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Family-Rela ed Li e E en s as P edic o s o Labo Ma ke Ma ginaliza ion T ajec o ies : A
Coho S udy o Swedish Twins
© 2023 he Au ho s
Published e sion
Wang, Mo; Raza, Au iba; Na usy e, Ju gi a; Sil en oinen, Ka i; Böcke man, Pe i;
S edbe g, Pia; Ropponen, Annina
Wang, M., Raza, A., Na usy e, J., Sil en oinen, K., Böcke man, P., S edbe g, P., & Ropponen, A.
(2023). Family-Rela ed Li e E en s as P edic o s o Labo Ma ke Ma ginaliza ion T ajec o ies : A
Coho S udy o Swedish Twins. Jou nal o Occupa ional and En i onmen al Medicine, 65(8),
627-634. h ps://doi.o g/10.1097/JOM.0000000000002869
2023
Family-Rela ed Li e E en s as P edic o s o Labo Ma ke
Ma ginaliza ion T ajec o ies
A Coho S udy o Swedish Twins
Mo Wang, PhD, Au iba Raza, PhD, Ju gi a Na usy e, PhD, Ka i Sil en oinen, PhD, Pe i Böcke man, PhD,
Pia S edbe g, PhD, and Annina Ropponen, PhD
Objec i es: The aims o he s udy a e o in es iga e ajec o ies o labo ma ke
ma ginaliza ion (LMM) and o examine he associa ions be ween amily- ela ed
li e e en s and LMM ajec o ies while accoun ing o amilial ac o s.
Me hods: This is a p ospec i e coho s udy o 37,867 Swedish wins. Da a we e
analyzed by g oup-based ajec o y modeling. Associa ions o amily- ela ed li e
e en s wi h ajec o y g oups we e es ima ed by mul inomial logis ic eg ession.
Resul s: Mos pa icipan s had no o low le els o LMM. Indi iduals who s ayed
ma ied o e ime o changed om single wi hou child en o ma ied wi h chil-
d en had a dec eased isk o LMM. The isk o LMM o e ime was highe among
indi iduals who changed om ma ied o being single. Conclusions: Being o
ge ing ma ied as well as ha ing child en dec eases he isk o LMM while di-
o ce is a isk ac o o LMM.
Keywo ds: sick lea e, disabili y pension, unemploymen , li e e en , win s udy
Labo ma ke ma ginaliza ion (LMM) can be cha ac e ized by unem-
ploymen , sickness absence (SA), and disabili y pension (DP).
1
In
many Eu opean coun ies, educing he ex en o LMM is a cen al pol-
icy conce n.
2,3
Sickness absence and DP a e also majo public heal h
conce ns and an economic challenge o indi iduals, employe s, and
he wel a e s a e.
4
Being on SA, pa icula ly long- e m SA, ends o ma -
ginalize employees om he labo ma ke and lead o pe manen exclu-
sion (eg, DP) om he wo k o ce.
5–7
Mo eo e , disabili y pensione s
and unemployed indi iduals o en epo nega i e consequences on
heal h, economy, social in eg a ion, and ace p ema u e mo ali y.
8,9
In addi-
ion, concep ualiza ion o LMM including measu es o bo h unemploymen
and SA/DP, which a e based on medical assessmen s, is ecommended.
1
The magni ude o LMM in Eu opean coun ies equi es mo e
knowledge abou he p edic o s o unemploymen and SA/DP o ini-
ia e e ec i e in e en ions.
4
Se e al s udies ha e p e iously epo ed
associa ions be ween demog aphic, socioeconomic, heal h- and
wo k- ela ed ac o s, and u u e unemploymen and SA/DP.
10–13
How-
e e , much ewe s udies ha e conside ed long- e m isks o LMM a-
jec o ies. The cou se o LMM can be he e ogeneous in he popula ion
because among some indi iduals he le el o LMM can be educed
while some indi iduals may emain high in LMM isk o e ime.
Hence, unde s anding he he e ogenei y and ajec o ies o LMM o e
ime is o c ucial impo ance and migh also acili a e indi idualized
ehabili a ion measu es ha imp o e a achmen o he labo ma ke .
Family- ela ed li e e en s, such as ma iage, ha ing child en o
di o ce, play an impo an ole in heal h and in e play wi h human
li es om bi h o dea h.
14–16
Any change in amily li e, such as ge -
ing ma ied, gi ing bi h, o losing a spouse, ha es uc u e amily
con igu a ions may ha e ex ensi e e ec s on men al and physical
heal h o he indi idual unde going he changes.
17
Fo ins ance, p e i-
ous s udies ha e epo ed ha hose who make a ansi ion om being
ma ied o di o ce ha e a poo e heal h han hose who ha e been con-
inuously ma ied, while some s udies sugges ha socioeconomic ac-
o s, such as educa ional le el, has play a ole in he associa ion.
15,17
A
s udy on single pa en s also ound signi ican ly highe a es o psycho-
logical dis ess among hose who sepa a e compa ed wi h ma ied pa -
en s.
18
Nega i e amily e en s, o example, di o ce and subop imal
heal h condi ions, a e expec ed o be associa ed wi h u u e ad e se la-
bo ma ke ou comes.
19,20
Because amily li e would no emain s ably
o e ime, o example, people can ge ma ied, ha e child en, o ge di-
o ce, hese changes may a ec economic ou comes and o he li ing
condi ions. The e o e, a measu e o his o y o amily- ela ed li e e en s
by accoun ing bo h ansi ions o ma i al s a us and changes in si ua ions
o ha ing child en is impo an o unde s anding he de elopmen o
ad e se ou comes o e he li e cou se.
Al hough indings om p e ious s udies sugges ha amily- ela ed
li e e en s a e associa ed wi h poo heal h, s udies in es iga ing
F om he Di ision o Insu ance Medicine, Depa men o Clinical Neu oscience,
Ka olinska Ins i u e , S ockholm, Sweden (M.W., A.R., J.N., K.S., P.S., A.R.);
Cen e o Epidemiology and Communi y Medicine, S ockholm Coun y Council,
Sweden (J.N.); Finnish Ins i u e o Occupa ional Heal h, Helsinki, Finland (A.
R.); Popula ion Resea ch Uni , Facul y o Social Sciences, Uni e si y o Helsinki,
Helsinki, Finland (K.S.); School o Business and Economics, Uni e si y o
Jy äskylä, Jy äskylä, Finland (P.B.); Labou Ins i u e o Economic Re-
sea ch LABORE, Helsinki, Finland (P.B.); and IZA Ins i u e o Labo Eco-
nomics, Bonn, Ge many (P.B.).
Funding sou ces: This s udy was unded by Fo e (2019-01284). The Swedish Twin p o-
jec o Disabili y pension and Sickness absence (STODS) ecei es unding h ough
he Swedish Resea ch Council unde he g an numbe 2017-00624. The Swedish
Twin Regis y is managed by Ka olinska Ins i u e and ecei es unding h ough
he Swedish Resea ch Council unde he g an numbe 2017-00641.
Wang, Raza, Na usy e, Sil en oinen, Böcke man, S edbe g, and Ropponen ha e no
ela ionships/condi ions/ci cums ances ha p esen po en ial con lic o in e es .
The JOEM edi o ial boa d and planne s ha e no inancial in e es ela ed o his esea ch.
E hical Conside a ions and Disclosu es: This s udy was app o ed by he Regional
E hical Re iew Boa d in S ockholm, Sweden. The da a ha suppo he indings
o his s udy a e a ailable om he o iginal sou ces: he Swedish Twin Regis y,
S a is ics Sweden, Swedish Social Insu ance Agency, and he Swedish Na ional
Boa d o Heal h and Wel a e. Res ic ions apply o he a ailabili y o he da a
used in his s udy based on he Swedish Twin p ojec o Disabili y pension and
Sickness absence (STODS), which we e used wi h e hical pe mission o he
cu en s udy and he e o e a e no publicly a ailable.
Supplemen al digi al con en s a e a ailable o his a icle. Di ec URL ci a ion
appea s in he p in ed ex and is p o ided in he HTML and PDF e sions o
his a icle on he jou nal’s Web si e (www.joem.o g).
Add ess co espondence o: Mo Wang, PhD, Depa men o Clinical Neu oscience
Di ision o Insu ance Medicine Ka olinska Ins i u e SE-171 77 S ockholm,
Sweden ([email protected]).
Copy igh © 2023 The Au ho (s). Published by Wol e s Kluwe Heal h, Inc. on be-
hal o he Ame ican College o Occupa ional and En i onmen al Medicine.
This is an open-access a icle dis ibu ed unde he e ms o he C ea i e Com-
mons A ibu ion-Non Comme cial-No De i a i es License 4.0 (CCBY-NC-
ND), whe e i is pe missible o download and sha e he wo k p o ided i is p op-
e ly ci ed. The wo k canno be changed in any way o used comme cially wi hou
pe mission om he jou nal.
DOI: 10.1097/JOM.0000000000002869
CME Lea ning Objec i es
A e comple ing his endu ing educa ional ac i i y,
he lea ne will be be e able o:
Discuss ajec o ies o labou ma ke ma ginaliza ion
Desc ibe he e ec s o s abili y and change in amily li e on
LMM ajec o ies
Ou line he impo ance o amily ela ed li e e en s o LMM
CME AVAILABLE FOR THIS ARTICLE AT ACOEM.ORG
JOEM •Volume 65, Numbe 8, Augus 2023 627
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amily- ela ed li e e en s in associa ion wi h labo ma ke ou comes,
such as unemploymen and SA/DP, a e limi ed. In mos Eu opean
coun ies, women wi h child en in he household ypically ha e a
pa - ime job,
21
and he in ol emen in employmen and concu en ly
ha ing child en a e conside ed as wo o he easons o high le els o
SA, pa icula ly o single mo he s.
22–24
On he o he hand, some
s udies ha e demons a ed ha he mul iple oles ha e a posi i e in-
luence on heal h and well-being.
25
Mo eo e , s udies om he No -
dic coun ies ha e shown ha no gi ing bi h is a isk ac o o SA
and DP compa ed wi h women gi ing bi h.
26,27
Soma ic and men al
mo bidi y bo h be o e and a e childbi h showed a s ong associa ion
wi h SA and DP.
27
Howe e , p e ious s udies ha e mainly ocused on
single amily- ela ed li e e en and knowledge on he e ec s o s abil-
i y and change o amily li e (eg, ansi ion om unma ied o ma ied,
om ma iage o di o ce, o om no ha ing o ha ing child en, e c)
on LMM ajec o ies is pa icula ly limi ed.
Mo eo e , an ea lie s udy based on he Finnish win coho
indica ed he ole o amilial con ounding (ie, gene ics and sha ed
en i onmen , mainly in childhood) on he associa ions be ween
amily- ela ed li e e en s (ie, ha ing a child, ma ying/di o ce) and DP
due o musculoskele al diagnoses.
28
The numbe o amily- ela ed li e
e en s a one ime poin p edic ed inc eased isk o DP, whe eas he ab-
sence o amily- ela ed li e e en s dec eased he isk. The assump ion
was ha amilial ac o s migh play a ole in he endency o ha ing
many amily- ela ed li e e en s o ha gene ics in luence bo h he isk
o DP due o musculoskele al diagnoses and he equency o li e
e en s.
29
By using a win design, unmeasu ed con ounde s can be ad-
jus ed o , because co wins a e ma ched on gene ic (100% o
TABLE 1. Desc ip i e S a is ics o he S udy Popula ion o 37,867 Twins
Whole Sample Disco dan Twin Pai s
(N= 37,867)
Twins Wi h S able
Family Li e (n= 4,647)
Twins Wi h Changed
Family Li e (n= 4,647)
Va iables n%n%n%χ
2
Sex P<0.05
Male 19,079 50.4 2,367 51.0 2,129 45.8
Female 18,788 49.6 2,280 49.1 2,518 54.2
Age, y P=1.00
20–24 8,562 22.6 526 11.3 526 11.3
25–29 9,574 25.3 1,473 31.7 1,473 31.7
30–34 8,715 23.0 1,396 30.0 1,396 30.0
35–40 11,016 29.1 1,252 26.9 1,252 26.9
Zygosi y P=1.00
Monozygo ic 8,547 22.6 972 20.9 972 20.9
Dizygo ic same sex 10,090 26.7 1,323 28.5 1,323 28.5
Dizygo ic opposi e sex 12,857 34.0 676 14.6 676 14.6
Unknown zygosi y 6,373 16.8 1,676 3.1 1,676 3.1
Educa ion, y P=0.50
<10 5,858 15.5 776 16.7 777 16.7
10–12 21,760 57.5 2,635 56.7 2,689 57.9
>12 9,099 24.0 1,096 23.6 1,176 25.3
Unknown/missing 1,150 3.0 140 3.0 5 0.1
A ea o esidence
a
P=0.16
Big ci ies 12,718 33.6 1,598 34.4 1,607 34.6
Medium-sized ci ies 13,318 35.2 1,542 33.2 1,668 35.9
Small ci ies/ illages 10,843 28.6 1,391 29.9 1,372 29.5
Unknown/missing 988 2.6 116 2.5 0 0.0
His o y o inpa ien ca e
Men al diagnosis 1,030 2.7 147 3.2 117 2.5 P=0.06
Soma ic diagnosis 14,535 38.4 1,829 39.4 2,665 57.5 P<0.05
Family- ela ed li e e en s (1990–1993) P<0.05
S able amily li e 31,544 83.3 4,647 100.0 ——
F om ma ied
b
wi hou child en o ma ied
b
wi h child en/ om ma ied
b
wi h child en o ma ied
b
wi hou child en
693 1.9 —— 511 11.0
F om ma ied
b
wi hou child en o single
c
wi h/wi hou child en 97 0.3 —— 68 1.5
F om ma ied
b
wi h child en o single
c
wi hou child en 469 1.2 —— 375 8.1
F om ma ied
b
wi h child en o single
c
wi h child en 653 1.7 —— 502 10.8
F om single
c
wi hou child en o ma ied
b
wi hou child en 713 1.9 —— 507 10.9
F om single
c
wi hou child en o ma ied
b
wi h child en 3,023 8.0 ——2,177 46.9
F om single
c
wi hou child en o single
c
wi h child en/ om single
c
wi h child en o single
c
wi hou child en
393 1.0 —— 300 6.5
F om single
c
wi h child en o ma ied
b
wi h/wi hou child en 282 0.7 —— 207 4.5
Ou comes (1994–2016)
Unemploymen 1,352 3.6 190 4.1 168 3.6 P=0.24
Sickness absence 4,382 11.6 622 13.4 621 13.4 P=0.98
Disabili y pension 3,037 8.0 424 9.1 363 7.8 P=0.02
Labo ma ke ma ginaliza ion 8,117 21.4 1,137 24.5 1,066 22.9 P=0.08
Signi ican esul s a e ma ked in bold.
a
A ea o esidence: big ci ies: S ockholm, Gö ebo g, and Malmö; medium-sized ci ies: ci ies wi h mo e han 90,000 inhabi an s wi hin 30-km dis ance om he cen e o he ci y; small ci ies/ illages.
b
Ma ied includes li ing wi h pa ne ; cohabi an .
c
Single includes di o ced, sepa a ed, o widowed.
Wang e al JOEM •Volume 65, Numbe 8, Augus 2023
628 © 2023 The Au ho (s). Published by Wol e s Kluwe Heal h, Inc. on behal o he Ame ican College o Occupa ional and En i onmen al Medicine.
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monozygo ic [MZ] and on a e age 50% o dizygo ic [DZ] win pai s)
and common ea ing en i onmen al a ia ion (100% o bo h MZ and
DZ wins). An exposu e is e alua ed a e adjus men o amilial ac-
o s wi h a co win con ol design (ma ched case-con ol analysis). This
is commonly compa ed wi h esul s o an analysis o he whole sam-
ple, whe e he wins a e conside ed as indi iduals o examine he im-
pac o amilial ac o s.
30,31
In addi ion, win s udies ha e epo ed ha
amilial ac o s, ha is, gene ic ac o s and amily en i onmen , ac-
coun o 36% o 50% o he a iance in SA and DP and app oxi-
ma ely 27% o li e e en s.
32–34
The e o e, i is impo an o accoun
o he possible in luence o amilial con ounding, which can op i-
mally be accomplished by using he win design.
AIMS
The i s aim o he s udy was o examine LMM ajec o ies (as
indica ed by unemploymen , SA and DP, sepa a ely and combined)
du ing 1994–2016. The second aim was o in es iga e he e ec s o s abil-
i y and change in amily li e du ing 1990–1993 (based on ha ing child en
and/o ma ying/di o cing) on LMM ajec o ies. Family- ela ed li e
e en s in disco dan win pai s we e speci ically in es iga ed o hei
LMM ajec o ies o accoun o he e ec s o amilial ac o s.
METHOD
Da a and Sample
This p ospec i e s udy was based on da a om he Swedish Twin
p ojec o Disabili y pension and Sickness absence (STODS) s udy,
which comp ises da a om se e al sou ces. F om he Swedish Twin Reg-
is y, he e is a o al o 119,907 win indi iduals bo n be ween 1925 and
1990, which consis s o nea ly all he wins bo n in Sweden du ing hese
yea s.
35
Da a on li e e en s, unemploymen , and sociodemog aphic a i-
ables we e ob ained om he Longi udinal In eg a ion Da abase o
Heal h Insu ance and Labou Ma ke S udies, S a is ics Sweden.
36
In o -
ma ion on SA and DP was ga he ed om he Mic oDa a o Analyses o
Social insu ance egis e om he Swedish Social Insu ance Agency. Da a
on he his o y o diagnosed diseases we e collec ed om he Swedish
Na ional Pa ien Regis e (da e and diagnosis o inpa ien ca e) om
he Na ional Boa d o Heal h and Wel a e.
37
The da a we e linked by
using unique pe sonal iden i ica ion numbe p o ided o all Swedish
esiden s.
The s udy popula ion comp ised all Swedish wins aged be ween 20
and 40 yea s and li ing in Sweden on Decembe 31, 1993 (N= 37,867).
Among hem, 18,378 we e comple e win pai s whe eas 10,090 we e
same-sex DZ wins, 12,857 opposi e-sex DZ wins, 8547 MZ wins, and
6373 we e o unknown zygosi y. The e we e 4647 win pai s disco dan
o amily- ela ed li e e en s, ha is, one win in a pai had s able amily li e
and he o he win had changed amily li e du ing 1990–1993.
Exposu e
The exposu e measu e included amily- ela ed li e e en s,
which was based on ha ing a child and/o ma ying/di o cing du ing
1990–1993. The li e e en s we e classi ied in o ca ego ies shown in
Supplemen a y Table 1, h p://links.lww.com/JOM/B331. Indi iduals
wi h s able amily li e had he same amily s a us, whe eas hose wi h
changed amily li e changed hei amily s a us du ing 1990–1993.
Some ca ego ies o amily- ela ed li e e en s included only ew indi-
iduals and we e me ged (Table 1).
Ou comes
Labo ma ke ma ginaliza ion was measu ed by (1) sum o ne
mon hs wi h unemploymen pe yea (calcula ed om annual days) du -
ing 1994–2016, (2) sum o ne mon hs wi h SA (>14 days) and DP pe
yea (calcula ed om annual ne days) du ing 1994–2016, and (3) com-
bined LMM, measu ed as he sum o annual mon hs wi h unemploy-
men , SA, and DP. Pa - ime SA/DP was con e ed o ull- ime, ha
is, 2 days on hal - ime SA/DP equaled 1 day o ull- ime SA/DP.
Sickness absence bene i s a e gene ally g an ed by he Social
Insu ance Agency o all indi iduals in Sweden om he age o 16 yea s
who ha e an income om wo k o unemploymen bene i s and who
ha e a educed wo k capaci y due o a disease o inju y.
38
Indi iduals
wi h a pe manen ly impai ed wo k capaci y due o a disease o inju y
a e eligible o DP bene i s. Employe s pay sick pay du ing he i s
14 days. The e is one quali ying day (mo e o sel -employed) wi hou
bene i s. A physician’s ce i ica e is equi ed a e 7 days o sel -ce i-
ica ion. Sickness absence amoun s o 80% o los income while DP o
app oxima ely 65%. En i lemen o unemploymen bene i s p esumes
FIGURE 1. T ajec o y g oups o unemploymen , SA and DP, and LMM (ie, combined measu e o unemploymen , SA, and DP)
mon hs and pe cen ages o wins (N= 37,867) wi hin each ajec o y g oup du ing 1994 and 2016.
JOEM •Volume 65, Numbe 8, Augus 2023 Li e E en s and Labo Ma ke Ma ginaliza ion
© 2023 The Au ho (s). Published by Wol e s Kluwe Heal h, Inc. on behal o he Ame ican College o Occupa ional and En i onmen al Medicine. 629
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a de ined minimum income om wo k. To ecei e compensa ion om
an unemploymen insu ance und, indi iduals mus be egis e ed as
unemployed a he Swedish Public Employmen Se ice. They should
be able and willing o ake a job igh away.
Co a ia es
Co a ia es ega ding sociodemog aphic ac o s we e measu ed
on Decembe 31, 1993, and consis ed o age, sex, yea s o educa ion,
and a ea o esidence. A his o y o men al and soma ic mo bidi y be-
o e 1994 om inpa ien ca e was also used as a co a ia e (Table 1).
S a is ical Analysis
S a is ical di e ences in he dis ibu ions o a iables in ela ion
o co a ia es, exposu e, and ou come we e assessed wi h χ
2
es s. P
alues less han 0.05 indica e a signi ican di e ence. G oup-based
ajec o y models we e used o iden i y ajec o y g oups o LMM in
1994–2016 among he whole sample. This p ocedu e is based on a
mix u e model ha p o ides he capaci y o iden i y subg oups o in-
di iduals who ollowed dis inc ajec o ies du ing he ime o obse a-
ion and es ima es a eg ession model o each disc e e g oup.
39
In ad-
di ion, his me hod could p o ide he possibili y o assess a ia ion and
s abili y o e ime o each iden i ied subg oup and he p opo ion o
indi iduals in each g oup. The bes i ing model in ela ion o he
numbe o g oups was es ed by using Bayesian in o ma ion c i e ion,
Akaike in o ma ion c i e ion, and a e age pos e io p obabili y. In his
s udy, we applied a p io i equi emen o a minimum o 2% o he s udy
popula ion o he smalles g oup. By applying hese c i e ia, six g oups
we e selec ed as he bes i ing model o he ou comes. De ailed
TABLE 2. Odds Ra ios Wi h 95% CIs o Changed Family Li e Compa ed Wi h S able Family Li e in Rela ion o Unemploymen
T ajec o y G oups Among Whole Sample and Wi hin Disco dan Twin Pai s
Whole Sample
a
Low inc easing
(n= 5,390)
Middle dec easing
(n= 5,704)
Middle luc uan
(n= 894)
High dec easing
(n= 3,106)
High luc uan
(n=2,471)
Family- ela ed li e e en s (1990–1993) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
F om ma ied
b
wi hou child en o ma ied
b
wi h
child en/ om ma ied
b
wi h child en o
ma ied
b
wi hou child en
0.65 (0.50–0.83) 0.71 (0.55–0.91) 0.62 (0.33–1.17) 0.67 (0.48–0.95) 0.65 (0.44–0.96)
F om ma ied
b
wi hou child en o single
c
wi h/
wi hou child en
1.86 (1.08–3.23) 2.04 (1.17–3.55) 4.44 (1.96–10.09) 1.26 (0.53–3.00) 1.30 (0.51–3.35)
F om ma ied
b
wi h child en o single
c
wi hou
child en
1.38 (1.06–1.78) 1.13 (0.84–1.54) 1.44 (0.86–2.42) 1.58 (1.13–2.19) 2.03 (1.48–2.78)
F om ma ied
b
wi h child en o single
c
wi h
child en
1.31 (1.04–1.65) 1.36 (1.07–1.72) 2.11 (1.39–3.21) 1.79 (1.38–2.33) 1.85 (1.40–2.45)
F om single
c
wi hou child en o ma ied
b
wi hou
child en
0.96 (0.77–1.19) 0.93 (0.75–1.16) 0.62 (0.33–1.16) 0.75 (0.54–1.04) 0.59 (0.39–0.88)
F om single
c
wi hou child en o ma ied
b
wi h
child en
0.85 (0.75–0.95) 0.88 (0.78–0.98) 0.72 (0.54–0.95) 0.93 (0.81–1.07) 0.83 (0.71–0.97)
F om single
c
wi hou child en o single
c
wi h
child en/ om single
c
wi h child en o single
c
wi hou child en
1.32 (0.98–1.79) 1.12 (0.81–1.55) 1.78 (0.98–3.25) 2.15 (1.56–2.95) 2.46 (1.77–3.42)
F om single
c
wi h child en o ma ied
b
wi h/
wi hou child en
0.86 (0.58–1.28) 1.61 (1.15–2.24) 2.17 (1.18–3.99) 1.81 (1.23–2.67) 1.39 (0.88–2.20)
Disco dan win pai s
Low inc easing
(n= 1,338)
Middle dec easing
(n= 1,318)
Middle luc uan
(n= 238)
High dec easing
(n= 768)
High luc uan
(n=641)
Family- ela ed li e e en s (1990–1993) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
F om ma ied
b
wi hou child en o ma ied
b
wi h
child en/ om ma ied
b
wi h child en o
ma ied
b
wi hou child en
0.60 (0.44–0.82) 0.80 (0.60–1.07) 0.66 (0.30–1.44) 0.73 (0.48–1.09) 0.68 (0.43–1.08)
F om ma ied
b
wi hou child en o single
c
wi h/
wi hou child en
1.68 (0.87–3.24) 1.69 (0.86–3.34) 3.38 (1.14–10.09) 1.47 (0.56–3.85) 1.05 (0.31–3.51)
F om ma ied
b
wi h child en o single
c
wi hou
child en
1.30 (0.96–1.76) 1.03 (0.73–1.47) 1.49 (0.84–2.66) 1.54 (1.04–2.27) 1.97 (1.34–2.88)
F om ma ied
b
wi h child en o single
c
wi h
child en
1.24 (0.94–1.63) 1.23 (0.92–1.64) 2.29 (1.38–3.81) 1.55 (1.12–2.15) 1.25 (0.86–1.79)
F om single
c
wi hou child en o ma ied
b
wi hou
child en
0.94 (0.71–1.23) 0.95 (0.73–1.25) 0.65 (0.31–1.35) 0.69 (0.46–1.04) 0.43 (0.35–0.74)
F om single
c
wi hou child en o ma ied
b
wi h
child en
0.82 (0.70–0.96) 0.81 (0.69–0.95) 0.74 (0.52–1.05) 0.96 (0.79–1.17) 0.79 (0.63–0.99)
F om single
c
wi hou child en o single
c
wi h
child en/ om single
c
wi h child en o single
c
wi hou child en
1.18 (0.82–1.69) 1.05 (0.72–1.54) 1.12 (0.47–2.65) 2.19 (1.51–3.18) 2.12 (1.43–3.14)
F om single
c
wi h child en o ma ied
b
wi h/
wi hou child en
0.81 (0.50–1.29) 1.43 (0.96–2.14) 1.82 (0.80–4.15) 1.51 (0.93–2.45) 1.20 (0.70–2.06)
Signi ican esul s a e ma ked in bold.
a
Sex, age, educa ion, a ea o esidence, and his o y o men al and soma ic diagnosis a baseline we e adjus ed in he model wi h he whole sample.
b
Ma ied includes li ing wi h pa ne ; cohabi an .
c
Single includes di o ced, sepa a ed, o widowed.
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630 © 2023 The Au ho (s). Published by Wol e s Kluwe Heal h, Inc. on behal o he Ame ican College o Occupa ional and En i onmen al Medicine.
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in o ma ion on goodness o i s a is ics is epo ed in Supplemen a y Ta-
ble 2, h p://links.lww.com/JOM/B331. Yea 1994 was de ined as he
s a ing ime poin and he pa e ns o mean numbe o mon hs wi h
unemploymen o ne mon hs wi h SA/DP we e measu ed annually
om 1994 up o 2016.
Mo eo e , we used he mul inomial logis ic eg ession model
o elucida ing he associa ions o amily- ela ed li e e en s wi h he
iden i ied LMM ajec o y g oups by con olling o he co a ia es.
The analysis was conduc ed o he whole sample and condi ional
models we e pe o med o disco dan win pai s (ie, one win in a pai
had change in amily li e in 1990–1993 and he o he did no ) o exam-
ine he in luence om amilial ac o s. I he associa ions om he
whole sample a enua ed o changed di ec ion in he disco dan win
pai analyses, his would sugges he impac om amilial ac o s, ha
is, sha ed ea ly en i onmen al ac o s and/o gene ics. Sensi i i y anal-
yses we e pe o med by excluding wins who did no each he age o
ma iage (ie, 18 yea s old, n= 1620 [4.3%]) in 1990 (n= 36,247) (See
Supplemen a y Table 3–6, h p://links.lww.com/JOM/B331 and Fig. 1,
h p://links.lww.com/JOM/B332). Howe e , only ma ginal di e ences
in he esul s we e obse ed. All analyses we e conduc ed by using
SAS S a is ical So wa e, e sion 9.4 (SAS Ins i u e Inc., Ca y, NC).
RESULTS
Table 1 p esen s desc ip i e s a is ics o amily- ela ed li e e en s,
sociodemog aphic ac o s, and his o y o inpa ien ca e a he baseline in
1990–1993 and LMM du ing he ollow-up om 1994 o 2016. Among
37,867 wins, 1352 indi iduals we e unemployed (3.6), 4382 had SA
(11.6%), and 3037 we e g an ed DP (8.0%) du ing he ollow-up. Among
disco dan win pai s, a la ge p opo ion o women (54.3% s 49.1%),
hose who had a his o y o soma ic diagnosis (57.5% s 39.4%) and
DP (7.8% s 9.1%) du ing ollow-up ime, we e ound in wins wi h
TABLE 3. Odds Ra ios Wi h 95% CIs o Changed Family Li e Compa ed Wi h S able Family Li e in Rela ion o SA/DP T ajec o y
G oups Among Whole Sample and Wi hin Disco dan Twin Pai s
Whole Sample
a
Low cons an
(n=5,557)
Low inc easing
(n=1,246)
Middle inc easing
(n=868)
Middle luc uan
(n= 1,127)
High cons an
(n=834)
Family- ela ed li e e en s (1990–1993) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
F om ma ied
b
wi hou child en o ma ied
b
wi h
child en/ om ma ied
b
wi h child en o ma ied
b
wi hou child en
0.72 (0.57–0.91) 0.88 (0.57–1.35) 0.46 (0.23–0.90) 0.49 (0.28–0.87) 0.35 (0.16–0.76)
F om ma ied
b
wi hou child en o single
c
wi h/
wi hou child en
1.82 (1.09–3.03) 1.16 (0.36–3.75) 2.44 (0.93–6.36) 1.16 (0.35–3.83) 1.40 (0.44–4.48)
F om ma ied
b
wi h child en o single
c
wi hou
child en
1.54 (1.21–1.96) 1.18 (0.73–1.92) 1.89 (1.20–2.96) 0.96 (0.55–1.68) 0.55 (0.27–1.12)
F om ma ied
b
wi h child en o single
c
wi h child en 1.46 (1.20–1.77) 1.28 (0.89–1.83) 1.30 (0.87–1.95) 2.23 (1.67–2.97) 0.97 (0.60–1.56)
F om single
c
wi hou child en o ma ied
b
wi hou
child en
1.03 (0.83–1.28) 0.75 (0.44–1.26) 0.70 (0.36–1.37) 0.65 (0.35–1.19) 1.03 (0.56–1.88)
F om single
c
wi hou child en o ma ied
b
wi h
child en
0.89 (0.80–0.99) 0.87 (0.70–1.09) 0.72 (0.53–0.97) 0.76 (0.59–0.98) 0.19 (0.11–0.35)
F om single
c
wi hou child en o single
c
wi h
child en/ om single
c
wi h child en o single
c
wi hou child en
1.28 (1.00–1.65) 1.15 (0.72–1.86) 1.88 (1.21–2.92) 1.24 (0.79–1.96) 0.51 (0.24–1.07)
F om single
c
wi h child en o ma ied
b
wi h/wi hou
child en
1.00 (0.73–1.37) 1.42 (0.87–2.31) 1.49 (0.88–2.55) 1.56 (0.98–2.48) 0.82 (0.39–1.72)
Disco dan win pai s
Low cons an
(n=1,533)
Low inc easing
(n= 326)
Middle inc easing
(n=232)
Middle luc uan
(n= 318)
High cons an
(n=184)
Family- ela ed li e e en s (1990–1993) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
F om ma ied
b
wi hou child en o ma ied
b
wi h
child en/ om ma ied
b
wi h child en o ma ied
b
wi hou child en
0.75 (0.57–0.99) 0.91 (0.55–1.51) 0.45 (0.21–0.99) 0.57 (0.31–1.05) 0.28 (0.11–0.73)
F om ma ied
b
wi hou child en o single
c
wi h/
wi hou child en
1.22 (0.62–2.40) 1.53 (0.46–5.03) 2.79 (0.94–8.26) 1.11 (0.26–4.73) 1.77 (0.46–6.86)
F om ma ied
b
wi h child en o single
c
wi hou
child en
1.53 (1.16–2.02) 1.06 (0.58–1.92) 1.94 (1.13–3.31) 1.14 (0.63–2.10) 0.48 (0.21–1.12)
F om ma ied
b
wi h child en o single
c
wi h child en 1.35 (1.06–1.71) 1.23 (0.78–1.94) 0.83 (0.47–1.46) 2.02 (1.41–2.90) 0.83 (0.47–1.49)
F om single
c
wi hou child en o ma ied
b
wi hou
child en
0.92 (0.70–1.21) 0.78 (0.44–1.39) 0.62 (0.27–1.42) 0.57 (0.28–1.18) 1.12 (0.56–2.24)
F om single
c
wi hou child en o ma ied
b
wi h
child en
0.87 (0.75–1.01) 0.87 (0.64–1.18) 0.69 (0.47–1.02) 0.57 (0.41–0.80) 0.20 (0.10–0.39)
F om single
c
wi hou child en o single
c
wi h
child en/ om single
c
wi h child en o single
c
wi hou child en
0.98 (0.72–1.34) 1.31 (0.77–2.25) 1.59 (0.92–2.75) 0.88 (0.49–1.57) 0.46 (0.19–1.09)
F om single
c
wi h child en o ma ied
b
wi h/wi hou
child en
0.95 (0.65–1.38) 1.31 (0.69–2.47) 1.10 (0.53–2.26) 1.49 (0.86–2.58) 1.01 (0.44–2.30)
Signi ican esul s a e ma ked in bold.
a
Sex, age, educa ion, a ea o esidence, and his o y o men al and soma ic diagnosis a baseline we e adjus ed in he model wi h he whole sample.
b
Ma ied includes li ing wi h pa ne ; cohabi an .
c
Single includes di o ced, sepa a ed o widowed.
JOEM •Volume 65, Numbe 8, Augus 2023 Li e E en s and Labo Ma ke Ma ginaliza ion
© 2023 The Au ho (s). Published by Wol e s Kluwe Heal h, Inc. on behal o he Ame ican College o Occupa ional and En i onmen al Medicine. 631
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change in amily li e compa ed wi h hei co wins wi h s able amily
li e (Table 1).
T ajec o y Analyses o LMM
We iden i ied six g oups o ajec o ies o annual unemploymen
and SA/DP mon hs as well as o a combined measu e o LMM mon hs
o he whole sample du ing 1994–2016 (Fig. 1).
Fo he whole sample, mos indi iduals (50.3%, 73.0%, and
56.7%) belonged o ei he “no unemploymen ,”“no SA/DP,”o “no labo
ma ke ma ginaliza ion”g oup wi h cons an ly no unemploymen , SA/
DP, o LMM mon h du ing 1994–2016. We also obse ed ha indi iduals
had appa en ly lowe unemploymen mon hs compa ed wi h SA/DP
mon hs o e ime. The e we e 2.5% o indi iduals who belonged o “mid-
dle luc ua ing”g oup ha showed app oxima ely 3 mon hs o unemploy-
men . Fo SA/DP and LMM ajec o ies, app oxima ely 2% o indi iduals
had 12 mon hs o SA/DP o LMM be ween 1999 and 2015 (Fig. 1).
Associa ion be ween Family-Rela ed Li e E en s and
LMM T ajec o ies
Table 2 p esen s adjus ed odds a ios (ORs) o change in am-
ily li e compa ed wi h s able amily li e in ela ion o unemploymen
ajec o y g oups among he whole sample. Inc eased likelihood o be-
longing o “no unemploymen ” ajec o y g oup was obse ed among
indi iduals who emained in he ma iage bu changed he s a us o
ha ing child en and among hose who changed om single wi hou
child en o ma ied wi h child en compa ed wi h indi iduals wi h s able
amily li e a e con olling o sociodemog aphic and a his o y o men-
al and soma ic diagnosis in he model. On he con a y, indi iduals
changed om ma ied o single ega dless o s a us o ha ing child en
and indi iduals changed om single wi h child en o ma ied wi h/
wi hou child en showed a highe likelihood o belonging o one o he
ajec o y g oups wi h some mon hs o unemploymen compa ed wi h
indi iduals wi h s able amily li e ( ange o ORs, 1.31–4.44) (Table 2).
Simila esul s we e obse ed o he associa ions be ween
amily- ela ed li e e en s and SA/DP and he combined measu e o
LMM ajec o ies in he whole sample. Ma ied indi iduals who
changed om li ing wi hou child en o li ing wi h child en, o om
li ing wi h child en o wi hou as well as indi iduals who changed
om single wi hou child en o ma ied wi h child en we e less likely
o ha e any mon h o SA/DP o LMM compa ed wi h indi iduals wi h
s able amily li e. Indi iduals who changed om ma ied o single s a us
ended o ha e a highe le el o SA/DP and LMM du ing 1994–2016
han hose wi h s able amily li e (Tables 3,4).
In addi ion, he analysis wi h disco dan win pai s showed some-
wha lowe ORs in ela ion o all ou comes in Tables 2 o 4. We ound no
sys ema ic e ec o amilial ac o s, bu hey canno be uled ou because
he poin es ima es we e a enua ed o some amily- ela ed li e e en s.
DISCUSSION
By applying a li e cou se app oach and using a la ge popula ion-
based coho o Swedish wins (N= 37,867) aged be ween 20 and
TABLE 4. Odds Ra ios Wi h 95% CIs o Changed Family Li e Compa ed Wi h S able Family Li e in Rela ion o LMM T ajec o y G oups
Among Whole Sample and Wi hin Disco dan Twin Pai s
Whole Sample
a
Low inc easing
(n= 4,151)
Middle
inc easing
(n= 978)
Middle
dec easing
(n=7,423)
Middle
luc uan
(n= 2,622)
High cons an
(n= 902)
Family- ela ed li e e en s (1990–1993) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
F om ma ied
b
wi hou child en o ma ied
b
wi h child en/ om
ma ied
b
wi h child en o ma ied
b
wi hou child en
0.66 (0.51–0.87) 0.38 (0.19–0.75) 0.62 (0.49–0.79) 0.64 (0.45–0.91) 0.38 (0.19–0.79)
F om ma ied
b
wi hou child en o single
c
wi h/wi hou child en 1.56 (0.85–2.85) 2.29 (0.87–6.01) 1.03 (0.56–1.89) 2.32 (1.19–4.53) 1.44 (0.45–4.57)
F om ma ied
b
wi h child en o single
c
wi hou child en 1.34 (1.01–1.77) 1.77 (1.12–2.81) 1.38 (1.08–1.77) 1.44 (1.03–2.02) 0.77 (0.41–1.44)
F om ma ied
b
wi h child en o single
c
wi h child en 1.11 (0.85–1.45) 1.91 (1.34–2.73) 1.71 (1.38–2.10) 2.51 (1.98–3.17) 1.18 (0.74–1.88)
F om single
c
wi hou child en o ma ied
b
wi hou child en 0.96 (0.75–1.23) 0.82 (0.47–1.45) 0.84 (0.68–1.03) 0.43 (0.27–0.69) 0.94 (0.52–1.68)
F om single
c
wi hou child en o ma ied
b
wi h child en 0.82 (0.72–0.94) 0.70 (0.53–0.93) 0.87 (0.78–0.96) 0.72 (0.61–0.85) 0.23 (0.14–0.38)
F om single
c
wi hou child en o single
c
wi h child en/ om single
c
wi h child en o single
c
wi hou child en
1.16 (0.82–1.62) 2.40 (1.58–3.67) 1.63 (1.25–2.12) 2.01 (1.45–2.78) 0.77 (0.39–1.52)
F om single
c
wi h child en o ma ied
b
wi h/wi hou child en 0.78 (0.51–1.19) 1.46 (0.85–2.51) 1.22 (0.89–1.69) 1.90 (1.34–2.71) 1.26 (0.67–2.38)
Disco dan win pai s
Low inc easing
(n= 1,062)
Middle
inc easing
(n= 261)
Middle
dec easing
(n=1,798)
Middle
luc uan
(n= 736)
High cons an
(n= 209)
Family- ela ed li e e en s (1990–1993) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
F om ma ied
b
wi hou child en o ma ied
b
wi h child en/ om
ma ied
b
wi h child en o ma ied
b
wi hou child en
0.71 (0.52–0.97) 0.32 (0.14–0.74) 0.67 (0.51–0.88) 0.67 (0.45–1.00) 0.34 (0.15–0.78)
F om ma ied
b
wi hou child en o single
c
wi h/wi hou child en 1.66 (0.83–3.31) 2.54 (0.86–7.54) 0.83 (0.37–1.81) 1.82 (0.78–4.24) 1.74 (0.45–6.74)
F om ma ied
b
wi h child en o single
c
wi hou child en 1.35 (0.97–1.88) 1.65 (0.95–2.88) 1.31 (0.98–1.75) 1.40 (0.96–2.07) 0.69 (0.33–1.44)
F om ma ied
b
wi h child en o single
c
wi h child en 1.18 (0.87–1.60) 1.32 (0.81–2.15) 1.43 (1.11–1.84) 2.06 (1.54–2.77) 0.92 (0.52–1.62)
F om single
c
wi hou child en o ma ied
b
wi hou child en 1.02 (0.76–1.36) 0.70 (0.35–1.41) 0.75 (0.58–0.98) 0.28 (0.15–0.52) 1.00 (0.51–1.94)
F om single
c
wi hou child en o ma ied
b
wi h child en 0.93 (0.78–1.11) 0.64 (0.44–0.92) 0.87 (0.75–0.99) 0.59 (0.47–0.73) 0.24 (0.13–0.44)
F om single
c
wi hou child en o single
c
wi h child en/ om single
c
wi h child en o single
c
wi hou child en
1.17 (0.79–1.73) 2.20 (1.32–3.69) 1.49 (1.09–2.03) 1.52 (1.02–2.26) 0.55 (0.23–1.30)
F om single
c
wi h child en o ma ied
b
wi h/wi hou child en 0.77 (0.46–1.26) 0.82 (0.37–1.84) 1.11 (0.76–1.63) 1.55 (1.00–2.40) 1.50 (0.75–3.01)
Signi ican esul s a e ma ked in bold.
a
Sex, age, educa ion, a ea o esidence, and his o y o men al and soma ic diagnosis a baseline we e adjus ed in he model wi h he whole sample.
b
Ma ied includes li ing wi h pa ne ; cohabi an .
c
Single includes di o ced, sepa a ed, o widowed.
Wang e al JOEM •Volume 65, Numbe 8, Augus 2023
632 © 2023 The Au ho (s). Published by Wol e s Kluwe Heal h, Inc. on behal o he Ame ican College o Occupa ional and En i onmen al Medicine.
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40 yea s, we iden i ied six ajec o ies o LMM including unemploy-
men , SA/DP, and a combined measu e du ing 1994–2016. This esul
is in acco dance wi h p e ious s udies which examined LMM ajec o ies
wi h speci ic pa ien g oup, sugges ing a he e ogenei y in LMM.
1,40
In
his s udy, majo i y o he indi iduals had no o conside ably low le els
o unemploymen , SA/DP, and combined measu e o LMM o e ime.
In line wi h he heal h selec ion hypo hesis, indi iduals wi h op imal
heal h condi ions a e mo e likely o s ay in employmen , whe eas indi-
iduals wi h poo e heal h a e mo e likely o be o emain unemployed,
ecei e sick pay, o DPs.
41
Hence, ou inding sugges s ha ou s udy
popula ion o ela i ely young age was in good heal h. In con as , he e
we e oughly 2% o indi iduals belonged o “high cons an ”g oup wi h
app oxima ely 12 mon hs o SA/DP o LMM annually o e ime. I is
possible ha his g oup consis ed o a la ge p opo ion o indi iduals
wi h long- e m SA o DP. In addi ion, we obse ed a dis inc ly lowe
le el o unemploymen compa ed wi h SA/DP, which is suppo ed by
ano he s udy.
1
I seems ha SA/DP is he majo componen o LMM.
Mo eo e , we could no in es iga e socioeconomic p o iles in ela ion
o he ajec o y g oups and u he s udy, wi h a ocus on hose ac o s,
migh gain mo e knowledge on he he e ogenei y o LMM.
In he analysis o amily- ela ed li e e en s and LMM ajec o-
ies, we ound ha indi iduals who we e s ably ma ied wi h changed
s a us o ha ing child en and who changed om single li ing wi hou
child en o ma ied li ing wi h child en had a lowe isk o ha ing un-
employmen , SA/DP, and combined LMM mon hs o e ime han indi-
iduals wi h s able amily li e. In gene al, indi iduals ul ill emo ional,
social, and ma e ial needs o en by in ol ing in di e en li e e en s
consis ing o spouses, child en, siblings, and o he con idan s. P e ious
s udies ha e epo ed ha a posi i e change in li e is associa ed wi h de-
c eased isk o DP and cance .
28
Ou indings show ha he bene i s o
main aining in he ela ionship and o ming a amily wi h child en a e
e en g ea e han emaining in s able amily li e wi hou any changes
(ie, nei he in ma i al s a us and no in ha ing child en).
Con a y o he posi i e changes, indi iduals who expe ienced
a di o ce had a highe isk o ha ing some mon hs o unemploymen ,
SA/DP, and he combined LMM du ing he ollow-up pe iod. Se e al
ea lie s udies ha e shown he nega i e consequences o di o ce on
heal h and labo ma ke ou comes.
15–17,19,20
This may be due o inc eased
s esses and s ains ha accompany a di o ce, such as inc eased
ca e-gi ing and inancial di icul ies. Pa icula ly o single pa en s, hey
a e mo e likely o expe ience psychological dis ess, inancial ha dship as
well as lowe le els o social suppo , which migh cause hem o lose sus-
ainable abili y o wo k.
18
Ano he possible explana ion o he indings is
he unheal hy li es yle. Fo example, he associa ion be ween hea y use o
alcohol and a highe isk o di o ce has been epo ed,
42
which is po en-
ially one o he easons o subsequen LMM. The e ec s s emming
om amilial ac o s we e no appa en in he p esen s udy; howe e ,
because he isk es ima es we e educed o some amily- ela ed li e
e en s, he in luence om amilial ac o s canno be igno ed.
S eng hs and Limi a ions
The main s eng hs o his s udy include he use o a sizeable
popula ion-based sample o wins (N= 37,867), which p o ided sa is-
ac o y s a is ical powe o he analyses. The o he s eng hs include
he long ollow-up pe iod (23 yea s), a p ospec i e coho design,
and he use o na ionwide egis e da a o high quali y,
37
which mini-
mizes he isk o loss o ollow-up and ecall o epo ing biases. In ad-
di ion, we could include disco dan win pai s in he analyses o ac-
coun o he in luence s emming om amilial ac o s. Howe e , anal-
yses wi h MZ and DZ win pai s we e no possible o pe o m because
he e was no enough s a is ical powe o s a i y by zygosi y. In his
s udy, we we e also able o include se e al impo an co a ia es, bu
he e migh be o he po en ial ac o s ha a e associa ed wi h he ou -
comes as well, such as occupa ional g oups, LMM a baseline, o un-
heal hy li es yle, ha should be add essed in u he s udies.
Rega ding limi a ions, in o ma ion on sick-lea e spells less
han 14 days was no accessible among employed indi iduals, which
means ha o employed indi iduals, he numbe o SA days con ibu -
ing o he combined numbe o SA/DP days migh be unde es ima ed.
Ano he limi a ion is ela ed o he li e cou se pe spec i e because we
assessed amily- ela ed li e e en s only e ospec i ely in 1990–1993.
Howe e , ou measu e o LMM was p ospec i e om 1994 o 2016
e lec ing he li e cou se app oach. Fu u e s udies should explo e he
concu en changes in amily- ela ed li e e en s and LMM using p o-
spec i e designs wi h easonable ollow-up ime. In addi ion, he ind-
ings om he s udy may no be gene alizable o indi iduals wi h
sho - e m SA spells (<14 days). S ill, he indings in his s udy can
be gene alized o indi iduals li ing in coun ies wi h compa able eco-
nomic and labo ma ke condi ions and heal h ca e and social insu ance
sys ems. Mo eo e , amily- ela ed li e e en s occu ed in one win may
ha e spillo e e ec s on he o he win. Howe e , he win design en-
su es ha he associa ion be ween amily- ela ed li e e en s and LMM
ajec o ies is no d i en by amilia ac o s.
CONCLUSIONS
Mos o he indi iduals had no o low le els o LMM du ing
1994–2016. S aying o ge ing ma ied and ha ing child en we e
associa ed wi h a lowe isk o LMM whe eas di o ce was a isk
ac o o LMM.
ACKNOWLEDGMENTS
The au ho s hank he Swedish Twin Regis y o access o da a.
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