Non-completion of secondary education and early disability in Norway: geographic patterns, individual and community risks

The proportion of young adults prematurely leaving the labour market due to disability pensions (DPs) has increased significantly during the last decade [1]. Recent statistics have shown that 1.8% of the Norwegian population between the ages of 18 and 29 receive DP, which is almost double since 2007 [2]. The leading reason for DP receipt among individuals below 40 years of age in Norway is mental illness [3]. Brage and Thune [3] attributed this increase in part to more precise diagnostics, changes in health status and growing requirements in the labour market. Early work-life exit among young people is a great public health challenge and a threat to the Nordic welfare state model, which depends on high employment rates [4]. Young adults who come to rely on social insurance benefits for most of their life course place a high socioeconomic burden on their society [5]. They also experience substantial lifetime consequences in terms of health and socioeconomic marginalisation [6, 7]. Increasing DP rates will, therefore, ultimately lead to a society with larger socioeconomic and health disparities. DP receipt is also an important area for scientific inquiry because DP is an indicator of society’s health status as a whole, given that DP eligibility criteria are strictly medical [8].

Social factors present at different levels of society, at the individual, family, community and national levels, strongly influence the health of young people [9]. Individual factors related to early DP have been extensively investigated, showing a clear educational gradient with heavy clustering of DP among non-completers of secondary education [10, 11]. Low education achievement is associated with lower work participation, higher risk of long-term socioeconomic marginalisation [12–15], unemployment [16] and mental and physical health issues [9, 17, 18]. School non-completers are also far more likely to receive DP [10, 11, 19] or depend on other medical and non-medical public benefits early in life [10, 11, 20]. Moreover, numerous studies have shown that childhood adversities, such as parental disability and low socioeconomic status, are associated with physical and mental health problems [21–27], low educational achievement [28, 29] and work disability [10, 30, 31] later in life.

A large body of research have linked area characteristics, both physical and social, to a range of health behaviours and health related outcomes [32–35]. Official statistics demonstrate, for instance, large geographical variations in DP recipient rates in Norway, and that certain structural (contextual) factors may partly explain this variation [2]. Nordic population studies have shown that the prevalence of DP correlates with municipal socioeconomic conditions, such as economic development, unemployment rate and education level [36–38]. Moreover, socioeconomically disadvantaged areas are associated with fewer health-promoting behaviours [33, 39], higher morbidity [33, 40, 41] and all-cause mortality [42]. A number of studies have examined the effect of local socioeconomic conditions on the incidence of DP receipt, but less attention has been paid to the variation in contextual risk across subgroups of the population. It is plausible that the socioeconomic context of the area may not equally affect health for all people and certain personal characteristics and features of the social environment may act as moderators [34, 43]. In other words, there may be statistical interactions between personal characteristics, features of the residential context and the health outcomes studied. According to the relative deprivation hypothesis, individuals who are disadvantaged, relative to others in a certain neighbourhood, will experience stress-inducing social comparisons, which may have adverse consequences for individual health [34, 44].

This study investigates how medically based DP among young adults varies geographically, and how municipal socioeconomic conditions interacts with non-completion of secondary education in determining DP risk.

This study examined how medically based DP among young adults varies geographically, and how municipal socioeconomic conditions interact with non-completion of secondary education in determining DP risk. Findings from the current study reinforce the relevance of the residential context in DP risk among young adults. In support of previous studies, we found that non-completers of secondary education are more likely to receive early DP than completers. Our parametric estimation, however, suggest that the association between school non-completion and DP receipt varies across municipalities. The key contributions of this study are related to the exploration of how different municipal socioeconomic conditions interact with non-completion of secondary education, to alter DP risk in young adulthood. Municipalities with high socioeconomic profiles are, in general, associated with both a lower risk of non-completion and DP receipt [36–38, 60]. But this association does not hold for all groups. We found that non-completion has a stronger association with DP in socioeconomically advantaged municipalities. In other words, living in a high-status municipality (i.e. high income, high education levels and low unemployment and social security payment rates) is associated with higher risk of DP among those who do not complete their secondary education.

Spatial clustering of DPs, which is evident at the municipality level, can be interpreted in light of Wilson’s [61] assumption that neighbourhood characteristics influence collective socialisation processes by shaping the type of role models youth are exposed to outside their homes. Interactions with community peers and adults shape the norms, values, aspirations and, ultimately, the behaviours of the residents. Hence, advantaged neighbourhoods, where most adults have attained advanced formal education and steady jobs, will foster behaviours and attitudes within the next generations that are conducive to success in both education and work. In less advantaged communities, where the share of the population participating in the labour force is low and the dependency on welfare benefits is high, the positive attitudes toward education and work career may be less common. Rege, et al. [62] suggest that being disability may have “contagion” effect in the community, meaning that the propensity to receive DP increases when many people around you also depend on DP. Community characteristics represent more than the sum of their parts. Socioeconomic factors at the level of individuals may fail to protect even the health of well-off people if they live in socioeconomically disadvantaged neighbourhoods [35], and socioeconomically privileged neighbourhoods may impose an added health risk to the marginalised.

Not only did we find that municipal factors were correlated with young inhabitants’ DP risk, but we also uncovered regional effects. The DP rates in neighbouring municipalities are significantly associated with DP risk, suggesting inter-municipal processes. Most municipalities are embedded within larger regional contexts, and common historical, political, economic, and cultural factors shape them. Todd [63] suggests that the inherited regional differences in social structure affect our practices and values, which, in turn, will dispose us to think and act institutionally. In western Norway, a region with traditional Christian orthodoxy [64], people strongly value education and express this value by attaining higher formal education. Official statistics show that the population of western Norway, in general, has better health and has the highest life expectancy in the country [65]. Thus, our finding of high secondary education completion rates and low DP prevalence in western Norway is not surprising. Like Markussen, et al. [66], we found that northern Norway has a higher non-completion rate than any other region. Yet, this region has no systematic clustering of high DP prevalence. Even outside of our focal age group, the education level here is relatively low and many employers have traditionally not required a secondary education.

In line with previous Norwegian population studies [10, 11], we found a strong association between school non-completion and DP risk in young adulthood. This association may emerge from risk factors not directly modelled. Poor health in adolescence is, for example, strongly associated with school non-completion [67]. Such health problems may, indeed, lower the chances of finding a job and increase the probability of receiving DP in young adulthood. Our analysis, however, show that the relationship between school non-completion and DP risk varies between municipalities and that the municipal socioeconomic environment has a substantial impact on this relationship. Previous Nordic population studies have demonstrated a relationship between municipal socioeconomic conditions and DP prevalence [36–38]. What stands out in our study is our finding that living in municipalities with high education and income levels and low unemployment and social security benefit rates was associated with higher DP risk among non-completers. Advantageous socioeconomic conditions are generally associated with increased individual probability of both completing secondary education and successfully entering the labour market [32, 38]. Nevertheless, population and community characteristics can, indeed, interact with individual characteristics [68] and, have differing impacts across population groups. Non-completers in areas with a lower education level may, according to the relative deprivation hypothesis [34, 44], be less at risk than non-completers in more socioeconomically advanced areas. Mishra and Carleton [69] demonstrated that subjective feelings of relative deprivation are linked with poorer physical and mental health. Moreover, social distance, distrust and lack of cohesion between population groups often characterise communities with high material and social inequalities [70]. This may lead to higher stress levels, especially for those at the bottom of the social ladder, resulting in higher prevalence of stress-related morbidity and health risk behaviours [71, 72]. Moreover, young adults without a secondary school degree may face greater difficulties in the labour market in societies with ample access to highly qualified applicants. Disparities between workers’ resources and structural features of the job market may negatively impact their health [73]. School non-completion may, in other words, be more detrimental and contribute to stronger health selection in socioeconomically advanced areas. Hence, municipalities with seemingly strong socioeconomic profiles pose added risks for disadvantaged young adults without a secondary school degree. Similar to Reime and Claussen [37], we found that rural settlement was associated with a lower risk of DP among young school leavers. The education level in rural parts of Norway is generally lower compared to more urban areas, with easier access to jobs not requiring a formal education.

Based on the relatively high portion of young people receiving DP in Norway, one might question how DPs are granted. Disability benefits granted to young people are a substitute for lost income due to disability. In order to be entitled as a young disabled person, one must be under 26 years old upon becoming seriously and permanently ill, and said illness must be clearly documented by a medical doctor/specialist. The causes of the increasing proportion of disabled young people in Norway are, however, highly complex and unclear [3]. It is primarily mental illness that causes young people to become disabled. One important explanation is likely that it has become more difficult for young people with mental illnesses to obtain and retain employment [3]. Another explanation of this growth is tied to changes in social security schemes and expectations related to receiving valuable welfare schemes. As time-limited disability benefits were replaced with work-disbursement benefits in 2010, many were transferred to this new benefit. Today, about 70% of those who received temporary disability benefits have been granted DP [74].

A major strength of our study is the use of large, nationally representative registry data with multiple explanatory factors at the individual, family and neighbourhood levels linked to population-based municipal socioeconomic factors. The use of high quality, official longitudinal registry data covering almost the entire Norwegian population greatly minimises the risk of selection bias and random errors in our analyses. However, using such a large dataset introduces the risk of identifying significant, but inconsequential effects [75]. Although studies based on large sample size have many advantages, marginally significant effects observed in such studies typically mean that the predictive effect of the exposure is quite modest [75]. Moreover, a large dataset with multiple explanatory variables introduces the risk of over-adjusting for inter-level confounding, in that contextual factors might determine some of the individual level variables [76]. We limited the risk of over-adjustment by including only a small number of individual and family level predictors that previous research has shown to affect DP risk. Our study has several limitations. First, there are many methodological challenges in the analysis of neighbourhood contextual effects, such as identification of the appropriate boundaries [77], endogeneity [78], structural confounding [79] and excessive extrapolation in multilevel modelling [78]. An obvious challenge related to the estimation of neighbourhood effects in Norway is the major differences in population density between the different regions of the country. A 30% random and stratified sample of the population leads to a small number of study participants in a significant proportion of neighbourhoods. Moreover, the issue with selective residential mobility poses interpretational challenges. For instance, advantageous socioeconomic circumstances and healthier individuals tend to move to or remain in less deprived neighbourhoods [80]. Finally, an ideal study should include longitudinal explanatory data at multiple appropriate levels and allow the levels (i.e. the context) to change over time. However, our data do not allow us to control for this and, thus, prevent the adoption of this analytic framework.

This study underlines the importance of completing secondary education in the prevention of medically based DP among young adults in modern society. However, the study also demonstrates the significance of the residential context and local socioeconomic environment in individual variation in DP receipt. Low educational achievement and DP receipt have several central determinants in common, but comparing the geographical distributions of non-completion and DP rates reveal regional divergence. The risk factors manifest themselves at different structural levels, and a risk measured at the individual level may have a different effect when evaluated at the municipal level. This creates divergence in the geographical distribution of non-completion and DP rates, and anything but a multilevel analysis would likely conflate these results. Moreover, this study suggests that the population under study largely defines the relationship between risk factors and early DP. Advantageous municipal socioeconomic conditions will, in general, increase both the individual probability of completing secondary education and successfully entering the labour market. However, among non-completers, these municipal conditions are associated with a higher risk of receiving DP in young adulthood. Furthermore, living in rural communities lowers the risk of early DP. The mostly rural northern Norway has the highest non-completion rates in the country without particularly high levels of DP. These communities offer relatively well-paid jobs in the maricultural and fishing industry that do not require high formal education. Young adults with no previous employment records have the highest risk of receiving DP. Young people who do not finish secondary education are more marginalised in societies that place a higher weight on formal education. As more students complete their education, the potential marginalisation and barriers into the job market for those who drop out increases. As our results suggest, environmental factors are important determinants of risk, and measures aimed at lowering DP rates will probably fail to reach their potential without an understanding of the risks posed by the local environment. Future efforts to promote social equality and successful transitions to adulthood with regard to work and health should focus on the interplay between the local community and individual factors.