Relative deprivation in the Nordic countries—child mental health problems in relation to parental financial stress

Abstract

Background:  The Nordic welfare system has been acknowledged as favourable for children, successfully contributing to low child mortality and poverty rates. Nevertheless, mental health problems among children and adolescents are common and the economic situation of the family has been highlighted as an important determinant. In spite of similar social, political and cultural structures, the Nordic countries differ; Iceland was most affected by the global financial crisis in 2008. The aim of this study was to examine potential differences in parental financial stress and the associations to child mental health between the Nordic countries as well as age and gender differences.  Methods:  The study sample consisted of 6330 children aged 4–16 years old included in the 2011 version of the Nordic Study of Children’s Health, Wellbeing and Quality of life. The Strengths and Difficulties Questionnaire was used to measure mental health problems.  Results:  In Iceland, 47.7% of the parents reported financial stress while ≤20% did so in the other countries except for Finland (33.5%). However, in case of parental financial stress the OR of mental health problems comparing children to parents with and without financial stress was significantly lower among the Icelandic children (OR 1.60, 95% CI 1.15–2.24) than among the others: Denmark OR 3.07 (95% CI 2.15–4.39), Finland OR 2.28 (95% CI 1.60–3.25), Norway OR 2.77 (95% CI 1.86–4.12), Sweden OR 3.31(95% CI 2.26–4.86). No significant age or gender differences in the ORs were observed.  Conclusions:  Besides socioeconomic situation, relative deprivation should be considered an important determinant of child mental health.

Introduction

The Nordic welfare system is noted as favourable for children, successfully contributing to low child mortality and poverty rates. ^1,2 By offering favourable parental leave and affordable public day care, the system enables both mothers and fathers to combine work and family life, factors which promote child health and wellbeing. ²

In spite of favourable conditions, mental health problems among children and adolescents in the Nordic countries are common ^3,4 which, in addition to causing suffering during childhood, can have long lasting effects into adulthood. ^4,5 The socioeconomic status of the family has been pointed out as an important determinant ^6,7 affecting the child through the mechanisms of parental emotional wellbeing and parenting practices. ^8,9 A direct association between the financial situation and child mental health problems has been found. ⁸

Study comparisons are complicated due to heterogenic methods and measures, ⁷ but previous studies have indicated negative associations among both younger ¹⁰ and older children ¹¹ . Gender patterns in the associations are unclear, few studies report analysis on gender differences and previous results are inconsistent. ⁷

Marmot and Wilkinson ¹² emphasize that health and wellbeing in wealthy countries are more strongly related to relative income than absolute, and that social position and psychological effects of relative deprivation are at least as important in explaining health inequalities as crude material conditions. Yngwe et al. ^13,14 found stronger association between relative deprivation and long-term illness (LTI) among those with greater ability to consume, and that associations between relative deprivation and self-rated health were not significant among individuals in the lowest income levels. Likewise, Bernburg et al. ¹⁵ found weaker associations between financial hardship and individual outcomes among adolescents in school-communities with a high prevalence of financial hardship than in school-communities with a low prevalence. Previous studies have also found self-reported financial stress clearly associated with negative health outcomes, ¹⁶ and that perceived financial stress rather than low income as such had negative effects on health. ¹⁷

In spite of sharing similar social, political and cultural structures, there are differences between the Nordic countries. For example, Iceland was the hardest hit by the global financial crisis in 2008. ^18,19 In the OECD (Organisation of Economic Co-operation and Development), the increase in income inequalities has been greatest in countries with previously low inequalities, particularly in Sweden where the increase was large, placing it in the top of the Nordic countries. Iceland was an exception as the inequalities decreased substantially, most likely due to a larger fall in income among those in high and middle income level. ¹⁹

The aim of this study was to examine the associations between parental financial stress and child mental health problems in the Nordic countries with a focus on potential differences between the countries. The aim was further to examine age and gender differences in the associations.

Methods

Study population

The data are from the Nordic Study of Children’s Health and Wellbeing (NordChild) conducted 2011 in Denmark (DK), Finland (FI), Iceland (IS), Norway (NO) and Sweden (SE). A random sample of ∼3000 children from each country was taken from the total population of children aged 2–17 years old, stratified by age and gender. A postal questionnaire addressed to children’s primary care givers was distributed. The overall response rate after reminders was 48.8% and was similar in all countries. The study sample consisted of 7805 children of whom 6330 (age 4–16) were included in the present analysis. Of the responding primary caregivers 83.4% were mothers. Ethical approval was achieved according to prescribed guidelines in each country.

Measurements

Child mental health problems were measured by the parent version of Strengths and Difficulties Questionnaire (SDQ), a widely used screening instrument for mental health problems among children 4–16 years old. ^20,21 The questionnaire has been translated and found valid for use in all the Nordic countries. ²² SDQ consists of five subscales including 25 items covering questions about emotional, peer and behavioural problems, hyperactivity and pro-social behaviour occurring the last 6 months. Each subscale generates a scale score ranging from 0 to 10. The total difficulties score (TDS) is the sum of the subscales covering hyperactivity, emotional, peer and behavioural problems, generating a scale score ranging from 0 to 40. ²⁰ As recommended, ^20,23 the 90th percentiles, for all countries combined, were used as cut-offs for mental health problems. For further information about the SDQ questionnaire, see http://www.sdqinfo.org/ . Previous studies have observed gender and age-specific differences in the mean score. ^23,24 Hence, the cut-offs were adjusted for gender and the age groups: preschool children (4–6 years old), primary school children (7–12 years old) and adolescents (13–16 years old).

Financial stress was assessed by two self-reported variables about the parents’ perception of the family’s financial situation previously used in Swedish studies. ^16,17 (i) Available cash reserve, assessed by the question: If you suddenly would find yourself in an unexpected situation would you be able to obtain an amount of 1500 Euros within a week? (yes or no). (ii) Ability to meet regular expenses, assessed by the question: Have you, during the last 12 months, had problems meeting the family’s regular expenses? Food, rent, bills, etc. (yes or no). Those who answered no to the first question and/or yes to the second one were defined as having financial stress.

Other aspects of socioeconomic status have also been found to be of importance for child mental health, ^6,7 e.g. parents’ educational level (university level or lower) and marital status (married/cohabiting or single) and thus included in the analysis. Parents’ birth country (Nordic or non-Nordic) was also included as being foreign born has been found strongly related to poverty ²⁵ even though studies are inconsistent regarding the associations to child mental health. Moderate or severe LTI of children was considered possibly contributing to financial stress and child mental health problems. LTI was defined as one or more modest or severe physical symptoms presented during at least 3 months throughout the last year. Finally, the parents’ health status was considered as possibly affecting child mental health and contributing to financial stress through decreased ability to work. ²⁶ Parents’ sick leave was used to assess parents’ health status and defined as long term if parents reported having taken 60 or more sick leave days the last 12 months.

Statistical analysis

The analysis was performed in two parts: (i) separately for each country and (ii) on the whole (Nordic) sample, stratified by age and gender.

• Mean TDS and prevalence of mental health problems (defined as SDQ-TDS score >90th percentile) were calculated for each country. Differences in mean TDS between the countries were then tested using independent t -test. A binary logistic regression analysis was performed to examine the associations between parental financial stress and child mental health. A hierarchical approach was used in the regression model building in order to observe whether the outcome estimate was affected partly by child age and gender, other aspects of socioeconomic status and at last child or parent health status. In the first model, child age and gender were entered, and in the second model parents’ educational level, marital status and birth country were added. In the last two models, the variables child LTI (Model 3) and parents’ sick leave (Model 4) were added separately. The crude odds ratios (OR) for Iceland differed from the crude ORs for the other countries but with a marginal overlap in the confidence intervals (CI) which challenged the conclusion about the statistical significance. Thus, in order to test that an interaction term Iceland * financial stress (countryIS * financial stress) was added to the regression model.

• Mean TDS and prevalence of mental health problems were calculated for boys and girls in each age group. A binary logistic regression analysis was performed on gender and age groups separately to examine the association between parents’ financial stress and child mental health. In order to adjust for the considered confounders, a hierarchical approach was again used in the regression model building. In Model 1, country and an interaction term (countryIS * financial stress) was included in the multiple regression model in order to adjust for observed differences between Iceland and the other countries. Otherwise the procedure was the same as above. Observed differences in the crude ORs between girls aged 7–12 and 13–16 years old, respectively, and children in other age/gender groups were further analysed by adding interaction terms for each group.

Results

The study sample is described in table 1 . A larger proportion of parents in Iceland reported financial stress (47.7%) than in the other countries. In Denmark, 17.8% reported financial stress, in Finland 33.5%, in Norway 18.7% and in Sweden 20.0%. Table 1 also shows that children in Norway and Sweden had lower mean scores on the SDQ-TDS than children in Denmark, Finland and Iceland.

Table 1

Characteristics of study sample

	Denmark ( n = 1384)	Finland ( n = 1200)	Iceland ( n = 1244)	Norway ( n = 1320)	Sweden ( n = 1182)	Nordic sample ( n = 6330)
Gender
Boys, n (%)	701 (50.7)	589 (49.1)	638 (51.3)	672 (50.9)	598 (50.6)	3198 (50.5)
Girls, n (%)	683 (49.3)	611 (50.9)	606 (48.7)	648 (49.1)	584 (49.4)	3132 (49.5)
Age
4–6 years, n (%)	349 (25.2)	304 (25.3)	271 (21.8)	296 (22.4)	282 (23.9)	1502 (23.7)
7–12 years, n (%)	635 (45.9)	591 (49.3)	623 (50.1)	622 (47.1)	548 (46.4)	3019 (47.7)
13–16 years, n (%)	400 (28.9)	305 (25.4)	350 (28.1)	402 (30.5)	352 (29.8)	1809 (28.6)
Family financial stress
Yes, n (%)	247 (17.8)	402 (33.5)	593 (47.7)	247 (18.7)	236 (20.0)	1725 (27.3)
No, n (%)	1064 (76.9)	766 (63.8)	632 (50.8)	1038 (78.6)	926 (78.3)	4426 (69.9)
SDQ-TDS Mean (SD) a	7.7 (4.3)	7.9 (4.1)	8.0 (4.4)	7.3 (4.2) b	7.4 (4.2) b	7.7 (4.3)

a: SDQ-TDS, Strength and Difficulties Questionnaire—Total Difficulties Score Mean (Standard deviations)

b: Mean SDQ-TDS significantly lower than in the other countries, P < 0.05

As shown in table 2 , the prevalence of mental health problems in all the countries was higher among children of parents reporting financial stress compared with children of parents reporting no financial stress in all the countries. The results were similar in the Nordic sample when analysed by gender and age groups: boys and girls in all age groups had higher prevalence of mental health problems if their parents reported financial stress (results not shown).

Table 2

Mean and SD of TDS and the prevalence of mental health problems (MHP)

	Financial stress			No financial stress
	n	TDS, mean (SD)	% MHP	n	TDS, mean (SD)	% MHP
Nordic sample	1707	8.9 (4.8)	19.1	4407	7.1 (3.9)	8.8
Denmark	246	9.4 (4.9)	24.0	1062	7.3 (4.0)	9.3
Finland	395	8.9 (4.8)	18.5	763	7.5 (3.6)	9.0
Iceland	589	8.7 (4.7)	16.1	626	7.4 (4.1)	10.7
Norway	244	8.9 (4.9)	18.4	1034	6.9 (3.9)	7.5
Sweden	233	9.4 (4.9)	23.2	922	6.8 (3.8)	8.4

Table 3 shows the results of the logistic regression analysis, which reveals that children of parents reporting financial stress had higher odds of mental health problems in all the countries. The results also show that the OR of mental health problems comparing children of parents with and without financial stress was lower in Iceland (OR 1.60 95% CI 1.15–2.24) than in the other Nordic countries: Denmark OR 3.07 (95% CI 2.15–4.39), Finland OR 2.28 (95% CI 1.60–3.25), Norway OR 2.77 (95% CI 1.86–4.12) and Sweden OR 3.31 (95% CI 2.26–4.86). The statistical significance of the difference in OR between Iceland and the other Nordic countries was confirmed when tested as the interaction countryIS * financial stress ( P = .004).

Table 3

Associations between children’s mental health problems and parental financial stress by country

Country	Mental health problems
	Crude a		Model 1		Model 2		Model 3		Model 4
	OR (95% CI)	n	OR (95% CI)	N	OR (95% CI)	n	OR (95% CI)	n	OR (95% CI)	n
Total b	2.43 (2.07–2.85)	6114	2.82 (2.34–3.34)	6114	2.26 (1.86–2.75)	5698	2.23 (1.81–2.74)	5620	2.16 (1.77–2.65)	5866
CountryIS * financial stress	–		P = 0.004		P = 0.018		P = 0.016		P = 0.027
Denmark	3.07 (2.15–4.39)	1308	3.09 (2.16–4.43)	1308	2.59 (1.77–3.78)	1282	2.77 (1.86–4.14)	1204	2.41 (1.63–3.56)	1260
Finland	2.28 (1.60–3.25)	1158	2.32 (1.62–3.31)	1158	2.09 (1.44–3.03)	1136	2.07 (1.41–3.03)	1091	2.10 (1.44–3.05)	1123
Iceland	1.60 (1.15–2.24)	1215	1.59 (1.14–2.23)	1215	1.33 (0.92–1.92)	1177	1.28 (0.87–1.89)	1100	1.31 (0.90–1.89)	1162
Norway	2.77 (1.86–4.12)	1278	2.76 (1.85–4.11)	1278	2.19 (1.42–3.38)	1239	2.04 (1.29–3.23)	1132	2.17 (1.39–3.39)	1209
Sweden	3.31 (2.26–4.86)	1155	3.28 (2.23–4.81)	1155	2.51 (1.65–3.81)	1134	2.46 (1.60–3.78)	1093	2.34 (1.51–3.63)	1112

a: Reference: no financial stress.

b: Total sample also adjusted for country, interaction term (countryIS * financial stress).

Model 1: adjusted for age and gender.

Model 2: adjusted for age, gender, parental education, birth country and marital status.

Model 3: adjusted for age, gender, parental education, birth country, marital status and child long term illness.

Model 4: adjusted for age, gender, parental education, birth country, marital status and parental long term sick leave.

When adjusted for parents’ educational level, civil status and birth country in a multiple logistic regression model ( table 3 ), the increased odds of mental health problems were no longer significant among the children in Iceland, but still significant and 2-fold higher or more among children in the other Nordic countries. Further adjusting for child LTI and parents’ sick leave did not affect the outcome estimate substantially.

As shown in table 4 , both boys and girls in all age groups of the Nordic sample had higher odds of mental health problems if parents reported financial stress. In model 2, when adjusted for country, parents’ birth country, civil status and educational level, the increased odds were no longer significant among girls in the preschool age and adolescent girls. Further adjusting for child LTI and parents’ sick leave did not affect the outcome estimate substantially.

Table 4

Associations between children’s mental health problems and parental financial stress by gender and age

	Mental health problems
	Crude a OR (95% CI) b	N	Model 1		Model 2		Model 3		Model 4
			OR (95% CI)	n	OR (95% CI)	n	OR (95% CI)	n	OR (95% CI)	n
Boys
Total	2.48 (1.98–3.10)	3092	2.88 (2.21–3.75)	3092	2.41 (1.82–3.19)	3023	2.33 (1.75–3.11)	2859	2.33 (1.75–3.10)	2969
4–6 years	2.59 (1.61–4.16)	744	3.25 (1.88–5.61)	744	2.90 (1.64–5.13)	727	2.94 (1.59–5.45)	679	3.13 (1.73–5.68)	717
7–12 years	2.55 (1.87–3.48)	1492	2.79 (1.93–4.04)	1492	2.30 (1.56–3.39)	1462	2.27 (1.53–3.38)	1389	2.24 (1.50–3.32)	1443
13–16 years	2.22 (1.41–3.48)	856	2.79 (1.65–4.72)	856	2.36 (1.32–4.22)	834	2.32 (1.27–4.22)	791	2.11 (1.15–3.87)	809
Girls
Total	2.39 (1.91–2.99)	3022	2.75 (2.11–3.59)	3022	2.14 (1.62–2.83)	2945	2.18 (1.62–2.92)	2761	2.04 (1.53–2.71)	2897
4–6 years	2.11 (1.36–3.27)	708	1.73 (1.01–2.96)	708	1.52 (0.87–2.66)	692	1.74 (0.98–3.11)	653	1.54 (0.88–2.70)	681
7–12 years	2.95 (2.11–4.12)	1440	3.84 (2.60–5.68)	1440	2.93 (1.95–4.41)	1408	2.70 (1.76–4.15)	1332	2.76 (1.82–4.18)	1386
13–16 years	1.89 (1.22–2.91)	874	2.49 (1.49–4.17)	874	1.66 (0.95–2.90)	845	1.72 (0.94–3.15)	776	1.53 (0.86–2.72)	830

a: Reference: no financial stress.

b: Differences in OR not statistically significant when tested with interaction terms.

Model 1: adjusted for country, interaction (countryIS * financial stress).

Model 2: adjusted for country, interaction (countryIS * financial stress), parental education, birth country and marital status.

Model 3: adjusted for country, interaction (countryIS * financial stress), parental education, birth country, marital status and child long term illness.

Model 4: adjusted for country, interaction (countryIS * financial stress), parental education, birth country, marital status and parental long term sick leave.

Discussion

A substantially larger proportion of parents in Iceland reported financial stress than parents in the other Nordic countries. Iceland was hit harder and more abruptly by the global financial crisis in 2008 than the other countries. ^18,19 However, even though Icelandic children had among the highest mean score on the SDQ-TDS, the odds of mental health problems in case of parental financial stress were significantly lower than among children in the other Nordic countries. This indicates that mental health problems among Icelandic children were not as strongly associated with financial stress as in the other countries. Theories about relative deprivation emphasize that subjective comparisons influence how people experience their situation ²⁷ which can lead to emotions of anger and injustice which in turn can have negative effects on health. ^27,28 Furthermore, the possibilities of participating in society become inhibited and perceived control over life reduced, both of which are important for health. ^12,28 These mechanisms of relative deprivation have been proposed to be a key issue in the negative associations between income inequality and population health ²⁹ and relevant for adults, children and adolescents. ^15,30 If approximately half of the Icelandic children were living in families with financial stress, it is likely that they did not perceive their situation as adverse. In contrast, children of parents with financial stress in the other Nordic countries might, if they were unfavourably comparing themselves to a majority of children living in families with no financial stress.

Modern western culture is characterized by materialism and individualism which emphasize the importance of money, properties and consumption. ³¹ Consumption as a cultural process can provide people with meaning, purpose and social identity. ¹² A Swedish study among young people found clothes’ branding of importance for developing and expressing identity and described shopping as a meaningful social practice. ³² Not being able to participate in cultural activities and freely express the identity desired may have negative effects on mental health and wellbeing. Another Swedish study among adolescents 10–18 years old found that not being able to buy things that others had was strongly related to health complaints, also when adjusted for the financial situation of the family. ³³ Marmot and Wilkinson ^12,28 describe how financial resources define one’s place in the social hierarchy which, if low, leads to stigma, social isolation and reduces control over life. In Iceland, financial stress may not have been as distinct a marker of social status as before the crisis, since the financial situation of the majority of the population was troubled in one way or another. When adjusted for marital status, educational level and parent birth country, the negative association between parental financial stress and child mental health among Icelandic children was no longer significant, indicating that the social situation of the family was more important in Iceland than the financial stress per se . In the other Nordic countries where the proportion of children living in families reporting financial stress was lower, adjusting for social situation did not affect the outcome estimates substantially. Financial stress in these countries might have been a more important indicator of social status and related to child mental health through the mechanisms of relative deprivation as argued previously. ^12,30

The association between parental financial stress and child mental health was found similar in all periods of childhood and among both boys and girls. The findings are in line with previous studies. ^10,11 . The absence of age differences was partly surprising as consumption and relative deprivation could be expected to be more of importance in adolescence than in younger ages. The results indicate that the mechanisms of relative deprivation may also exist among younger children, as Pickett and Wilkinson ³⁰ concluded. Previous studies are inconsistent about gender differences. ⁷

The welfare system of the Nordic countries has been successful in providing favourable prerequisites for child health and wellbeing. ¹ However, it has been proposed that modern values inherent to individualism and materialism (e.g. overemphasis on self-actualization and consumption) trigger individual expectations to levels beyond what is realistic to achieve. ^31,34 This might contribute to an explanation of the extended mental health problems among children in spite of otherwise favourable conditions, not least if children also are unfavourably comparing themselves to others. In congruence with Pickett and Wilkinson, ³⁰ our results therefore indicate that reducing income inequalities in rich countries, such as the Nordic countries, probably would be more favourable for child-wellbeing than further economic growth.

Strengths and limitations

The main strength of this study is the comprehensive sample of children in a broad age span from all Nordic countries. This enabled comparisons between countries, gender and various age groups. The random sampling process increased the representativeness of the study, which on the other hand was limited by a low response rate. A comparison of study participants and the general population showed that single parents and parents with low education were underrepresented. The prevalence of children living in families with financial stress thus might be underestimated in our study. The underrepresentation was similar in all the countries and thus not influencing differences in the ratios.

All data in our study were parental reported which can be considered both a strength and limitation: It captured parents’ perceptions of the financial situation regardless of income level, which is a strength; however it is limited since the information about child mental health was dependent on parents’ awareness about their children’s health. A cross-national study of adolescents’ (11, 13 and 15 years old) self-rated health found the strongest associations between health status and the material conditions of the family among Icelandic adolescents when assessed by the adolescents themselves. ³⁵ This emphasizes the importance of clarifying who is reporting and what is being reported in research and discussion of child mental health. The SDQ has been found a comprehensive measurement of overall mental health problems among children 4–16 years old ²⁴ and corresponds sensitively with clinical diagnoses of psychiatric disorders. ²¹ The SDQ prediction is most precise when all three versions (parent, teacher and self-report among children 11–16 years old) are used simultaneously which however seldom is possible in large population studies ²¹ and was not possible in this study. The parent and teacher versions have been found to predict overall problems with similar precision ²¹ and to have good scale reliability. ²⁴

A higher proportion of mothers answered the questionnaire as main caregivers indicating that mothers still take the main responsibility for childcare. Thus, the results of this study are valid only for children’s primary caregivers, not mothers and/or fathers in general.

Analysis of the role of parental emotional wellbeing and parenting practices as potential moderators in the association between financial stress and child mental health was not possible and is a limitation which should be addressed in future research.

The cross-sectional design prohibits any conclusions about causality. In the study design, we presupposed that financial stress affected mental health to a greater extent than vice versa—however, the opposite may also be possible.

Conclusions

In this study, negative associations between parental financial stress and child mental health problems were observed among children 4–16 years old in all the Nordic countries. The odds of mental health problems in case of parental financial stress were significantly lower among children in Iceland where proportions of children living in families with and without financial stress were approximately the same. This emphasizes the importance of considering relative deprivation and income inequality as a significant determinant of child mental health problems.

Acknowledgement

The NordChild studies are conducted in collaboration between the Nordic countries and we want to express our gratitude to the members of the NordChild research group.

Funding

This study was funded by the Nordic Council of Ministers.

Conflicts of interest : None declared.

Key points

• In Iceland, the odds of child mental health problems in case of financial stress were significantly lower than in the other Nordic countries.

• No significant gender differences were found in the association between financial stress and mental health among children in any of the age groups.

• The study emphasizes the importance of relative deprivation to be considered both in research and policy making as a contributor to child mental health.