasing pattern of findings was not found around a random date for a group of continuously married individuals. Hospitalizations for cancer and musculoskeletal disorders appeared to be unrelated to the process of widowhood. Hospitalizations for poisonings increased after widowhood. The results imply that the process of widowhood is multifaceted and that various types of health changes should be studied separately and before the actual loss.

Time-varying effects of socio-demographic and economic factors on the use of institutional long-term care before dementia-related death: A Finnish register-based study.

OBJECTIVES: The effects of socio-demographic and economic factors on institutional long-term care (LTC) among people with dementia remain unclear. Inconsistent findings may relate to time-varying effects of these factors as dementia progresses. To clarify the question, we estimated institutional LTC trajectories by age, marital status and household income in the eight years preceding dementia-related and non-dementia-related deaths. METHODS: We assessed a population-representative sample of Finnish men and women for institutional LTC over an eight-year period before death. Deaths related to dementia and all other causes at the age of 70+ in 2001-2007 were identified from the Death Register. Dates in institutional LTC were obtained from national care registers. We calculated the average and time-varying marginal effects of age, marital status and household income on the estimated probability of institutional LTC use, employing repeated-measures logistic regression models with generalised estimating equations (GEE). RESULTS: The effects of age, marital status and household income on institutional LTC varied across the time before death, and the patterns differed between dementia-related and non-dementia-related deaths. Among people who died of dementia, being of older age, non-married and having a lower income predicted a higher probability of institutional LTC only until three to four years before death, after which the differences diminished or disappeared. Among women in particular, the probability of institutional LTC was nearly equal across age, marital status and income groups in the last year before dementia-related death. Among those who died from non-dementia-related causes, in contrast, the differences widened until death. CONCLUSIONS: We show that individuals with dementia require intensive professional care at the end of life, regardless of their socio-demographic or economic resources. The results imply that the potential for extending community living for people with dementia is likely to be difficult through modification of their socio-demographic and economic environments.

Does the risk of hospitalisation for ischaemic heart disease rise already before widowhood?

BACKGROUND: The death of a spouse has been shown to increase mortality from various causes, including ischaemic heart disease. It is unclear, however, whether cardiac problems are already on the rise before widowhood. METHODS: Using longitudinal register data of Finnish widows-to-be aged 65 and over at baseline (N=19 185), we assessed the risk of hospitalisation for ischaemic heart disease 18 months before and after widowhood. Hospital admissions were derived from national hospital discharge registers between 1996 and 2002. Analyses used population-averaged and fixed-effects logistic models, the latter of which controlled for unobserved time-invariant characteristics, such as genetic susceptibility, personality and behavioural and medical history. RESULTS: For men, fixed-effects model revealed that hospitalisation for ischaemic heart disease increased twofold already 0-3 months prior to the death of a spouse (OR=2.09, 95% CI 1.22 to 3.60), relative to the period of 15-18 months before widowhood. It stayed at a heightened level up to 6 months following bereavement (OR=2.15, 95% CI 1.07 to 4.30). Among women, the fixed-effects analysis detected no statistically significant increase in hospitalisation for ischaemic heart disease before or after widowhood. CONCLUSIONS: These findings indicate that men are already vulnerable to cardiac problems before the death of a wife. Medical interventions and health counselling could be targeted to the husbands of terminally ill patients, in order to improve their cardiovascular health over the transition to widowhood.

Number of children and later-life mortality among Finns born 1938-50.

We investigated the association between number of offspring and later-life mortality of Finnish men and women born 1938-50, and whether the association was explained by living conditions in own childhood and adulthood, chronic conditions, fertility timing, and unobserved characteristics common to siblings. We used a longitudinal 1950 census sample to estimate mortality at ages 50-72. Relative to parents of two children, all-cause mortality is highest among childless men and women, and elevated among those with one child, independently of observed confounders. Fixed-effect models, which control for unobserved characteristics shared by siblings, clearly support these findings among men. Cardiovascular mortality is higher among men with no, one, or at least four children than among those with two. Living conditions in adulthood contribute to the association between the number of children and mortality to a greater extent than childhood background, and chronic conditions contribute to the excess mortality of the childless.

Is young fatherhood causally related to midlife mortality? A sibling fixed-effect study in Finland.

BACKGROUND: Previous studies have shown that young fatherhood is associated with higher later-life mortality. It is unclear whether the association is credible, in the sense that mortality and young fatherhood appear to be associated because both are determined by family-related environmental, socioeconomic and genetic characteristics. METHODS: We used a household-based 10% sample drawn from the 1950 Finnish census to estimate all-cause mortality of fathers born during 1940-1950. The fathers were followed from age 45 until death, or the end of age 54. We used a standard Cox model and a sibling fixed-effects Cox model to examine whether the effect of young fatherhood was independent of observed adulthood characteristics and unobserved early-life characteristics shared by brothers. RESULTS: Men who had their first child before the age of 22 or at ages 22-24 had higher mortality as compared with their brothers who had their first child at the median or mean age of 25-26. Men who had their first child later at ages 30-44 had lower mortality than their brothers who had a first child before the age of 25. The pattern of results from a standard model was similar to that obtained from a fixed-effects sibling model. CONCLUSIONS: The findings suggest a causal effect of young fatherhood on mortality and highlight the need to support young fathers in their family life to improve health behaviours and health.

Life expectancy in long-term institutional care by marital status: multistate life table estimates for older Finnish men and women.

OBJECTIVES: We estimate (a) probabilities of moving to and from long-term institutional care and probabilities of death and (b) life expectancy in the community and in care by gender and marital status. METHOD: A 40% random sample of Finns aged 65+ at the end of 1997 (n = 301,263) drawn from the population register was linked with register-based information on sociodemographic characteristics, entry and exit dates for long-term institutional care, and dates of death in 1998-2003. Probabilities and life expectancies were estimated using multistate life tables. RESULTS: At age 65, women are expected to spend more of their remaining lifetime in institutions than men (1.6 and 0.7 years, respectively). These care expectancies remain similar even for survivors to very advanced ages. Gender differences are driven by women's higher chances of entering institutions at ages above 80 years and lower chances of exit. At age 65, 59% of women and 36% of men will ever enter long-term institutions. The married spend less of their longer life expectancy in institutions than the non-married. The large gender difference in care use exists within each marital status group. DISCUSSION: The resources that are needed to provide long-term care services will increase as age of death increases. We demonstrate significantly longer care expectancy among women and among the unmarried.

Gender, living arrangements, and social circumstances as determinants of entry into and exit from long-term institutional care at older ages: a 6-year follow-up study of older Finns.

PURPOSE: Due to population aging, the need for long-term institutional care is increasing. We study the potentially modifiable sociodemographic factors that affect the rate of entry into and exit from long-term care. DESIGN AND METHODS: A 40% sample from the population registration data of Finns aged 65 and older living in private households at the end of 1997 (n = 280,722) was followed for first entry into (n = 35,926) and subsequent exit -- due to death or return to the community -- from long-term institutional care until the end of 2003. RESULTS: Being female, old, living alone, and of low socioeconomic status increased the risk for entering long-term care. Exit was affected by the same factors, but the associations were weaker and, with the exception of age, in the opposite direction. Women's higher risk for entry was due to older age and greater likelihood of living alone. The effects of living arrangements and socioeconomic factors on entry were stronger among men and were attenuated after adjustment for each other and for health status. The mean duration of care was 1,064 days among women and 686 among men. IMPLICATIONS: Gender, age, living arrangements, and socioeconomic status are major determinants of institutional residence. Women and certain other population groups, e.g., those living alone, are likely to spend a longer time in institutional care because of higher rates of entry and lower rates of exit. These results have implications for the financing of long-term care and for targeting of interventions aimed at delaying it.