Psychosomatic complaints and school failure: A prospective Swedish national cohort study

Psychosomatic complaints and school failure: A prospective Swedish national cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychosomatic complaints and school failure: A prospective Swedish national cohort study Joakim Wahlström, Viveca Östberg, Sara Brolin Låftman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7999037/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Psychosomatic complaints — health issues without a clear medical cause and often used as indicators of adolescent mental distress — have increased in Sweden and elsewhere during recent decades. Yet, evidence on their long-term influence remains limited, including links to educational outcomes. Education is a key determinant of future living conditions, and school failure in adolescence can have long-lasting impacts. In Sweden, graduation from upper secondary school represents an important educational milestone. This study examined associations between psychosomatic complaints at age 16 and (1) ineligibility for upper secondary school at age 16, and (2) non-graduation from upper secondary school by age 20. Methods Data was obtained from Futura01, a Swedish national cohort of adolescents attending grade 9 (the final year of compulsory school, age 16) in spring of 2017 (n = 5,346). Psychosomatic complaints were assessed using self-reports on the frequency of headache, stomach ache, and sleep difficulties. Registry data provided information on upper secondary school eligibility and graduation. Covariates included sex, parental education, migration background, living arrangements, and psychiatric conditions. Linear probability models were performed. Results Higher levels of psychosomatic complaints at age 16 were associated with increased probabilities of ineligibility for upper secondary school at age 16 and, among eligible students, subsequent non-graduation from upper secondary school by age 20, even after adjusting for covariates. Conclusions Psychosomatic complaints in adolescence may negatively influence educational attainment, potentially contributing to later socioeconomic and health disadvantages. These findings underscore the importance of addressing adolescent health complaints to support educational success. Psychosomatic symptoms Health complaints Educational attainment School performance Adolescents Longitudinal Figures Figure 1 Figure 2 1. Introduction Psychosomatic complaints are health issues without a clear medical cause and are often used as indicators of mental distress in adolescents (Cosma et al., 2020 ; Potrebny et al., 2017 ). Mental distress is one aspect of mental health problems, encompassing symptoms that range from mild to severe but do not meet the criteria for a psychiatric diagnosis, whereas mental disorders represent more severe conditions that typically require healthcare intervention (Dalman et al., 2022 ). Psychosomatic complaints can manifest across psychological (e.g., feeling nervous), somatic (e.g., headaches), and musculoskeletal (e.g., back pain) dimensions (Giannotta et al., 2022 ) and have also been linked to, or can serve as indicators of, stress (Corell et al., 2022 ; Låftman & Östberg, 2024 ). In both Sweden and elsewhere, the prevalence of psychosomatic complaints in adolescence has increased in recent decades (Cosma et al., 2020 ; Högberg et al., 2022 ; Potrebny et al., 2017 ; Reiß et al., 2024 ). A study examining the development of psychological and somatic complaints among 15-year-olds from 41 countries between 1994–2022 revealed diverse patterns across countries and between boys and girls, including linear, U-shaped, and quadratic trends (Schrijvers et al., 2024 ). Since 2002, the Nordic countries have displayed highly similar patterns of increase (Stattin & Eriksson, 2024 ). In Sweden specifically, the proportion of 15-year-olds reporting at least two psychosomatic complaints more often than once a week rose steadily between 1985 and 2022, increasing from about 15% among boys and 30% among girls to over 45% and 75%, respectively (Public Health Agency of Sweden, 2023 ). Yet, it should be noted that these prevalence estimates decline markedly when a stricter cut-off is applied, illustrating how measurement choices can substantially influence reported levels of psychosomatic complaints. The sharp increase in psychosomatic complaints among adolescents has sparked considerable discussion about its underlying causes. When viewed as indicators of mental distress, the growing prevalence of such complaints may reflect factors such as rising school-related stress and academic demands (Högberg et al., 2020 ) as well as changing labour market demands and the pressures of a more individualised society (Löfstedt et al., 2020 ). At the same time, cultural and social transformations, driven by digitalisation and the pervasive influence of social media have reshaped patterns of social interaction, leisure, and identity formation among young people, and could also contribute to declining adolescent mental health (Boer et al., 2021 ). Moreover, broader societal challenges, including concerns about climate change and the rapid development of emerging technologies such as artificial intelligence, may further exacerbate risks to adolescents’ mental well-being (McGorry et al., 2024 ). Some scholars, however, argue that the rise in psychosomatic complaints may not be as alarming as it initially appears. It has been suggested that the high prevalence of self-reported mental health problems among adolescents may partly reflect a greater willingness to disclose such issues due to reduced stigma and the widespread adoption of mental health terminology in everyday language, sometimes in ways that diverge from its clinical meaning (Baxter et al., 2014 ; Verhulst, 2015 ; Wiens et al., 2017 ). Within this debate, the measurement of psychosomatic complaints has also faced scrutiny (Wickström & Lindholm, 2020 ), particularly regarding the commonly used, but arbitrary, cut-off of reporting multiple complaints more often than once a week (Cosma et al., 2023 ; Public Health Agency of Sweden, 2023 ). Despite these concerns, prior research indicates that psychosomatic complaints in adolescence may persist long-term and affect individuals’ mental health in adulthood, extending beyond the immediate distress they cause (Bohman et al., 2012 ; Giannotta et al., 2022 ; Grigorian et al., 2023 ). However, the extent to which these complaints influence outcomes in other life domains, such as education, remains poorly understood. Educational attainment is a key determinant of health across the life course (IHME–CHAIN Collaborators, 2024). Education shapes labour market opportunities and income, while also providing skills in information-gathering and decision-making that can enhance a sense of personal control (Mirowsky & Ross, 2007 ). Consequently, school dropout has been framed as a significant public health concern (Freudenberg & Ruglis, 2007 ; De Ridder et al., 2012 ), and promoting school success at the population level has been highlighted as a strategy for reducing health inequalities (Conti et al., 2010 ). Although prior research has established links between adolescent mental disorders and poorer educational outcomes, including lower grades, higher dropout rates, and reduced access to higher education (Bortes et al., 2022 ; Brännlund et al., 2017 ; Dalsgaard et al., 2020 ; Jonsson et al., 2010 ; Mitchell et al., 2022 ; Wickersham et al., 2021 ), the potential impact of psychosomatic complaints on educational trajectories has received much less attention. 1.1 Previous research and potential mechanisms In the Swedish context, one study based on a relatively small and age-diverse sample found that higher levels of both psychological and psychosomatic complaints in childhood were associated with a lower probability of entering university education over a 10-year follow-up period (Låftman & Magnusson, 2017 ). Another Swedish study reported that higher levels of psychosomatic symptoms among students in grade 8 were inversely associated with lower school performance in grade 9 and linked to a slightly lower probability of graduating from upper secondary school (Plenty et al., 2021 ). Research from other countries has similarly shown different aspects of young people’s self-reported health, such as low subjective well-being, poor self-rated health, and externalising and internalising symptoms, predict lower rates of school completion and poorer academic performance (Bücker et al., 2018 ; De Ridder et al., 2012 ; Hjorth et al., 2016 ; Koivusilta et al., 2024 ; Slominski et al., 2011 ; Veldman et al., 2014 ). While the two aforementioned Swedish studies accounted for several relevant covariates, they did not include data on clinically assessed psychiatric conditions which may be an important confounder in the association between psychosomatic complaints and school performance (Melkevik et al., 2016 ). Psychosomatic complaints frequently co-occur with symptoms of depression and anxiety in adolescence (Campo, 2012) and are more common among adolescents with ADHD compared to the general population (Fors et al., 2025) — three psychiatric conditions that are themselves linked to lower chances of school success. Including measures of these conditions is therefore crucial for isolating the association between psychosomatic complaints and academic achievement. Psychosomatic complaints may influence educational outcomes through multiple pathways. Health symptoms such as headaches, stomach aches, or poor sleep can directly impair daily functioning, leading to difficulties with concentration, increased absenteeism, and lower academic performance (Musshafen et al., 2021 ; Ragnarsson et al., 2022 ). In addition, psychosomatic complaints often reflect underlying stress (Corell et al., 2022 ; Låftman & Östberg, 2024 ), which has been shown to be negatively associated with school achievement (Schraml et al., 2012 ). Stress may interfere with learning through a variety of mechanisms, including impairments in working memory and concentration (Almarzouki, 2024 ), increased cognitive load and reduced self-efficacy (Ma, 2025 ), and maladaptive learning strategies coupled with lower academic motivation (Costa et al., 2024 ). These pathways suggest that psychosomatic complaints constitute both direct and indirect risk factors for poorer school outcomes. Beyond immediate effects on school performance, psychosomatic complaints may have longer-term consequences for educational attainment. Adolescents who experience early academic difficulties may continue to struggle not necessarily because of ongoing health problems, but because the initial impact of these complaints sets in motion a chain of disadvantage that persists over time (McLeod & Kaiser, 2004 ). Indeed, early school failure or poor performance consistently predicts later educational attainment (Andrew, 2014 ; Casillas et al., 2021; Gubbels, 2019). Moreover, the relationship between health and academic achievement is bidirectional: while health problems can impede learning, academic struggles may in turn increase stress and internalising symptoms (Weidman et al., 2015 ). This dynamic interplay highlights the need to carefully consider the direction and underlying mechanisms of these associations. Accordingly, when examining the long-term influence of psychosomatic complaints on educational outcomes, it is essential to account for their potential concurrent impact on school performance to capture both direct and indirect pathways. 1.2 The Swedish school system In Sweden, children begin compulsory preschool the year they turn six (school year 0) and typically complete their compulsory education the year they turn 16 (school year 9). Eligibility for upper secondary school (school years 10–12) requires passing grades in the three core subjects Swedish, English, and Mathematics along with a specified number of additional passing grades, ranging from five to nine out of the 13 remaining subjects, depending on the chosen upper secondary programme (Dollmann et al., 2023 ). Students graduating from compulsory school apply to their preferred upper secondary school and programme, with admission based on their grades from compulsory school (Arensmeier, 2022 ). Over the past decade, approximately 85% of students finishing compulsory school have met the eligibility criteria for upper secondary education (Statistics Sweden, n.d.). Upper secondary school comprises 18 national programmes, including 12 vocational programmes (e.g., the Construction Programme) and 6 academic programmes (e.g., the Natural Science Programme). Specialised “individual programmes” are also available for students who are not eligible for a regular programme or require customised education due to certain disabilities (Arensmeier, 2022 ). Upper secondary education is designed to be completed within three years, and roughly two-thirds of students who enrol graduate within this period (National Agency for Education in Sweden, 2021 ). Approximately 5% of students require an additional year, primarily due to changing programmes. Completion of upper secondary school significantly improves employment prospects, and admission to tertiary education is contingent upon upper secondary school performance. Consequently, not entering or failing to complete upper secondary education constitutes a major risk factor for future socioeconomic disadvantage. 1.3 Aim of the study The aim of the present study was to investigate the prospective association between psychosomatic complaints at age 16 and two indicators of school failure: (1) the probability of being ineligible for upper secondary school at age 16, and (2) among those who were eligible, the probability of not graduating from upper secondary school by age 20, accounting for prior school achievement. 2. Methods The data for this study were derived from Futura01, which is based on a Swedish national sample of adolescents attending grade 9 in spring 2017 (i.e., the final term of compulsory school; age ≈ 16 years). A random sample of 500 schools across Sweden was drawn, and in each school, one class was selected. In all, 343 schools agreed to participate, corresponding to a school-level response rate of 69%. Paper and pencil questionnaires were distributed in classrooms and completed during school hours, yielding 5,537 respondents (response rate 82%) (Raninen, 2020 ). Official registry information on educational achievement, sex, parental education, respondents’ and parents’ country of birth, as well as on diagnoses of psychiatric conditions and prescriptions of psychiatric medication was linked to the survey data. The analytical sample includes individuals with complete information on all study variables (n = 5,346). Ethical approval for the study has been obtained from the Swedish Ethical Review Authority (ref. 2021-06504-01; 2022-02781-02). 2.1 Measures Outcomes Eligibility for upper secondary school at age 16 was based on information obtained from the Grade 9 Register in 2017. Requirements differ across programme types: higher education preparatory programmes require passing grades in Swedish, English, Mathematics, and nine additional subjects, whereas vocational programmes require passing grades in Swedish, English, Mathematics, and five additional subjects (Jonsson & Mood, 2023 ). For this study, only individuals meeting the eligibility criteria for all programme types were classified as eligible, in order to create a sufficiently large group that could be classified as non-eligible. Graduation from upper secondary school by age 20 was determined using data from the 2021 LISA Register (Longitudinal Integrated Database for Health Insurance and Labour Market Studies), which provides detailed information on the level and type of completed education. From these data, a binary variable was created distinguishing respondents who had graduated from upper secondary school by age 20, i.e., within one additional year, from those who had not. Exposure Psychosomatic complaints at age 16 were assessed with the survey question: “During the past six months, how often have you had…” followed by three items: a) “headache”, b) “stomach ache”, and c) “difficulties falling asleep”. Response categories were: (0) “Less often or never”, (1) “Some time a month”, (2) “Once a week”, (3) “A few times a week”, and (4) “Every day”. The items demonstrated acceptable internal consistency (Cronbach’s α = 0.65). Responses were summed to create an index ranging from 0 to 12, with higher scores indicating more frequent psychosomatic complaints. These items have been used in previous studies of adolescent psychosomatic complaints (Grigorian et al., 2023 ; Låftman & Magnusson, 2017 ; Wahlström et al., 2023 ). Covariates Several factors in adolescents’ lives are likely to influence both health and educational outcomes. Being female, having a migrant background, not living with both parents, and living in a family with lower socioeconomic status are associated with higher levels of psychosomatic complaints (Corell et al., 2022 ). Conversely, on average, girls, those without a migrant background, adolescents living with both parents, and those with more highly educated parents tend to perform better academically (Ramberg et al., 2021 ). Additionally, since differences may exist between first- and second-generation immigrants, it is important to consider both the participants’ and their parents’ countries of birth (Jonsson & Mood, 2023 ). Sex was obtained from participants’ Swedish personal identity numbers and classified as male or female. Living arrangements at age 16 was based on the survey question: “How do you live?” and distinguished between respondents living with both parents in the same household, in shared residence, with only one parent (with or without a stepparent), or in other household arrangements (e.g., alone or with relatives). Parental education was derived from registry data and categorised according to the highest level of education attained among the parents: neither parent had completed tertiary education, one parent had completed tertiary education, or both parents had completed tertiary education. For individuals with only one registered parent, those whose parent had completed tertiary education were included in the category “both parents with tertiary education”. Migration background was constructed from registry information on participants’ and their parents’ country of birth, resulting in four categories: born in Sweden to two Swedish-born parents; born in Sweden to one Swedish-born parent; born in Sweden to two foreign-born parents; and born abroad (including 22 individuals with missing country-of-birth data, assumed to be born outside Sweden). Psychiatric conditions at or before age 16 was operationalised as a binary variable based on information from the National Patient Register and the National Prescribed Drug Register. Individuals were classified as having a psychiatric condition if, at any time up to and including 2017, they had received a diagnosis of depression, anxiety, or ADHD, and/or if they had been prescribed and collected any of the following medications (identified using ATC codes): antipsychotics (N05A), anxiolytics (N05B), hypnotics/sedatives (N05C), antidepressants (N06A), or psychostimulants (N06B). These medications are commonly used in the treatment of depression, anxiety, and ADHD. Grades from compulsory school were obtained from the Grade 9 register in 2017. The variable represents the total sum of grades across the 16 subjects assessed in compulsory school, where grades are coded as A = 20, B = 17.5, C = 15, D = 12.5, E = 10, and F = 0. The total score ranges from 0 to 320. For the analyses, this variable was divided into five approximately equal groups (quintiles) to distinguish between lower- and higher-preforming students. 2.2 Statistical analysis We estimated a series of linear probability models (LPM) for the two outcomes: ineligibility for upper secondary school at age 16 and non-graduation from upper secondary school by age 20. To account for the hierarchical structure of the data, with students nested within classes at baseline, we used the reghdfe command in Stata. Class fixed effects (n = 335) controlled for unobserved class-level characteristics, isolating within-class associations. Standard errors were clustered at the class level to provide robust inferences accounting for within-class correlation. For the analysis of non-graduation from upper secondary school, we excluded the 478 individuals who were ineligible for upper secondary school at age 16, as well as 4 students who were the sole members of their class (for whom fixed effects could not be applied). This approach aimed to capture the long-term influence of psychosomatic complaints while ensuring that early school failure did not confound the association with later educational attainment. Coefficients are presented along with 95% confidence intervals (95% CI). We first estimated bivariate models including the exposure or one covariate at a time, followed by multivariable models. Model 1 included psychosomatic complaints, sex, parental education, migration background, and living arrangements. Model 2 additionally adjusted for psychiatric conditions. Predicted probabilities of each outcome were then calculated across the full range of the psychosomatic complaints index based on estimates from the models. These were plotted alongside the observed prevalence (smoothed using a two-point moving average) to visually assess alignment between predicted and empirical values across symptom levels. To further disentangle the long-term effects of psychosomatic complaints from earlier academic performance, we replicated the analyses for non-graduation from upper secondary school stratified by compulsory school grades (at age 16). These analyses did not include class fixed effects, as doing so would have excluded a substantial number of individuals who were the sole members of their class within a given grade stratum. Results from sensitivity analyses stratified by sex are presented in the Supplementary Material. All analyses were conducted in Stata version 17 (StataCorp, 2021 ). 3. Results Table 1 presents descriptive statistics for the study population. Overall, 10.0% of the sample were ineligible for upper secondary school at age 16, and among those who were eligible, 17.2% had not graduated from upper secondary school by age 20. The mean value of psychosomatic complaints was 4.1 (standard deviation: 2.8), with a more detailed breakdown of reported complaints provided in the Supplementary Material (Table S1 & Figure S1 ). Table 1 Descriptive statistics for the study population (n = 5,346). n % Mean s.d. Not eligible for upper secondary school at age 16 536 10.0 Not graduated from upper secondary school by age 20 a 826 17.2 Psychosomatic complaints at age 16 (0–12) 4.1 2.8 Sex Female 2,706 50.6 Male 2,640 49.4 Parental tertiary education None 2,133 39.9 One parent 1,621 30.3 Both parents 1,592 29.8 Migration background Born in Sweden to two Swedish-born parents 3,692 69.1 Born in Sweden to one Swedish-born parent 596 11.2 Born in Sweden with two parents born abroad 525 9.8 Born abroad 533 10.0 Living arrangements (at age 16) Both parents in the same household 3,636 68.0 Shared residence 763 14.3 Lives with one parent 795 14.9 Other 152 2.8 Psychiatric conditions (at or before age 16) 611 11.4 Grades from compulsory school (0-320) a Quintile 1 987 20.5 192.1 13.2 Quintile 2 966 20.1 225.3 8.0 Quintile 3 924 19.2 249.9 6.5 Quintile 4 937 19.5 273.6 7.2 Quintile 5 996 20.7 303.7 10.5 a Excluding those not eligible for upper secondary school at age 16, n = 4,810 Regarding covariates, the sample was evenly divided by sex (50.6% female, 49.4% male). Parental education levels varied: 39.9% had no parent with tertiary education, 30.3% had one parent with tertiary education, and 29.8% had two parents with tertiary education. Most respondents (69.1%) were born in Sweden to two Swedish-born parents, 11.2% were born in Sweden to one Swedish-born parent, 9.8% were born in Sweden to two foreign-born parents, and 10.0% were born abroad. At age 16, 68.0% of respondents lived with both parents in the same household, 14.3% had shared residence arrangements, 14.9% lived with one parent, and 2.8% lived in other household types (e.g., alone or with relatives). In addition, 11.4% of respondents were classified as having a psychiatric condition at or before age 16. Mean values for the quintiles of compulsory school grades are presented at the bottom of Table 1 . [Table 1 about here] Table 2 presents coefficients and 95% confidence intervals (CIs) from linear probability models predicting ineligibility for upper secondary school at age 16. In the crude model, higher levels of psychosomatic complaints were associated with an increased probability of ineligibility (coefficient: 0.009; 95% CI: 0.006, 0.012). This association remained statistically significant after adjusting for sex, parental education, migration background, and living arrangements in Model 1, and persisted in Model 2, which additionally controlled for psychiatric conditions at or before age 16. Figure 1 illustrates the predicted probabilities from the three models alongside the observed prevalence (smoothed using a moving average) of ineligibility across levels of psychosomatic complaints. Prevalence at the highest symptom levels should be interpreted with caution due to the small number of participants in these groups. Nevertheless, the predicted probabilities closely followed the observed prevalence, displaying a clear gradient across symptom levels. In the fully adjusted model, predicted ineligibility increased from approximately 7% at low symptom levels to nearly 16% at the highest levels. Table 2 Ineligibility for upper secondary school at age 16: Differences in probability with 95% confidence intervals (95% CI) from Linear Probability Models (LPM) accounting for class fixed effects (n = 5,346). % ineligible Crude Model 1 Model 2 Coefficient 95% CI Coefficient 95% CI Coefficient 95% CI Psychosomatic complaints 0.009*** 0.006, 0.012 0.009*** 0.006, 0.012 0.007*** 0.004, 0.010 Sex Female (ref.) 8.8 0.000 - 0.000 - 0.000 - Male 11.3 0.026** 0.009, 0.043 0.042*** 0.025, 0.059 0.041*** 0.024, 0.057 Parental tertiary education None 17.2 0.104*** 0.082, 0.126 0.090*** 0.068, 0.112 0.090*** 0.068, 0.111 One parent 7.2 0.023*** 0.005, 0.040 0.023* 0.005, 0.040 0.022* 0.004, 0.039 Both parents (ref.) 3.3 0.000 - 0.000 - 0.000 - Migration background Born in Sweden to two Swedish-born parents (ref.) 6.5 0.000 - 0.000 - 0.000 - Born in Sweden to one Swedish-born parent 7.4 0.010 -0.013, 0.032 0.001 -0.021, 0.023 0.003 -0.019, 0.024 Born in Sweden with two parents born abroad 16.6 0.077*** 0.039, 0.114 0.063** 0.026, 0.100 0.062** 0.026, 0.099 Born abroad 31.0 0.211*** 0.165, 0.257 0.199*** 0.155, 0.243 0.207*** 0.163, 0.250 Living arrangements (at age 16) Both parents in the same household (ref.) 7.9 0.000 - 0.000 - 0.000 - Shared residence 7.7 0.009 -0.012, 0.029 0.014 -0.006, 0.034 0.012 -0.008, 0.032 Lives with one parent 17.7 0.086*** 0.058, 0.113 0.052*** 0.025, 0.078 0.044** 0.018, 0.070 Other 31.6 0.232*** 0.161, 0.302 0.183*** 0.118, 0.248 0.169*** 0.105, 0.233 Psychiatric conditions (at or before age 16) No (ref.) 8.7 0.000 - 0.000 - Yes 20.0 0.108*** 0.074, 0.142 0.096*** 0.064, 0.128 ***p < 0.001 **p < 0.01 *p < 0.05. [Table 2 about here] [Figure 1 about here] Table 3 shows coefficients and 95% CIs from linear probability models predicting non-graduation from upper secondary school by age 20 among those eligible at age 16. In the crude model, higher levels of psychosomatic complaints were associated with an increased probability of not graduating (coefficient: 0.015; 95% CI: 0.011, 0.020). This association remained statistically significant after adjusting for covariates in Models 1 and 2. Figure 2 visualises the predicted probabilities and observed prevalence (smoothed) of non-graduation across psychosomatic complaint levels. The predicted probabilities closely aligned with the observed prevalence, revealing a clear gradient pattern across symptom levels. In the fully adjusted model, predicted non-graduation increased from approximately 11% at low symptom levels to nearly 29% at the highest levels. Table 3 Non-graduation from upper secondary school by age 20: Differences in probability with 95% confidence intervals (95% CI) from Linear Probability Models (LPM) among those who were eligible for upper secondary school at age 16, accounting for class fixed effects (n = 4,806). % ineligible Crude Model 1 Model 2 Coefficient 95% CI Coefficient 95% CI Coefficient 95% CI Psychosomatic complaints 0.015*** 0.011, 0.020 0.016*** 0.012, 0.021 0.014*** 0.010, 0.019 Sex Female (ref.) 16.3 0.000 - 0.000 - 0.000 - Male 18.1 0.015 -0.009, 0.039 0.046*** 0.022, 0.070 0.045*** 0.021, 0.069 Parental tertiary education None 21.7 0.072*** 0.045, 0.099 0.054*** 0.027, 0.081 0.054*** 0.028, 0.081 One parent 16.3 0.033* 0.005, 0.061 0.024 -0.004, 0.052 0.023 -0.004, 0.051 Both parents (ref.) 12.9 0.000 - 0.000 - 0.000 - Migration background Born in Sweden to two Swedish-born parents (ref.) 14.3 0.000 - 0.000 - 0.000 - Born in Sweden to one Swedish-born parent 18.7 0.037* 0.001, 0.072 0.027 -0.008, 0.062 0.028 -0.006, 0.063 Born in Sweden with two parents born abroad 27.6 0.113*** 0.069, 0.158 0.106*** 0.061, 0.150 0.105*** 0.062, 0.149 Born abroad 29.6 0.116*** 0.065, 0.167 0.113*** 0.062, 0.164 0.122*** 0.071, 0.173 Living arrangements (at age 16) Both parents in the same household (ref.) 14.8 0.000 - 0.000 - 0.000 - Shared residence 18.3 0.035* 0.002, 0.068 0.032 -0.018, 0.065 0.029 -0.003, 0.062 Lives with one parent 27.5 0.107*** 0.068, 0.146 0.074*** 0.036, 0.112 0.068*** 0.030, 0.105 Other 21.2 0.056 -0.033, 0.145 0.031 -0.059, 0.120 0.014 -0.075, 0.102 Psychiatric conditions (at or before age 16) No (ref.) 15.6 0.000 - 0.000 - Yes 31.5 0.144*** 0.105, 0.183 0.126*** 0.087, 0.165 ***p < 0.001 **p < 0.01 *p < 0.05. [Table 3 about here] [Figure 2 about here] The results from the analyses stratified by school performance at age 16 are displayed in Table 4 . Participants were divided into five quintiles based on compulsory school grades, and the analyses presented in Table 3 were repeated within each stratum. In the crude models, psychosomatic complaints were significantly associated with non-graduation across all quintiles, with somewhat stronger associations observed in the first and third quintiles. In the fully adjusted models, the associations remained statistically significant in the first, third, and fourth quintiles, showing no consistent pattern based on school performance. Table 4 Non-graduation from upper secondary school by age 20: Differences in probability with 95% confidence intervals (95% CI) from Linear Probability Models (LPM) among those who were eligible for upper secondary school at age 16. Analyses are stratified by quintiles of compulsory school grades at age 16. Mean grades % non-graduates Crude a Model 1 b Model 2 c Coefficient 95% CI Coefficient 95% CI Coefficient 95% CI Quintile 1 (n = 987) 192.1 34.3 Psychosomatic complaints 0.017** 0.007, 0.027 0.015** 0.004, 0.025 0.014** 0.004, 0.024 Quintile 2 (n = 966) 225.3 20.2 Psychosomatic complaints 0.012* 0.003, 0.021 0.010* 0.000, 0.020 0.009 -0.001, 0.019 Quintile 3 (n = 924) 249.9 13.9 Psychosomatic complaints 0.016*** 0.008, 0.024 0.013** 0.004, 0.021 0.011* 0.002, 0.019 Quintile 4 (n = 937) 273.6 9.2 Psychosomatic complaints 0.009* 0.002, 0.017 0.011** 0.003, 0.018 0.010* 0.002, 0.017 Quintile 5 (n = 996) 303.7 7.9 Psychosomatic complaints 0.008* 0.001, 0.014 0.007* 0.001, 0.014 0.007 -0.000, 0.014 ***p < 0.001 **p < 0.01 *p < 0.05 a Crude analyses include only psychosomatic complaints. b Model 1 includes psychosomatic complaints, sex, parental education, migration background, and living arrangements. c Model 2 includes psychosomatic complaints, sex, parental education, migration background, living arrangements, and psychiatric conditions (at or before age 16) [Table 4 about here] Analyses stratified by sex, presented in the Supplementary Material (Table S2; Figures S2 and S3), revealed similar associations for both females and males. However, males had a higher probability of both outcomes compared to females. 4. Discussion Psychosomatic complaints are common among adolescents in Sweden and elsewhere, and their prevalence has increased over recent decades (Public Health Agency of Sweden, 2023 ; Schrijvers et al., 2024 ). Despite this, the potential long-term consequences of such complaints, especially regarding educational attainment, remain understudied. The present study examined the prospective association between adolescent psychosomatic complaints and school failure using data based on a Swedish nationally representative sample combining survey responses and register information. We found that higher levels of psychosomatic complaints during the final year of compulsory school (age 16) were associated with increased probabilities of ineligibility for upper secondary school at age 16, and, among adolescents who were eligible, of not having graduated from upper secondary school by age 20. These associations remained robust and statistically significant in fully adjusted models accounting for sociodemographic factors, psychiatric conditions, and prior school performance. Comparisons between model estimates and the observed prevalence of school failure across psychosomatic symptom levels underscore a largely linear, graded association, although estimates at the highest symptom levels should be interpreted cautiously due to small sample sizes. Experiencing health complaints such as sleeping problems and recurring bodily pain may have direct effects on academic performance (Musshafen et al., 2021 ; Ragnarsson et al., 2022 ). Poor sleep can lead to drowsiness during school hours, impairing concentration and learning, while regular headaches or stomach aches may further reduce focus and increase absenteeism. Psychosomatic complaints are also commonly interpreted as indicators of mental distress and have been shown to reflect stress among adolescents (Låftman & Östberg, 2024 ; Potrebny et al., 2017 ). Consistent with evidence from prior longitudinal studies, various indicators of mental distress, including subjective well-being and internalising symptoms, have been found to predict subsequent lower educational achievement (Bücker et al., 2018 ; De Ridder et al., 2012 ; Hjorth et al., 2016 ; Koivusilta et al., 2024 ; Slominski et al., 2011 ; Veldman et al., 2014 ). Mental distress may affect school performance through multiple pathways, including increased truancy, difficulties completing schoolwork, and poorer relationships with teachers (Needham et al., 2004 ). Given that school demands are a common source of adolescent stress (Högberg et al., 2020 ), disentangling the intertwined relationship between psychosomatic complaints, stress, and academic performance is challenging. Nevertheless, there is strong evidence for specific mechanisms linking stress to academic outcomes, including disruptions to cognitive functioning and reductions in academic motivation (Almarzouki, 2024 ; Costa et al., 2024 ; Ma, 2025 ). Prior studies have lacked information on clinically assessed mental disorders, which may confound the link between psychosomatic complaints and school failure (Melkevik et al., 2016 ). By adjusting for prior psychiatric conditions, the present study more accurately isolates this relationship, suggesting that psychosomatic complaints can independently influence educational outcomes. This finding is particularly relevant for policy and intervention efforts, given concerns in Sweden about what psychosomatic complaints represent and the risk of pathologising everyday problems (Wickström & Lindholm, 2020 ). Our results revealed a clear gradient in the association between psychosomatic complaints and educational achievement. Even small increases in symptom levels were associated with increased risks of school failure, but the effects became more substantial when multiple complaints occurred frequently. This pattern suggests that while occasional complaints may reflect normal “everyday problems”, they can still warrant attention, particularly when they accumulate. Yet, the critique by Wickström and Lindholm remains relevant: categorising a large share of adolescents, such as three fourths of Swedish 15-year-old girls, as having mental health problems may overstate the situation and offer limited policy value, especially when many adolescents simultaneously report high levels of well-being. Rather than relying on arbitrary cut-offs, psychosomatic complaints might be better understood along a continuum, where both their number and frequency have meaningful implications for current and future outcomes. The observed prospective association found in the current study may partly reflect the short-term effects of psychosomatic complaints on academic functioning, which can hinder current school performance and, consequently, reduce opportunities for future educational attainment (McLeod & Kaiser, 2004 ). At the same time, the direction of influence may also run the other way: failing grades in compulsory school can be stressful and negatively impact students’ well-being, potentially giving rise to psychosomatic complaints (Högberg et al., 2021 ). To reduce this potential bias, we excluded respondents who were already ineligible for upper secondary school at age 16 when examining non-graduation, and the association remained significant. Additionally, because admission to upper secondary school is determined by grades from compulsory school, high-achieving students often enter more resourced and academically stimulating environments, potentially reinforcing existing educational advantages (Fjellman & Hansen, 2024 ). Therefore, we further examined whether the association between psychosomatic complaints and educational attainment varied across different levels of compulsory school grades. The results were largely consistent across grade strata, indicating that psychosomatic complaints predict educational outcomes beyond pre-existing academic differences. These findings suggest that psychosomatic complaints may represent an independent risk factor for educational underachievement rather than merely reflecting prior performance. Taken together, our results should also be considered in light of broader structural factors shaping educational pathways. Recent debates in Sweden about the grading system, particularly regarding the retention of failing grades, their role in admission to upper secondary school, and the impact of recent reforms on adolescent well-being, highlight how institutional structures can shape the relationship between health and academic performance (Arensmeier, 2022 ). In this context, psychosomatic complaints may not only impair individual academic functioning but also exacerbate structural inequalities in educational attainment, as adolescents experiencing health-related difficulties face greater barriers to progression within a stratified school system. 4.1 Strengths and limitations A major strength of this study lies in the data material, which combines adolescent survey reports of psychosomatic complaints with official registry information on educational attainment. This linkage eliminates attrition in the outcome variables and, in the prospective analysis, allows for adjustment for prior school performance, thereby strengthening the ability to isolate the association between psychosomatic complaints and later non-graduation from upper secondary school. The inclusion of data on clinically assessed diagnoses of depression, anxiety, and ADHD as well as prescription for medications used to treat these conditions further improves this estimation by accounting for potential confounding due to underlying psychiatric conditions. Nevertheless, it should be acknowledged that not all individuals experiencing symptoms seek health care and are therefore not captured in these registers (Alonso et al., 2018 ; Moitra et al., 2022 ). In addition, registry-based information on parental educational attainment is an asset, as it reduces the risk of misclassification and selective non-response often associated with adolescents’ self-reported data on parental characteristics (Engzell & Jonsson, 2015 ). However, several limitations need to be considered as well. First, although the data are based on a nationally representative sample of schools, only 69% of invited schools agreed to partake in the survey collection, raising the possibility of school-level selection bias. Yet, no systematic differences were found between participating and non-participating schools in terms of average grades or student composition regarding parental education and country of birth (Raninen, 2020 ). At the student level, the response rate was 82%, and non-participants may have differed systematically from respondents. In our data, approximately 10% of students were ineligible for upper secondary school at age 16, compared to about 15% in national statistics in the same year (Statistics Sweden, n.d.), suggesting an underrepresentation of lower-achieving students. Second, although the longitudinal design allows for temporal separation between psychosomatic complaints at age 16 and upper secondary school graduation, the possibility of reverse causality cannot be entirely ruled out. School performance and health develop in tandem over time. Difficulties in school can lead to increased psychosomatic complaints, illustrating a social causation mechanism, where social position influences later health (Mossakowski, 2014 ). Conversely, such complaints may hinder academic progress, reflecting a health selection mechanism in which health status affects later socioeconomic position. This reciprocal relationship complicates causal interpretation. To address this, we excluded individuals ineligible for upper secondary school at age 16 and conducted analyses stratified by baseline performance; however, these measures can only partially account for the dynamic interplay between health and education. Our findings suggest the presence of health selection mechanisms, consistent with previous research (Agnafors et al., 2021 ; Koivusilta et al., 2024 ), while social causation likely also contributes. Therefore, the results should be interpreted within a life-course framework that recognises multiple, mutually reinforcing influences over time. Third, psychosomatic complaints were measured using only three items, which limits the ability to capture the full range of such complaints. More comprehensive scales, such as the eight-item measure used in the Health Behaviour in School-aged Children (HBSC) study (Cosma et al., 2023 ), enable finer distinctions between different complaint types (e.g., Giannotta et al., 2022 ). Different dimensions of adolescent health complaints may influence school performance in distinct ways, and a multidimensional measure would allow these effects to be captured more accurately (e.g., Musshafen et al., 2021 ; Ragnarsson et al., 2022 ). 4.2 Conclusion In sum, the findings indicate that psychosomatic complaints during adolescence can have lasting effects on educational attainment, beyond earlier school failure and performance, and independently of psychiatric conditions. The study highlights the importance of recognising these complaints not merely as transient discomforts but as conditions with the potential to affect long-term outcomes. Given that educational achievement is a key determinant of future socioeconomic and health status, psychosomatic complaints may indirectly shape individuals’ life trajectories and well-being. For policymakers and educators, these results underscore the value of early identification and support for adolescents experiencing frequent psychosomatic complaints, as well as efforts to address their underlying determinants. Future research should further explore how such complaints influence outcomes across educational, occupational, social, and health domains. Abbreviations ADHD Attention-Deficit/Hyperactivity Disorder ATC Anatomical Therapeutic Chemical CI Confidence Interval HBSC Health Behaviour in School-aged Children LISA Longitudinal Integrated Database for Health Insurance and Labour Market Studies LPM Linear Probability Model Declarations Ethics approval and consent to participate The study was approved by the Swedish Ethical Review Authority (ref. 2021-06504-01; 2022-02781-02 2022-06502-02). According to the Swedish Ethical Review Act (SFS 2003:460), parental consent is not required for adolescents aged 15 or older if they realise what the research means for them. Informed consent was obtained from all study participants. All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable Availability of data and materials The data used for the current study are available from Karolinska Institutet but restrictions apply to the availability of these data, and are therefore not publicly available. Data are however available from the Principal Investigator Dr. Jonas Raninen ( [email protected] ) upon reasonable request and with permission of Karolinska Institutet and ethical approval from the Swedish Ethical Review Authority. Competing interests The authors declare that they have no competing interests Funding The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The study was financed by the Swedish Research Council for Health, Working Life and Welfare (Forte) (grant no. 2021-00537). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7999037","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602896003,"identity":"21023d40-6225-41f8-a508-d8efbee7a2ad","order_by":0,"name":"Joakim Wahlström","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBACxgYGZoYEEEuCuQEswk+CFiDzAJCWbCBsETOEgmkxOEBIfXvzY4OHOQyJ/bMbmz9/3GMTbXz+jAHjjwo8Dus5ZpyQuI0hccadg20SB56l5W67kWPAzHMGj5YZCcYHgFpyG24ktjEcOHAYqIXHgJmxDZ+W9M9gLfNvJDZ/AGnZ3A902M9/+LTkgB2Wu+FGYoMESMsGhhwDBt4GfH45U2yQuE2ifiPQYRJnDqTlzriRVnCY5xhuLYbt7Zslf26zMZa7kXz4Q8UBm9z+/sMbH/6owaMF4gIJVNEDuDUwMMjjkxwFo2AUjIJRAAYAmBheVLpMakQAAAAASUVORK5CYII=","orcid":"","institution":"Stockholm University","correspondingAuthor":true,"prefix":"","firstName":"Joakim","middleName":"","lastName":"Wahlström","suffix":""},{"id":602896006,"identity":"e098f919-b782-4ccb-8f1c-ada19fe97c79","order_by":1,"name":"Viveca Östberg","email":"","orcid":"","institution":"Stockholm University","correspondingAuthor":false,"prefix":"","firstName":"Viveca","middleName":"","lastName":"Östberg","suffix":""},{"id":602896008,"identity":"aead7441-c588-478f-b8da-17689542c2c1","order_by":2,"name":"Sara Brolin Låftman","email":"","orcid":"","institution":"Stockholm University","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"Brolin","lastName":"Låftman","suffix":""}],"badges":[],"createdAt":"2025-10-31 13:38:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7999037/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7999037/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104561889,"identity":"e444deb6-8363-4fd0-a7b4-a87d0e102400","added_by":"auto","created_at":"2026-03-13 10:27:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34812,"visible":true,"origin":"","legend":"\u003cp\u003ePredicted probabilities (in percentages) and observed prevalence of ineligibility for upper secondary school at age 16, by level of psychosomatic complaints (n = 5,346).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7999037/v1/0df8244b8b923bbc9007989c.png"},{"id":104561808,"identity":"b80f1c86-b54e-4b93-889f-25e2448260b2","added_by":"auto","created_at":"2026-03-13 10:27:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38509,"visible":true,"origin":"","legend":"\u003cp\u003ePredicted probabilities (in percentages) and observed prevalence of non-graduation from upper secondary school by age 20, by level of psychosomatic complaints (n = 4,806).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7999037/v1/fe5cbb0cd1a3211df957586e.png"},{"id":104561903,"identity":"7ca77446-840f-4f0f-a1c7-48aeb87ba303","added_by":"auto","created_at":"2026-03-13 10:27:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1247171,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7999037/v1/992e069b-198e-4ba1-bc1c-4990a617cb20.pdf"},{"id":104561856,"identity":"865ae8be-6dd6-4fe5-9907-02ab8f3ae582","added_by":"auto","created_at":"2026-03-13 10:27:22","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":61053,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7999037/v1/b79e51b98811e06cf573bc19.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychosomatic complaints and school failure: A prospective Swedish national cohort study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePsychosomatic complaints are health issues without a clear medical cause and are often used as indicators of mental distress in adolescents (Cosma et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Potrebny et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Mental distress is one aspect of mental health problems, encompassing symptoms that range from mild to severe but do not meet the criteria for a psychiatric diagnosis, whereas mental disorders represent more severe conditions that typically require healthcare intervention (Dalman et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Psychosomatic complaints can manifest across psychological (e.g., feeling nervous), somatic (e.g., headaches), and musculoskeletal (e.g., back pain) dimensions (Giannotta et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and have also been linked to, or can serve as indicators of, stress (Corell et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; L\u0026aring;ftman \u0026amp; \u0026Ouml;stberg, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn both Sweden and elsewhere, the prevalence of psychosomatic complaints in adolescence has increased in recent decades (Cosma et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; H\u0026ouml;gberg et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Potrebny et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Rei\u0026szlig; et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). A study examining the development of psychological and somatic complaints among 15-year-olds from 41 countries between 1994\u0026ndash;2022 revealed diverse patterns across countries and between boys and girls, including linear, U-shaped, and quadratic trends (Schrijvers et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Since 2002, the Nordic countries have displayed highly similar patterns of increase (Stattin \u0026amp; Eriksson, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In Sweden specifically, the proportion of 15-year-olds reporting at least two psychosomatic complaints more often than once a week rose steadily between 1985 and 2022, increasing from about 15% among boys and 30% among girls to over 45% and 75%, respectively (Public Health Agency of Sweden, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Yet, it should be noted that these prevalence estimates decline markedly when a stricter cut-off is applied, illustrating how measurement choices can substantially influence reported levels of psychosomatic complaints.\u003c/p\u003e\u003cp\u003eThe sharp increase in psychosomatic complaints among adolescents has sparked considerable discussion about its underlying causes. When viewed as indicators of mental distress, the growing prevalence of such complaints may reflect factors such as rising school-related stress and academic demands (H\u0026ouml;gberg et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) as well as changing labour market demands and the pressures of a more individualised society (L\u0026ouml;fstedt et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). At the same time, cultural and social transformations, driven by digitalisation and the pervasive influence of social media have reshaped patterns of social interaction, leisure, and identity formation among young people, and could also contribute to declining adolescent mental health (Boer et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Moreover, broader societal challenges, including concerns about climate change and the rapid development of emerging technologies such as artificial intelligence, may further exacerbate risks to adolescents\u0026rsquo; mental well-being (McGorry et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSome scholars, however, argue that the rise in psychosomatic complaints may not be as alarming as it initially appears. It has been suggested that the high prevalence of self-reported mental health problems among adolescents may partly reflect a greater willingness to disclose such issues due to reduced stigma and the widespread adoption of mental health terminology in everyday language, sometimes in ways that diverge from its clinical meaning (Baxter et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Verhulst, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Wiens et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Within this debate, the measurement of psychosomatic complaints has also faced scrutiny (Wickstr\u0026ouml;m \u0026amp; Lindholm, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), particularly regarding the commonly used, but arbitrary, cut-off of reporting multiple complaints more often than once a week (Cosma et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Public Health Agency of Sweden, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these concerns, prior research indicates that psychosomatic complaints in adolescence may persist long-term and affect individuals\u0026rsquo; mental health in adulthood, extending beyond the immediate distress they cause (Bohman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Giannotta et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Grigorian et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, the extent to which these complaints influence outcomes in other life domains, such as education, remains poorly understood.\u003c/p\u003e\u003cp\u003eEducational attainment is a key determinant of health across the life course (IHME\u0026ndash;CHAIN Collaborators, 2024). Education shapes labour market opportunities and income, while also providing skills in information-gathering and decision-making that can enhance a sense of personal control (Mirowsky \u0026amp; Ross, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Consequently, school dropout has been framed as a significant public health concern (Freudenberg \u0026amp; Ruglis, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; De Ridder et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), and promoting school success at the population level has been highlighted as a strategy for reducing health inequalities (Conti et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Although prior research has established links between adolescent mental disorders and poorer educational outcomes, including lower grades, higher dropout rates, and reduced access to higher education (Bortes et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Br\u0026auml;nnlund et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Dalsgaard et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Jonsson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Mitchell et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wickersham et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), the potential impact of psychosomatic complaints on educational trajectories has received much less attention.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Previous research and potential mechanisms\u003c/h2\u003e\u003cp\u003eIn the Swedish context, one study based on a relatively small and age-diverse sample found that higher levels of both psychological and psychosomatic complaints in childhood were associated with a lower probability of entering university education over a 10-year follow-up period (L\u0026aring;ftman \u0026amp; Magnusson, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Another Swedish study reported that higher levels of psychosomatic symptoms among students in grade 8 were inversely associated with lower school performance in grade 9 and linked to a slightly lower probability of graduating from upper secondary school (Plenty et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Research from other countries has similarly shown different aspects of young people\u0026rsquo;s self-reported health, such as low subjective well-being, poor self-rated health, and externalising and internalising symptoms, predict lower rates of school completion and poorer academic performance (B\u0026uuml;cker et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; De Ridder et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Hjorth et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Koivusilta et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Slominski et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Veldman et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile the two aforementioned Swedish studies accounted for several relevant covariates, they did not include data on clinically assessed psychiatric conditions which may be an important confounder in the association between psychosomatic complaints and school performance (Melkevik et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Psychosomatic complaints frequently co-occur with symptoms of depression and anxiety in adolescence (Campo, 2012) and are more common among adolescents with ADHD compared to the general population (Fors et al., 2025) \u0026mdash; three psychiatric conditions that are themselves linked to lower chances of school success. Including measures of these conditions is therefore crucial for isolating the association between psychosomatic complaints and academic achievement.\u003c/p\u003e\u003cp\u003ePsychosomatic complaints may influence educational outcomes through multiple pathways. Health symptoms such as headaches, stomach aches, or poor sleep can directly impair daily functioning, leading to difficulties with concentration, increased absenteeism, and lower academic performance (Musshafen et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ragnarsson et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In addition, psychosomatic complaints often reflect underlying stress (Corell et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; L\u0026aring;ftman \u0026amp; \u0026Ouml;stberg, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), which has been shown to be negatively associated with school achievement (Schraml et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Stress may interfere with learning through a variety of mechanisms, including impairments in working memory and concentration (Almarzouki, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), increased cognitive load and reduced self-efficacy (Ma, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), and maladaptive learning strategies coupled with lower academic motivation (Costa et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These pathways suggest that psychosomatic complaints constitute both direct and indirect risk factors for poorer school outcomes.\u003c/p\u003e\u003cp\u003eBeyond immediate effects on school performance, psychosomatic complaints may have longer-term consequences for educational attainment. Adolescents who experience early academic difficulties may continue to struggle not necessarily because of ongoing health problems, but because the initial impact of these complaints sets in motion a chain of disadvantage that persists over time (McLeod \u0026amp; Kaiser, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Indeed, early school failure or poor performance consistently predicts later educational attainment (Andrew, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Casillas et al., 2021; Gubbels, 2019). Moreover, the relationship between health and academic achievement is bidirectional: while health problems can impede learning, academic struggles may in turn increase stress and internalising symptoms (Weidman et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This dynamic interplay highlights the need to carefully consider the direction and underlying mechanisms of these associations. Accordingly, when examining the long-term influence of psychosomatic complaints on educational outcomes, it is essential to account for their potential concurrent impact on school performance to capture both direct and indirect pathways.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.2 The Swedish school system\u003c/h2\u003e\u003cp\u003eIn Sweden, children begin compulsory preschool the year they turn six (school year 0) and typically complete their compulsory education the year they turn 16 (school year 9). Eligibility for upper secondary school (school years 10\u0026ndash;12) requires passing grades in the three core subjects Swedish, English, and Mathematics along with a specified number of additional passing grades, ranging from five to nine out of the 13 remaining subjects, depending on the chosen upper secondary programme (Dollmann et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Students graduating from compulsory school apply to their preferred upper secondary school and programme, with admission based on their grades from compulsory school (Arensmeier, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Over the past decade, approximately 85% of students finishing compulsory school have met the eligibility criteria for upper secondary education (Statistics Sweden, n.d.).\u003c/p\u003e\u003cp\u003eUpper secondary school comprises 18 national programmes, including 12 vocational programmes (e.g., the Construction Programme) and 6 academic programmes (e.g., the Natural Science Programme). Specialised \u0026ldquo;individual programmes\u0026rdquo; are also available for students who are not eligible for a regular programme or require customised education due to certain disabilities (Arensmeier, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Upper secondary education is designed to be completed within three years, and roughly two-thirds of students who enrol graduate within this period (National Agency for Education in Sweden, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Approximately 5% of students require an additional year, primarily due to changing programmes.\u003c/p\u003e\u003cp\u003eCompletion of upper secondary school significantly improves employment prospects, and admission to tertiary education is contingent upon upper secondary school performance. Consequently, not entering or failing to complete upper secondary education constitutes a major risk factor for future socioeconomic disadvantage.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Aim of the study\u003c/h2\u003e\u003cp\u003eThe aim of the present study was to investigate the prospective association between psychosomatic complaints at age 16 and two indicators of school failure: (1) the probability of being ineligible for upper secondary school at age 16, and (2) among those who were eligible, the probability of not graduating from upper secondary school by age 20, accounting for prior school achievement.\u003c/p\u003e\u003c/div\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe data for this study were derived from Futura01, which is based on a Swedish national sample of adolescents attending grade 9 in spring 2017 (i.e., the final term of compulsory school; age\u0026thinsp;\u0026asymp;\u0026thinsp;16 years). A random sample of 500 schools across Sweden was drawn, and in each school, one class was selected. In all, 343 schools agreed to participate, corresponding to a school-level response rate of 69%. Paper and pencil questionnaires were distributed in classrooms and completed during school hours, yielding 5,537 respondents (response rate 82%) (Raninen, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Official registry information on educational achievement, sex, parental education, respondents\u0026rsquo; and parents\u0026rsquo; country of birth, as well as on diagnoses of psychiatric conditions and prescriptions of psychiatric medication was linked to the survey data. The analytical sample includes individuals with complete information on all study variables (n\u0026thinsp;=\u0026thinsp;5,346). Ethical approval for the study has been obtained from the Swedish Ethical Review Authority (ref. 2021-06504-01; 2022-02781-02).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Measures\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOutcomes\u003c/span\u003e\u003c/p\u003e\u003cp\u003eEligibility for upper secondary school at age 16 was based on information obtained from the Grade 9 Register in 2017. Requirements differ across programme types: higher education preparatory programmes require passing grades in Swedish, English, Mathematics, and nine additional subjects, whereas vocational programmes require passing grades in Swedish, English, Mathematics, and five additional subjects (Jonsson \u0026amp; Mood, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). For this study, only individuals meeting the eligibility criteria for all programme types were classified as eligible, in order to create a sufficiently large group that could be classified as non-eligible.\u003c/p\u003e\u003cp\u003eGraduation from upper secondary school by age 20 was determined using data from the 2021 LISA Register (Longitudinal Integrated Database for Health Insurance and Labour Market Studies), which provides detailed information on the level and type of completed education. From these data, a binary variable was created distinguishing respondents who had graduated from upper secondary school by age 20, i.e., within one additional year, from those who had not.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eExposure\u003c/span\u003e\u003c/p\u003e\u003cp\u003ePsychosomatic complaints at age 16 were assessed with the survey question: \u0026ldquo;During the past six months, how often have you had\u0026hellip;\u0026rdquo; followed by three items: a) \u0026ldquo;headache\u0026rdquo;, b) \u0026ldquo;stomach ache\u0026rdquo;, and c) \u0026ldquo;difficulties falling asleep\u0026rdquo;. Response categories were: (0) \u0026ldquo;Less often or never\u0026rdquo;, (1) \u0026ldquo;Some time a month\u0026rdquo;, (2) \u0026ldquo;Once a week\u0026rdquo;, (3) \u0026ldquo;A few times a week\u0026rdquo;, and (4) \u0026ldquo;Every day\u0026rdquo;. The items demonstrated acceptable internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.65). Responses were summed to create an index ranging from 0 to 12, with higher scores indicating more frequent psychosomatic complaints. These items have been used in previous studies of adolescent psychosomatic complaints (Grigorian et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; L\u0026aring;ftman \u0026amp; Magnusson, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Wahlstr\u0026ouml;m et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCovariates\u003c/span\u003e\u003c/p\u003e\u003cp\u003eSeveral factors in adolescents\u0026rsquo; lives are likely to influence both health and educational outcomes. Being female, having a migrant background, not living with both parents, and living in a family with lower socioeconomic status are associated with higher levels of psychosomatic complaints (Corell et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Conversely, on average, girls, those without a migrant background, adolescents living with both parents, and those with more highly educated parents tend to perform better academically (Ramberg et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Additionally, since differences may exist between first- and second-generation immigrants, it is important to consider both the participants\u0026rsquo; and their parents\u0026rsquo; countries of birth (Jonsson \u0026amp; Mood, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSex was obtained from participants\u0026rsquo; Swedish personal identity numbers and classified as male or female.\u003c/p\u003e\u003cp\u003e Living arrangements at age 16 was based on the survey question: \u0026ldquo;How do you live?\u0026rdquo; and distinguished between respondents living with both parents in the same household, in shared residence, with only one parent (with or without a stepparent), or in other household arrangements (e.g., alone or with relatives).\u003c/p\u003e\u003cp\u003eParental education was derived from registry data and categorised according to the highest level of education attained among the parents: neither parent had completed tertiary education, one parent had completed tertiary education, or both parents had completed tertiary education. For individuals with only one registered parent, those whose parent had completed tertiary education were included in the category \u0026ldquo;both parents with tertiary education\u0026rdquo;.\u003c/p\u003e\u003cp\u003eMigration background was constructed from registry information on participants\u0026rsquo; and their parents\u0026rsquo; country of birth, resulting in four categories: born in Sweden to two Swedish-born parents; born in Sweden to one Swedish-born parent; born in Sweden to two foreign-born parents; and born abroad (including 22 individuals with missing country-of-birth data, assumed to be born outside Sweden).\u003c/p\u003e\u003cp\u003ePsychiatric conditions at or before age 16 was operationalised as a binary variable based on information from the National Patient Register and the National Prescribed Drug Register. Individuals were classified as having a psychiatric condition if, at any time up to and including 2017, they had received a diagnosis of depression, anxiety, or ADHD, and/or if they had been prescribed and collected any of the following medications (identified using ATC codes): antipsychotics (N05A), anxiolytics (N05B), hypnotics/sedatives (N05C), antidepressants (N06A), or psychostimulants (N06B). These medications are commonly used in the treatment of depression, anxiety, and ADHD.\u003c/p\u003e\u003cp\u003eGrades from compulsory school were obtained from the Grade 9 register in 2017. The variable represents the total sum of grades across the 16 subjects assessed in compulsory school, where grades are coded as A\u0026thinsp;=\u0026thinsp;20, B\u0026thinsp;=\u0026thinsp;17.5, C\u0026thinsp;=\u0026thinsp;15, D\u0026thinsp;=\u0026thinsp;12.5, E\u0026thinsp;=\u0026thinsp;10, and F\u0026thinsp;=\u0026thinsp;0. The total score ranges from 0 to 320. For the analyses, this variable was divided into five approximately equal groups (quintiles) to distinguish between lower- and higher-preforming students.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Statistical analysis\u003c/h2\u003e\u003cp\u003eWe estimated a series of linear probability models (LPM) for the two outcomes: ineligibility for upper secondary school at age 16 and non-graduation from upper secondary school by age 20. To account for the hierarchical structure of the data, with students nested within classes at baseline, we used the \u003cem\u003ereghdfe\u003c/em\u003e command in Stata. Class fixed effects (n\u0026thinsp;=\u0026thinsp;335) controlled for unobserved class-level characteristics, isolating within-class associations. Standard errors were clustered at the class level to provide robust inferences accounting for within-class correlation.\u003c/p\u003e\u003cp\u003eFor the analysis of non-graduation from upper secondary school, we excluded the 478 individuals who were ineligible for upper secondary school at age 16, as well as 4 students who were the sole members of their class (for whom fixed effects could not be applied). This approach aimed to capture the long-term influence of psychosomatic complaints while ensuring that early school failure did not confound the association with later educational attainment.\u003c/p\u003e\u003cp\u003eCoefficients are presented along with 95% confidence intervals (95% CI). We first estimated bivariate models including the exposure or one covariate at a time, followed by multivariable models. Model 1 included psychosomatic complaints, sex, parental education, migration background, and living arrangements. Model 2 additionally adjusted for psychiatric conditions.\u003c/p\u003e\u003cp\u003ePredicted probabilities of each outcome were then calculated across the full range of the psychosomatic complaints index based on estimates from the models. These were plotted alongside the observed prevalence (smoothed using a two-point moving average) to visually assess alignment between predicted and empirical values across symptom levels.\u003c/p\u003e\u003cp\u003eTo further disentangle the long-term effects of psychosomatic complaints from earlier academic performance, we replicated the analyses for non-graduation from upper secondary school stratified by compulsory school grades (at age 16). These analyses did not include class fixed effects, as doing so would have excluded a substantial number of individuals who were the sole members of their class within a given grade stratum.\u003c/p\u003e\u003cp\u003eResults from sensitivity analyses stratified by sex are presented in the Supplementary Material. All analyses were conducted in Stata version 17 (StataCorp, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents descriptive statistics for the study population. Overall, 10.0% of the sample were ineligible for upper secondary school at age 16, and among those who were eligible, 17.2% had not graduated from upper secondary school by age 20. The mean value of psychosomatic complaints was 4.1 (standard deviation: 2.8), with a more detailed breakdown of reported complaints provided in the Supplementary Material (Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e \u0026amp; Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive statistics for the study population (n\u0026thinsp;=\u0026thinsp;5,346).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003es.d.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot eligible for upper secondary school at age 16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot graduated from upper secondary school by age 20\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e826\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints at age 16 (0\u0026ndash;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,706\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,640\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParental tertiary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,621\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,592\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMigration background\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden to two Swedish-born parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3,692\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden to one Swedish-born parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e596\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden with two parents born abroad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn abroad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e533\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving arrangements (at age 16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents in the same household\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3,636\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShared residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e763\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLives with one parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e795\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatric conditions (at or before age 16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e611\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrades from compulsory school (0-320)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e987\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e192.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e966\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e225.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e924\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e249.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e937\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e273.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e996\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e303.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003eExcluding those not eligible for upper secondary school at age 16, n\u0026thinsp;=\u0026thinsp;4,810\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding covariates, the sample was evenly divided by sex (50.6% female, 49.4% male). Parental education levels varied: 39.9% had no parent with tertiary education, 30.3% had one parent with tertiary education, and 29.8% had two parents with tertiary education. Most respondents (69.1%) were born in Sweden to two Swedish-born parents, 11.2% were born in Sweden to one Swedish-born parent, 9.8% were born in Sweden to two foreign-born parents, and 10.0% were born abroad. At age 16, 68.0% of respondents lived with both parents in the same household, 14.3% had shared residence arrangements, 14.9% lived with one parent, and 2.8% lived in other household types (e.g., alone or with relatives). In addition, 11.4% of respondents were classified as having a psychiatric condition at or before age 16. Mean values for the quintiles of compulsory school grades are presented at the bottom of Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here]\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents coefficients and 95% confidence intervals (CIs) from linear probability models predicting ineligibility for upper secondary school at age 16. In the crude model, higher levels of psychosomatic complaints were associated with an increased probability of ineligibility (coefficient: 0.009; 95% CI: 0.006, 0.012). This association remained statistically significant after adjusting for sex, parental education, migration background, and living arrangements in Model 1, and persisted in Model 2, which additionally controlled for psychiatric conditions at or before age 16. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the predicted probabilities from the three models alongside the observed prevalence (smoothed using a moving average) of ineligibility across levels of psychosomatic complaints. Prevalence at the highest symptom levels should be interpreted with caution due to the small number of participants in these groups. Nevertheless, the predicted probabilities closely followed the observed prevalence, displaying a clear gradient across symptom levels. In the fully adjusted model, predicted ineligibility increased from approximately 7% at low symptom levels to nearly 16% at the highest levels.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIneligibility for upper secondary school at age 16: Differences in probability with 95% confidence intervals (95% CI) from Linear Probability Models (LPM) accounting for class fixed effects (n\u0026thinsp;=\u0026thinsp;5,346).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% ineligible\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eCrude\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.009***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.006, 0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.009***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.006, 0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.007***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.004, 0.010\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.026**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.009, 0.043\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.042***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.025, 0.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.041***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.024, 0.057\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParental tertiary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.104***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.082, 0.126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.090***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.068, 0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.090***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.068, 0.111\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.023***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.005, 0.040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.023*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.005, 0.040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.022*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.004, 0.039\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMigration background\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden to two Swedish-born parents (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden to one Swedish-born parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.013, 0.032\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.021, 0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.019, 0.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden with two parents born abroad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.077***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.039, 0.114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.063**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.026, 0.100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.062**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.026, 0.099\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn abroad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.211***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.165, 0.257\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.199***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.155, 0.243\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.207***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.163, 0.250\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving arrangements (at age 16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents in the same household (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShared residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.012, 0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.006, 0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.008, 0.032\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLives with one parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.086***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.058, 0.113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.052***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.025, 0.078\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.044**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.018, 0.070\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.232***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.161, 0.302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.183***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.118, 0.248\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.169***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.105, 0.233\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatric conditions (at or before age 16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.108***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.074, 0.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.096***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.064, 0.128\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e about here]\u003c/p\u003e\u003cp\u003e[Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here]\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows coefficients and 95% CIs from linear probability models predicting non-graduation from upper secondary school by age 20 among those eligible at age 16. In the crude model, higher levels of psychosomatic complaints were associated with an increased probability of not graduating (coefficient: 0.015; 95% CI: 0.011, 0.020). This association remained statistically significant after adjusting for covariates in Models 1 and 2. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e visualises the predicted probabilities and observed prevalence (smoothed) of non-graduation across psychosomatic complaint levels. The predicted probabilities closely aligned with the observed prevalence, revealing a clear gradient pattern across symptom levels. In the fully adjusted model, predicted non-graduation increased from approximately 11% at low symptom levels to nearly 29% at the highest levels.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNon-graduation from upper secondary school by age 20: Differences in probability with 95% confidence intervals (95% CI) from Linear Probability Models (LPM) among those who were eligible for upper secondary school at age 16, accounting for class fixed effects (n\u0026thinsp;=\u0026thinsp;4,806).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% ineligible\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eCrude\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.015***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.011, 0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.016***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.012, 0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.014***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.010, 0.019\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.009, 0.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.046***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.022, 0.070\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.045***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.021, 0.069\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParental tertiary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.072***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.045, 0.099\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.054***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.027, 0.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.054***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.028, 0.081\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.033*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.005, 0.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.004, 0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.004, 0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMigration background\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden to two Swedish-born parents (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden to one Swedish-born parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.037*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001, 0.072\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.008, 0.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.006, 0.063\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn in Sweden with two parents born abroad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.113***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.069, 0.158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.106***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.061, 0.150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.105***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.062, 0.149\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorn abroad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.116***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.065, 0.167\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.113***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.062, 0.164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.122***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.071, 0.173\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving arrangements (at age 16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents in the same household (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShared residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.035*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002, 0.068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.032\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.018, 0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.003, 0.062\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLives with one parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.107***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.068, 0.146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.074***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.036, 0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.068***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.030, 0.105\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.056\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.033, 0.145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.059, 0.120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.075, 0.102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatric conditions (at or before age 16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo (ref.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.144***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.105, 0.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.126***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.087, 0.165\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e about here]\u003c/p\u003e\u003cp\u003e[Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e about here]\u003c/p\u003e\u003cp\u003eThe results from the analyses stratified by school performance at age 16 are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Participants were divided into five quintiles based on compulsory school grades, and the analyses presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e were repeated within each stratum. In the crude models, psychosomatic complaints were significantly associated with non-graduation across all quintiles, with somewhat stronger associations observed in the first and third quintiles. In the fully adjusted models, the associations remained statistically significant in the first, third, and fourth quintiles, showing no consistent pattern based on school performance.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNon-graduation from upper secondary school by age 20: Differences in probability with 95% confidence intervals (95% CI) from Linear Probability Models (LPM) among those who were eligible for upper secondary school at age 16. Analyses are stratified by quintiles of compulsory school grades at age 16.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean grades\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% non-graduates\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eCrude\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eModel 1\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eModel 2\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 1 (n\u0026thinsp;=\u0026thinsp;987)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e192.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.017**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.007, 0.027\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.015**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.004, 0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.014**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.004, 0.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 2 (n\u0026thinsp;=\u0026thinsp;966)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e225.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.012*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.003, 0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.010*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000, 0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.001, 0.019\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 3 (n\u0026thinsp;=\u0026thinsp;924)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e249.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.016***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.008, 0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.013**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.004, 0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.011*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.002, 0.019\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 4 (n\u0026thinsp;=\u0026thinsp;937)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e273.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.009*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.002, 0.017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.011**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.003, 0.018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.010*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.002, 0.017\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuintile 5 (n\u0026thinsp;=\u0026thinsp;996)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e303.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosomatic complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.008*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001, 0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.007*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.001, 0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.000, 0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003ea\u003c/sup\u003e Crude analyses include only psychosomatic complaints.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003eb\u003c/sup\u003e Model 1 includes psychosomatic complaints, sex, parental education, migration background, and living arrangements.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003ec\u003c/sup\u003e Model 2 includes psychosomatic complaints, sex, parental education, migration background, living arrangements, and psychiatric conditions (at or before age 16)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e about here]\u003c/p\u003e\u003cp\u003eAnalyses stratified by sex, presented in the Supplementary Material (Table S2; Figures S2 and S3), revealed similar associations for both females and males. However, males had a higher probability of both outcomes compared to females.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003ePsychosomatic complaints are common among adolescents in Sweden and elsewhere, and their prevalence has increased over recent decades (Public Health Agency of Sweden, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Schrijvers et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Despite this, the potential long-term consequences of such complaints, especially regarding educational attainment, remain understudied. The present study examined the prospective association between adolescent psychosomatic complaints and school failure using data based on a Swedish nationally representative sample combining survey responses and register information. We found that higher levels of psychosomatic complaints during the final year of compulsory school (age 16) were associated with increased probabilities of ineligibility for upper secondary school at age 16, and, among adolescents who were eligible, of not having graduated from upper secondary school by age 20. These associations remained robust and statistically significant in fully adjusted models accounting for sociodemographic factors, psychiatric conditions, and prior school performance. Comparisons between model estimates and the observed prevalence of school failure across psychosomatic symptom levels underscore a largely linear, graded association, although estimates at the highest symptom levels should be interpreted cautiously due to small sample sizes.\u003c/p\u003e\u003cp\u003eExperiencing health complaints such as sleeping problems and recurring bodily pain may have direct effects on academic performance (Musshafen et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ragnarsson et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Poor sleep can lead to drowsiness during school hours, impairing concentration and learning, while regular headaches or stomach aches may further reduce focus and increase absenteeism. Psychosomatic complaints are also commonly interpreted as indicators of mental distress and have been shown to reflect stress among adolescents (L\u0026aring;ftman \u0026amp; \u0026Ouml;stberg, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Potrebny et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Consistent with evidence from prior longitudinal studies, various indicators of mental distress, including subjective well-being and internalising symptoms, have been found to predict subsequent lower educational achievement (B\u0026uuml;cker et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; De Ridder et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Hjorth et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Koivusilta et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Slominski et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Veldman et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Mental distress may affect school performance through multiple pathways, including increased truancy, difficulties completing schoolwork, and poorer relationships with teachers (Needham et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Given that school demands are a common source of adolescent stress (H\u0026ouml;gberg et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), disentangling the intertwined relationship between psychosomatic complaints, stress, and academic performance is challenging. Nevertheless, there is strong evidence for specific mechanisms linking stress to academic outcomes, including disruptions to cognitive functioning and reductions in academic motivation (Almarzouki, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Costa et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Ma, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrior studies have lacked information on clinically assessed mental disorders, which may confound the link between psychosomatic complaints and school failure (Melkevik et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). By adjusting for prior psychiatric conditions, the present study more accurately isolates this relationship, suggesting that psychosomatic complaints can independently influence educational outcomes. This finding is particularly relevant for policy and intervention efforts, given concerns in Sweden about what psychosomatic complaints represent and the risk of pathologising everyday problems (Wickstr\u0026ouml;m \u0026amp; Lindholm, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Our results revealed a clear gradient in the association between psychosomatic complaints and educational achievement. Even small increases in symptom levels were associated with increased risks of school failure, but the effects became more substantial when multiple complaints occurred frequently. This pattern suggests that while occasional complaints may reflect normal \u0026ldquo;everyday problems\u0026rdquo;, they can still warrant attention, particularly when they accumulate. Yet, the critique by Wickstr\u0026ouml;m and Lindholm remains relevant: categorising a large share of adolescents, such as three fourths of Swedish 15-year-old girls, as having mental health problems may overstate the situation and offer limited policy value, especially when many adolescents simultaneously report high levels of well-being. Rather than relying on arbitrary cut-offs, psychosomatic complaints might be better understood along a continuum, where both their number and frequency have meaningful implications for current and future outcomes.\u003c/p\u003e\u003cp\u003eThe observed prospective association found in the current study may partly reflect the short-term effects of psychosomatic complaints on academic functioning, which can hinder current school performance and, consequently, reduce opportunities for future educational attainment (McLeod \u0026amp; Kaiser, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). At the same time, the direction of influence may also run the other way: failing grades in compulsory school can be stressful and negatively impact students\u0026rsquo; well-being, potentially giving rise to psychosomatic complaints (H\u0026ouml;gberg et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). To reduce this potential bias, we excluded respondents who were already ineligible for upper secondary school at age 16 when examining non-graduation, and the association remained significant. Additionally, because admission to upper secondary school is determined by grades from compulsory school, high-achieving students often enter more resourced and academically stimulating environments, potentially reinforcing existing educational advantages (Fjellman \u0026amp; Hansen, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Therefore, we further examined whether the association between psychosomatic complaints and educational attainment varied across different levels of compulsory school grades. The results were largely consistent across grade strata, indicating that psychosomatic complaints predict educational outcomes beyond pre-existing academic differences. These findings suggest that psychosomatic complaints may represent an independent risk factor for educational underachievement rather than merely reflecting prior performance.\u003c/p\u003e\u003cp\u003eTaken together, our results should also be considered in light of broader structural factors shaping educational pathways. Recent debates in Sweden about the grading system, particularly regarding the retention of failing grades, their role in admission to upper secondary school, and the impact of recent reforms on adolescent well-being, highlight how institutional structures can shape the relationship between health and academic performance (Arensmeier, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In this context, psychosomatic complaints may not only impair individual academic functioning but also exacerbate structural inequalities in educational attainment, as adolescents experiencing health-related difficulties face greater barriers to progression within a stratified school system.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Strengths and limitations\u003c/h2\u003e\u003cp\u003eA major strength of this study lies in the data material, which combines adolescent survey reports of psychosomatic complaints with official registry information on educational attainment. This linkage eliminates attrition in the outcome variables and, in the prospective analysis, allows for adjustment for prior school performance, thereby strengthening the ability to isolate the association between psychosomatic complaints and later non-graduation from upper secondary school. The inclusion of data on clinically assessed diagnoses of depression, anxiety, and ADHD as well as prescription for medications used to treat these conditions further improves this estimation by accounting for potential confounding due to underlying psychiatric conditions. Nevertheless, it should be acknowledged that not all individuals experiencing symptoms seek health care and are therefore not captured in these registers (Alonso et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Moitra et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In addition, registry-based information on parental educational attainment is an asset, as it reduces the risk of misclassification and selective non-response often associated with adolescents\u0026rsquo; self-reported data on parental characteristics (Engzell \u0026amp; Jonsson, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, several limitations need to be considered as well. First, although the data are based on a nationally representative sample of schools, only 69% of invited schools agreed to partake in the survey collection, raising the possibility of school-level selection bias. Yet, no systematic differences were found between participating and non-participating schools in terms of average grades or student composition regarding parental education and country of birth (Raninen, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). At the student level, the response rate was 82%, and non-participants may have differed systematically from respondents. In our data, approximately 10% of students were ineligible for upper secondary school at age 16, compared to about 15% in national statistics in the same year (Statistics Sweden, n.d.), suggesting an underrepresentation of lower-achieving students.\u003c/p\u003e\u003cp\u003eSecond, although the longitudinal design allows for temporal separation between psychosomatic complaints at age 16 and upper secondary school graduation, the possibility of reverse causality cannot be entirely ruled out. School performance and health develop in tandem over time. Difficulties in school can lead to increased psychosomatic complaints, illustrating a social causation mechanism, where social position influences later health (Mossakowski, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Conversely, such complaints may hinder academic progress, reflecting a health selection mechanism in which health status affects later socioeconomic position. This reciprocal relationship complicates causal interpretation. To address this, we excluded individuals ineligible for upper secondary school at age 16 and conducted analyses stratified by baseline performance; however, these measures can only partially account for the dynamic interplay between health and education. Our findings suggest the presence of health selection mechanisms, consistent with previous research (Agnafors et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Koivusilta et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), while social causation likely also contributes. Therefore, the results should be interpreted within a life-course framework that recognises multiple, mutually reinforcing influences over time.\u003c/p\u003e\u003cp\u003eThird, psychosomatic complaints were measured using only three items, which limits the ability to capture the full range of such complaints. More comprehensive scales, such as the eight-item measure used in the Health Behaviour in School-aged Children (HBSC) study (Cosma et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), enable finer distinctions between different complaint types (e.g., Giannotta et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Different dimensions of adolescent health complaints may influence school performance in distinct ways, and a multidimensional measure would allow these effects to be captured more accurately (e.g., Musshafen et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ragnarsson et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Conclusion\u003c/h2\u003e\u003cp\u003eIn sum, the findings indicate that psychosomatic complaints during adolescence can have lasting effects on educational attainment, beyond earlier school failure and performance, and independently of psychiatric conditions. The study highlights the importance of recognising these complaints not merely as transient discomforts but as conditions with the potential to affect long-term outcomes. Given that educational achievement is a key determinant of future socioeconomic and health status, psychosomatic complaints may indirectly shape individuals\u0026rsquo; life trajectories and well-being. For policymakers and educators, these results underscore the value of early identification and support for adolescents experiencing frequent psychosomatic complaints, as well as efforts to address their underlying determinants. Future research should further explore how such complaints influence outcomes across educational, occupational, social, and health domains.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eADHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAttention-Deficit/Hyperactivity Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eATC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnatomical Therapeutic Chemical\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHBSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Behaviour in School-aged Children\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLISA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLongitudinal Integrated Database for Health Insurance and Labour Market Studies\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLPM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLinear Probability Model\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Swedish Ethical Review Authority (ref. 2021-06504-01; 2022-02781-02 2022-06502-02). According to the Swedish Ethical Review Act (SFS 2003:460), parental consent is not required for adolescents aged 15 or older if they realise what the research means for them. Informed consent was obtained from all study participants. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch4\u003eAvailability of data and materials\u0026nbsp;\u003c/h4\u003e\n\u003ch4\u003eThe data used for the current study are available from Karolinska Institutet but restrictions apply to the availability of these data, and are therefore not publicly available. Data are however available from the Principal Investigator Dr. Jonas Raninen ([email protected]) upon reasonable request and with permission of Karolinska Institutet and ethical approval from the Swedish Ethical Review Authority.\u003c/h4\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The study was financed by the Swedish Research Council for Health, Working Life and Welfare (Forte) (grant no. 2021-00537). The funders had no role in the study design, analysis or interpretation of the data, nor in the writing of the manuscript. Open access funding provided by Stockholm University.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eJW conceived the study, performed the statistical analyses, and drafted a first version of the manuscript. SBL and V\u0026Ouml; critically revised the manuscript\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgnafors S, Barmark M, Sydsj\u0026ouml; G. Mental health and academic performance: a study on selection and causation effects from childhood to early adulthood. 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J Affect Disord. 2017;210:22\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2016.11.018\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2016.11.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Psychosomatic symptoms, Health complaints, Educational attainment, School performance, Adolescents, Longitudinal","lastPublishedDoi":"10.21203/rs.3.rs-7999037/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7999037/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePsychosomatic complaints \u0026mdash; health issues without a clear medical cause and often used as indicators of adolescent mental distress \u0026mdash; have increased in Sweden and elsewhere during recent decades. Yet, evidence on their long-term influence remains limited, including links to educational outcomes. Education is a key determinant of future living conditions, and school failure in adolescence can have long-lasting impacts. In Sweden, graduation from upper secondary school represents an important educational milestone. This study examined associations between psychosomatic complaints at age 16 and (1) ineligibility for upper secondary school at age 16, and (2) non-graduation from upper secondary school by age 20.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eData was obtained from Futura01, a Swedish national cohort of adolescents attending grade 9 (the final year of compulsory school, age 16) in spring of 2017 (n\u0026thinsp;=\u0026thinsp;5,346). Psychosomatic complaints were assessed using self-reports on the frequency of headache, stomach ache, and sleep difficulties. Registry data provided information on upper secondary school eligibility and graduation. Covariates included sex, parental education, migration background, living arrangements, and psychiatric conditions. Linear probability models were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eHigher levels of psychosomatic complaints at age 16 were associated with increased probabilities of ineligibility for upper secondary school at age 16 and, among eligible students, subsequent non-graduation from upper secondary school by age 20, even after adjusting for covariates.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePsychosomatic complaints in adolescence may negatively influence educational attainment, potentially contributing to later socioeconomic and health disadvantages. These findings underscore the importance of addressing adolescent health complaints to support educational success.\u003c/p\u003e","manuscriptTitle":"Psychosomatic complaints and school failure: A prospective Swedish national cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 10:25:08","doi":"10.21203/rs.3.rs-7999037/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-16T10:04:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T07:20:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-08T11:45:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129626287282007047187709926618333377032","date":"2026-03-06T05:13:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T08:56:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192388702914384323377947860007049800119","date":"2026-02-27T11:54:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226685192019122394225691525789206307952","date":"2026-02-26T12:42:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164189034586702558884528895195820431981","date":"2026-02-25T11:26:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-13T17:13:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-05T12:01:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-04T08:01:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-04T07:59:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-31T13:34:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99aacfb4-caf6-49c2-b6e7-6cf7fc789bb9","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T10:25:09+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 10:25:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7999037","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7999037","identity":"rs-7999037","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}