Bjørn-Atle Reme

• Beck, Kathryn Christine; Reme, Bjørn-Atle & Wörn, Jonathan (2026). Secular trends in primary care utilisation for mental health problems: a Norwegian register-based population-wide study. Journal of Epidemiology and Community Health. ISSN 0143-005X. p. 1–7. doi: 10.1136/jech-2026-226059. Full text in Research Archive Show summary

  Background Evidence from several countries suggests increasing mental health problems among children and adolescents, raising concerns about deteriorating population mental health. Whether rising consultation rates reflect worsening morbidity or changes in help-seeking remains unclear. We aimed to describe secular trends in mental health consultations in Norway and compare trends for symptom-coded versus disorder-coded anxiety and depression. Methods We conducted a nationwide repeated cross-sectional study of all individuals aged 10–46 years in Norway during 2010–2024 (N=3 728 002). Using linked administrative registers of general practitioner contacts, we estimated annual sex- and age-specific prevalence of any mental health consultation (International Classification of Primary Care (ICPC-2) P codes), distinguishing anxiety/depression symptoms (P01, P03) from disorders (P74, P76). Quasibinomial regression estimated annual prevalence ratios (PRs) and post-2020 changes. Results From 2010 to 2024, the prevalence of mental health diagnoses increased by 62% (9.9% to 16.0%), rising 66% for girls/women (11.8% to 19.6%) and 54% for boys/men (8.2% to 12.6%). Shares of anxiety-symptom consultations increased from 0.44% to 1.7%, while anxiety disorder consultations rose modestly (0.95% to 1.4%). Shares of depressive symptom consultations increased from 0.73% to 1.8%, whereas depressive disorder consultations were stable (2.8% to 2.7%). Annual PRs were consistently higher for symptom than disorder codes, and after 2020 depressive symptom prevalence accelerated among adults aged 21–30. Conclusion The prevalence of mental health problems increased substantially from 2010 to 2024, driven primarily by symptom-coded consultations. These patterns suggest lowered help-seeking thresholds and/or changes in coding, although changes in underlying distress cannot be excluded. The findings have implications for practitioners and policymakers planning resource allocation.

• Reme, Bjørn-Atle; Magnus, Per; Håberg, Siri Eldevik & Kinge, Jonas Minet (2026). General practitioner utilization by age, sex and disease in Norway from 2012–2023: a national health registry study. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 44(1). doi: 10.1080/02813432.2026.2666623. Full text in Research Archive Show summary

  Objective: To describe trends in the number of general practitioner consultations in primary care, stratified by age, sex, and diagnosis. Method: Register-based population-wide repeated cross-sectional study. Data from the Norwegian Control and Distribution of Health Reimbursement (KUHR) database, linked to data from the Norwegian Population Registry. Participants: All Norwegians alive and living in the country each year from 2012 to 2023. The population grew from 4,985,870 in 2012 to 5,488,984 persons in 2023 during this period. Main outcome measure: The average annual number of general practitioner consultations per inhabitant in primary healthcare. Results: The average number of yearly General Practitioner (GP) visits per inhabitant increased from 3.1 to 3.6 for women and from 2.2 to 2.4 for men from 2012 to 2023. Age-specific utilization trends revealed the largest increase among 16–19-year-old women, whose GP visits rose from 2.05 to 2.99 per year. Diagnosis-specific trends highlighted a substantial increase in consultations for mental illness among women, from 0.31 to 0.46 per inhabitant, with the largest relative growth among 6–15-year-old girls (+139%). Conversely, consultations for heart disease saw the largest relative decline, particularly among women aged 67 to 79 (−68.3%) and men aged 80 to 89 (−0.94 consultations per inhabitant). Conclusions: Primary care utilization has increased over the past decade, with notable variation by age, sex, and diagnosis. The particularly strong increase in consultations for mental illness among young individuals highlight the potential for considering other medical professionals, such as specially trained nurses, to serve as the primary point of contact for young individuals with mental health challenges.

• Reme, Bjørn-Atle; Sunde, Hans Fredrik; Torvik, Fartein Ask; Kinge, Jonas Minet; Strand, Bjørn Heine & Wörn, Jonathan (2026). Parental income in childhood and health outcomes across age groups: a register-based study from Norway. BMC Medicine. 24(1). doi: 10.1186/s12916-026-04735-w. Full text in Research Archive Show summary

  Abstract Background Parental socioeconomic status is associated with health outcomes across age. However, the specific age-, gender-, and disease-related patterns linking parental income during early childhood to healthcare utilization across age remain poorly characterized. Enhanced understanding of these associations is essential to inform targeted interventions and improve health equity. Methods This cross-sectional study analyzed primary care consultations for all Norwegian residents aged 10–59 in 2018 ( N  = 2,882,669), merged with parental income records from 1958 up until 2017. The analysis was restricted to GP consultations for diseases or disorders, excluding consultations for symptoms and complaints. Analyses were stratified by sex, age, and type of health problem. We also examined how adult income and education mitigate socioeconomic disparities in healthcare utilization. Results Individuals from low parental income backgrounds had higher primary care utilization. In the lowest parental income quintile, females averaged 1.89 (SD 3.30) and males 1.24 (SD 2.65) consultations per year, compared to 1.60 (SD 2.94) and 1.00 (SD 2.21), respectively, in the highest quintile. Socioeconomic differences varied by age and disease type. Among females, the largest inequality occurred at age 24, with 1.97 (95% CI 1.89–2.05) consultations in the lowest quintile versus 1.17 (95% CI 1.11–1.23) in the highest. For males, inequality was largest at age 31, with 1.22 (95% CI 1.15–1.30) versus 0.78 (95% CI 0.74–0.83) consultations. Disease-specific differences showed the largest odds ratios for psychological (females: OR 1.54, 95% CI 1.51–1.57; males: OR 1.64, 95% CI 1.60–1.68) and endocrine/nutritional issues (females: OR 1.34, 95% CI 1.32–1.37; males: OR 1.35, 95% CI 1.31–1.38). Adjusting for adult education and income eliminated most disparities, except for musculoskeletal and endocrine/nutritional health problems. Conclusions Lower parental income in childhood was associated with higher adult primary care use, particularly for psychological, musculoskeletal, and endocrine conditions, with heterogeneity by age and sex. These associations were attenuated when accounting for individuals’ own education and income, suggesting that policies that enhance educational attainment and economic opportunity can help reduce health inequalities.

• Pedersen, Ida Victoria Katjivena; Reme, Bjørn-Atle; Mølland, Eirin & Kinge, Jonas Minet (2025). Birth weight and school performance. Economics and Human Biology. ISSN 1570-677X. 59. doi: 10.1016/j.ehb.2025.101542. Full text in Research Archive Show summary

  This study investigates the long-term association between birth weight and school performance in Norway, with a focus on how this relationship has evolved alongside demographic changes. We contribute to the literature by examining this link in a contemporary context using nearly two decades of administrative data. Our findings indicate that higher birth weight is consistently associated with better school performance, particularly in mathematics. This association remains robust across multiple model specifications, including those that account for unobserved family heterogeneity. We also find a slightly stronger association among girls, though the gender interaction is small and not robust in the twin design. Overall, the results underscore birth weight as a stable predictor of academic achievement and highlight its relevance for understanding early-life determinants of human capital development.

• Delalic, Lamija; Wörn, Jonathan & Reme, Bjørn-Atle (2025). Early parental death and being not in education, employment, or training (NEET-status) in Norway: a population-wide study on the moderating role of parental education. European Journal of Public Health. ISSN 1101-1262. 35(5), p. 889–895. doi: 10.1093/eurpub/ckaf081. Full text in Research Archive Show summary

  Childhood parental death has been linked to adverse young adult outcomes, potentially influenced by family background. This study quantifies the association between parental death during childhood and NEET-status (not in education, employment, or training) in young adulthood, focusing on the moderating role of parental education. Causes of death were leveraged to explore the extent of confounding in the relationship between parental death and NEET-status. The study utilized Norwegian registry data from birth cohorts 1977–87 (574 229 individuals). We identified individuals with and without the experience of parental death between ages 0–17 and tracked their NEET-status between ages 22–29. Poisson regression models estimated incidence risk ratios for NEET years based on parental death, parental education, their interaction, and control variables. To address confounding, causes of death were categorized as more exogenous (i.e. neoplasms) or more endogenous (e.g. suicide or drug-related deaths). Early parental death and lower parental education were both linked to more years in NEET status. Incidence risk ratios varied by cause of death, ranging from 1.19 for neoplasms [95% confidence interval (CI): 1.13–1.25] to 2.36 for drug-related causes (95% CI: 2.17–2.56). Lower parental education amplified the association between NEET-status and parental death from most causes, but to the smallest extent for neoplasms. The association between parental death and NEET status was stronger among individuals with parents with lower parental education. When the cause of death was unrelated to parental education, the modifying effect of parental education was smaller, suggesting that stronger associations in low-education families may largely reflect confounding factors.

• Gjefsen, Hege Marie; Grøsland, Mari; Grøtting, Maja Weemes & Reme, Bjørn-Atle (2025). Being a frontline worker in a health emergency: Healthcare workers’ absences and health during the COVID-19 pandemic. Labour Economics. ISSN 0927-5371. 96. doi: 10.1016/j.labeco.2025.102727. Full text in Research Archive
• Reme, Bjørn-Atle; Hart, Rannveig Kaldager & Lind, Jo Thori (2025). Early-life death of a sibling and primary care utilisation during middle age: a population-wide cohort study. Journal of Epidemiology and Community Health. ISSN 0143-005X. 79(8), p. 588–593. doi: 10.1136/jech-2024-222632. Full text in Research Archive Show summary

  Background The death of a family member has been linked to higher mortality for those grieving. However, much less is known about different types of health problems of the surviving sibling during middle age. Methods Individual-level register data on all Norwegian residents born between 1969 and 1979 were linked to cause-specific primary care utilisation between 2015 and 2019. Incidence rate ratios (IRRs) of different types of health conditions in mid-life (age 36–50) were calculated, comparing individuals who experienced the death of a sibling during childhood or early adulthood (age 0–29) and those who did not. Results The study included 556 593 participants (mean (SD) age in 2017, 43.3 (3.15) years; 273 491 women (49.1%)). The death of a sibling was positively associated with all-cause primary care utilisation (IRR=1.11; 95%CI, 1.08 to 1.13). The highest cause-specific estimates were found for psychological (IR=1.17; 95%CI, 1.11 to 1.23) and cardiovascular (IRR=1.14; 95%CI, 1.05 to 1.23) health problems. Suicide was the cause of death with the strongest association with all-cause primary care (IRR=1.16; 95%CI, 1.09 to 1.23). When examining the intersection of type-specific health problems and causes of death, the highest estimate was found for psychological problems and sibling suicide (IRR=1.53, 95%CI, 1.32 to 1.77). Conclusion Early-life sibling death was associated with more health problems several decades after the trauma. The persistence of these associations suggests that these problems are substantial, and at least partly caused by the trauma. More needs to be learnt interventions that could mitigate these adverse effects.

• Reme, Bjørn-Atle; Røgeberg, Ole; Wörn, Jonathan; Bratsberg, Bernt Magne & Skirbekk, Vegard Fykse (2025). The distribution of technology induced job loss: Evidence from a population-wide study in Norway. PLOS ONE. 20(4). doi: 10.1371/journal.pone.0321072. Full text in Research Archive
• Kinge, Jonas Minet; Øien, Henning; Dieleman, Joseph L.; Reme, Bjørn-Atle; Knudsen, Ann Kristin Skrindo & Godager, Geir [Show all 11 contributors for this article] (2025). Forecasting total and cause-specific health expenditures for 116 health conditions in Norway, 2022–2050. BMC Medicine. 23(1). doi: 10.1186/s12916-025-03917-2. Full text in Research Archive Show summary

  Background This study forecasts total and cause-specific health expenditures in Norway to 2050 and quantifies the contribution of four key drivers—total population growth, population aging, changes in disease prevalence, and cost per case—on future health care spending. Methods We forecast spending for 116 health conditions in Norway from 2022 to 2050, using historical and forecasted data of population growth, disease prevalence, gross domestic product (GDP), health spending, and residual factors. Our analysis included a reference scenario that forecasted disease-specific health spending; two alternative scenarios examining the effects of alternative unit cost developments; and a scenario examining the consequences of improved behavioral and metabolic risk factors. Results Health spending increased from 10.6% (95% uncertainty interval, 10.2–11.1) of GDP in 2022 to 14.3% (13.0–15.7) in 2050 in the reference scenario. Among the top aggregate causes of Norwegian health spending in 2022, the spending for neurological disorders rose the most, from 1.7% (1.6–1.8) to 2.7% (2.3–3.1) of GDP, surpassing mental and substance use disorders which rose from 2.2% (2.1–2.3) to 2.4% (2.2–2.6) of GDP. Of the 116 single conditions analyzed, dementias accounted for the highest spending in 2022. This expenditure was forecasted to increase considerably from 1.1% (1.09–1.2) to 1.9% (1.6–2.2) of GDP by 2050, largely due to population aging. Spending on other old-age-related conditions like falls, stroke, and diabetes, was also forecasted to increase. Increased population, aging, and spending per case contributed to increased future spending. Reduced behavioral and metabolic risks were forecasted to increase the number of elderly persons and reduce age-specific disease prevalence but had little impact on forecasted health spending. Conclusions Health spending growth was forecasted regardless of the scenario, and Norway needs to plan for this. However, policymakers can curb total spending growth, while maintaining health care quality and output, by ensuring more efficient allocation and effective use of resources. While the overall impact of behavioral and metabolic risk reductions on total healthcare spending was modest, reducing risk factors is needed if countries aim to achieve a healthier, longer-living population.

• Skyrud, Katrine Damgaard; Rotevatn, Torill Alise; Øien, Henning & Reme, Bjørn-Atle (2025). Young doctors’ attrition and retention in the GP scheme: a national cohort study from Norway. Scandinavian Journal of Public Health. ISSN 1403-4948. p. 1–11. doi: 10.1177/14034948251317465. Full text in Research Archive
• Reme, Bjørn-Atle; Røgeberg, Ole & Torvik, Fartein Ask (2024). School performance and the social gradient in young adult death in Norway. Nature Human Behaviour. 9, p. 84–89. doi: 10.1038/s41562-024-02053-w. Full text in Research Archive Show summary

  Young adults from low socioeconomic backgrounds face an increased risk of early mortality. Here we utilize population-wide data from 17 Norwegian birth cohorts (N = 986,573) to assess whether this risk gradient was explained by early-life educational performance, specifically grade point average at 16 years of age. We show that the gradients in both parental education and income largely disappeared when adjusting for school performance in the models. Specifically, among boys, those with the lowest parental education had an unadjusted hazard ratio (HR) of 2.04 (95% confidence interval (CI) 1.86–2.22) compared with peers with the highest parental education, while for girls, the HR was 1.64 (95% CI 1.35–1.93). After adjusting for school performance, these estimates dropped to 0.99 (95% CI 0.79–1.19) for boys and 0.87 (95% CI 0.55–1.19) for girls. Similarly, the mortality risk for those from the lowest parental income quartile decreased from 1.79 (95% CI 1.67–1.91) to 1.25 (95% CI 1.12–1.38) for boys and from 1.63 (95% CI 1.44–1.83) to 1.24 (95% CI 1.03–1.46) for girls. Low educational performance remained strongly associated with early mortality in analyses accounting for unobserved heterogeneity at the family level; boys with a grade point average in the lowest quartile had an HR of 3.04 (95% CI 2.38–3.89), while for girls, the HR was 1.79 (95% CI 1.22–2.63). External causes of death, particularly accidents and poisoning, were most overrepresented among individuals with poor school performance.

• Kravdal, Øystein; Wörn, Jonathan; Hart, Rannveig Kaldager & Reme, Bjørn-Atle (2024). The influence of parental cancer on the mental health of children and young adults: Evidence from Norwegian register data on healthcare consultations. Demographic Research. ISSN 1435-9871. 50, p. 763–796. doi: 10.4054/DEMRES.2024.50.27. Full text in Research Archive Show summary

  Objective: The aim was to examine how parental cancer affects the mental health of offspring aged 6–30, and age variations in this effect. Methods: Individual fixed-effects models were estimated from register data covering the entire Norwegian population in 2010–2018. The outcome variable was whether the individual (offspring) had at least one consultation within a year with a general practitioner (GP) or specialist where a mental health diagnosis or symptom was reported. Results: The consultation probability was higher after a parental cancer diagnosis than before (e.g., 15% higher in the first year after the diagnosis). This was to a large extent driven by subsequent parental deaths, but there was also a small post-diagnosis increase among offspring whose parent survived the observation period. The consultation probability increased by 83% the year a parent died among offspring who were 19–30 at that time, after a smaller increase over a few of the preceding years. A decline occurred later. The death seemed to have a weaker, but more lasting, effect on those who were 8–18 years old at the time of the death, and these did not experience a clear pre-death increase. Conclusions: Parental cancer death seems to weaken offspring’s mental health – and no less among young adults than among children. By contrast, having a parent with cancer who remains alive at least throughout the observation period has relatively little impact. Contribution: We show associations between parental cancer and offspring’s mental health, paying special attention to whether the parent dies. This may inform discussions about supporting offspring.

• Nordmo, Magnus; Kleppestø, Thomas Haarklau; Reme, Bjørn-Atle; Sunde, Hans Fredrik; Soest, Tilmann von & Torvik, Fartein Ask (2024). The diminishing association between adolescent mental disorders and educational performance from 2006–2019. JCPP Advances. 4(3). doi: 10.1002/jcv2.12239. Full text in Research Archive Show summary

  Background A rising prevalence of adolescent mental disorders in the Western world has been widely reported, raising concerns for adolescent development and well-being. Mental disorders are known to negatively impact educational performance. Yet it remains uncertain whether the relationship between mental disorders and educational outcomes has also changed over time and if the change is more pronounced among high compared to low performing students. The aims of this paper are to (1) describe the change over time in the prevalence of common mental disorders in adolescence; (2) determine whether the change in prevalence of common mental disorders differs between high and low performing students; and (3) assess whether the associations between mental health disorders and educational performance have changed over time. Methods To address these issues, this study examines potential shifts in the associations between diagnoses of ADHD and internalizing disorders and educational performance among 843,692 Norwegian students graduating from lower secondary education between 2006 and 2019. We utilize population-wide register data on ADHD and internalizing disorders from primary and specialist care combined with educational outcomes. Results Our analysis revealed a marked rise in ADHD prevalence, from 1.0% in 2006 to 2.6% in 2019. Concurrently, diagnoses of internalizing disorders also increased from 1.9% to 4.2%. This increasing trend in diagnoses spanned across all high school grade point average (GPA) categories, thereby not supporting the notion that the rise is predominantly observed among high-performing adolescents. Importantly, the strength of the associations of internalizing disorders and ADHD with GPA diminished significantly over time. For instance, the difference between the average GPA standardized score for boys with and without an ADHD diagnosis shrunk from 1.0 in 2006 to 0.73 in 2019. Conclusions We discuss various potential explanations for this observation and suggest that changes in diagnostic thresholds is a contributing factor.

• Kingsbury, Mila; Alaie, Iman; Clayborne, Zahra; Reme, Bjørn-Atle; Nilsen, Wendy & Colman, Ian (2024). Pathways From Early Life Adversities to Youth Marginalization: A Longitudinal Study of Youth Not in Education, Employment, or Training. Journal of Adolescent Health. ISSN 1054-139X. 76(1), p. 105–114. doi: 10.1016/j.jadohealth.2024.08.011. Full text in Research Archive Show summary

  Purpose Youth who are Not in Education, Employment, or Training (NEET) are at risk for numerous long-term occupational, social, and mental health–related sequelae. The aim of the present study was to investigate mediated pathways from early life risk factors to NEET status in early adulthood, with a particular focus on the role of the family environment during adolescence. Methods Participants were 6,403 respondents from the National Longitudinal Survey of Children and Youth, who were aged 10–11 years in cycles 1 (1994–1995) to 4 (2000–2001). Parents reported on indicators of early life adversity as well as parent-child conflict at age 12–13. Adolescents reported on their mental health and behaviour at age 14–15. NEET status was assessed at age 24 using tax information from the linked T1 Family File. Indirect pathways from childhood exposures, through adolescent factors, to NEET status in young adulthood were assessed via mediation analysis. Results At age 10/11, living with a single parent, low household income, stressful life events, and having a parent with a chronic condition were associated with greater likelihood of being NEET at age 24; parents’ social support was negatively associated with NEET. These associations were mediated through parental depression at age 10/11, parent-child conflict at age 12/13, and adolescent mental health and behaviour at age 14/15. Discussion Our results add to a large body of literature linking family stressors, parental depression, parent-child interaction, and adolescent behaviour symptoms, suggesting a chain of influence through these factors toward young adult marginalization from the labour market.

• Beck, Kathryn Christine; Røhr, Helene Lie; Reme, Bjørn-Atle & Flatø, Martin (2023). Distressing testing: A propensity score analysis of high-stakes exam failure and mental health. Child Development. ISSN 0009-3920. 95(1), p. 242–260. doi: 10.1111/cdev.13985. Full text in Research Archive Show summary

  This study used rich individual-level registry data covering the entire Norwegian population to identify students aged 17–21 who either failed a high-stakes exit exam or who received the lowest passing grade from 2006 to 2018. Propensity score matching on high-quality observed characteristics was utilized to allow meaningful comparisons (N = 18,052, 64% boys). Results showed a 21% increase in odds of receiving a psychological diagnosis among students who failed the exam. Adolescents were at 57% reduced odds of graduating and 44% reduction in odds of enrolling in tertiary education 5 years following the exam. Results suggest that failing a high-stakes exam is associated with mental health issues and therefore may impact adolescents more broadly than captured in educational outcomes.

• Wörn, Jonathan; Reme, Bjørn-Atle & Skirbekk, Vegard Fykse (2023). Job loss and psychological distress during the COVID-19 pandemic: a national prospective cohort study. BMC Public Health. 23(1), p. 1–6. doi: 10.1186/s12889-023-16303-5. Full text in Research Archive
• Reme, Bjørn-Atle; Gjesvik, Jonas & Magnusson, Karin (2023). Predictors of the post-COVID condition following mild SARS-CoV-2 infection. Nature Communications. 14. doi: 10.1038/s41467-023-41541-x. Full text in Research Archive Show summary

  Abstract Whereas the nature of the post-COVID condition following mild acute COVID-19 is increasingly well described in the literature, knowledge of its risk factors, and whether it can be predicted, remains limited. This study, conducted in Norway, uses individual-level register data from 214,667 SARS-CoV-2 infected individuals covering a range of demographic, socioeconomic factors, as well as cause-specific healthcare utilization in the years prior to infection to assess the risk of post-COVID complaints ≥3 months after testing positive. We find that the risk of post-COVID was higher among individuals who prior to infection had been diagnosed with psychological (OR = 2.12, 95% CI 1.84–2.44), respiratory (OR = 2.03, 95% CI 1.78–2.32), or general and unspecified health problems (OR = 1.78, 95% CI 1.52–2.09). To assess the predictability of post-COVID after mild initial disease, we use machine learning methods and find that pre-infection characteristics, combined with information on the SARS-CoV-2 virus type and vaccine status, to a considerable extent (AUC = 0.79, 95% CI 0.75–0.81) could predict the occurrence of post-COVID complaints in our sample.

• Reme, Bjørn-Atle; Grøsland, Mari; Gjefsen, Hege Marie & Magnusson, Karin (2023). Impact of the COVID-19 pandemic on sick leave among healthcare workers: A register-based observational study. Occupational and Environmental Medicine. ISSN 1351-0711. 80(6), p. 319–325. doi: 10.1136/oemed-2022-108555. Full text in Research Archive Show summary

  Abstract Objectives To assess the impact of the COVID-19 pandemic on sick leave among healthcare workers (HCWs) in primary and specialist care and examine its causes. Methods Using individual-level register data, we studied monthly proportions of sick leave (all-cause and not related to SARS-CoV-2 infection) from 2017 to February 2022 for all HCWs in primary (N=60 973) and specialist care (N=34 978) in Norway. First, we estimated the impact of the pandemic on sick leave, by comparing the sick leave rates during the pandemic to sick leave rates in 2017–2019. We then examined the impact of COVID-19-related workload on sick leave, by comparing HCWs working in healthcare facilities with different levels of COVID-19 patient loads. Results HCWs had elevated monthly rates of all-cause sick leave during the COVID-19 pandemic of 2.8 (95% CI 2.67 to 2.9) and 2.2 (95% CI 2.07 to 2.35) percentage points in primary and specialist care. The corresponding increases for sick leave not related to SARS-CoV-2 infection were 1.2 (95% CI 1.29 to 1.05) and 0.7 (95% CI 0.52 to 0.78) percentage points. All-cause sick leave was higher in areas with high versus low COVID-19 workloads. However, after removing sick leave episodes due to SARS-CoV-2 infections, there was no difference. Conclusions There was a substantial increase in sick leave among HCWs during the pandemic. Our results suggest that the increase was due to HCWs becoming infected with SARS-CoV-2 and/or sector-wide effects, such as strict infection control measures. More differentiated countermeasures should, therefore, be evaluated to limit capacity constraints in healthcare provision.

• Reme, Bjørn-Atle; Wörn, Jonathan & Skirbekk, Vegard Fykse (2022). Longitudinal evidence on the development of socioeconomic inequalities in mental health due to the COVID-19 pandemic in Norway. Scientific Reports. 12(1). doi: 10.1038/s41598-022-06616-7. Full text in Research Archive
• Reme, Bjørn-Atle; Kotsadam, Andreas; Bjelland, Johannes; Sundsøy, Pål Roe & Lind, Jo Thori (2022). Quantifying social segregation in large-scale networks. Scientific Reports. 12(1). doi: 10.1038/s41598-022-10273-1. Full text in Research Archive Show summary

  Abstract We present a measure of social segregation which combines mobile phone data and income register data in Oslo, Norway. In addition to measuring the extent of social segregation, our study shows that social segregation is strong, robust, and that social networks are particularly clustered among the richest. Using location data on the areas where people work, we also examine whether exposure to other social strata weakens measured segregation. Lastly, we extend our analysis to a large South Asian city and show that our main results hold across two widely different societies.

• Sunde, Hans Fredrik; Kleppestø, Thomas Haarklau; Gustavson, Kristin; Nordmo, Magnus; Reme, Bjørn-Atle & Torvik, Fartein Ask (2022). The ADHD deficit in school performance across sex and parental education: A prospective sibling‐comparison register study of 344,152 Norwegian adolescents. JCPP Advances. 2(1), p. 1–9. doi: 10.1002/jcv2.12064. Full text in Research Archive Show summary

  Background Attention-Deficit Hyperactivity Disorder (ADHD) is associated with impaired school performance, but the impact of ADHD may vary across sex, family background, and school subjects. By using prospective population-wide register data, we describe impairment in academic performance related to ADHD across different school subjects and investigate how this impairment differ across sex and parental education. Methods We examined grades and Grade Point Averages (GPA) at age ∼16 among 344,152 Norwegian children born between 1997 and 2002. We linked grades with diagnoses from publicly funded general practitioners and with demographic information. Associations between ADHD diagnosed between age 10 and 16 and school performance were estimated with linear models, including sibling-models which control for unobserved variables shared within families. Results Children with ADHD (4.0%) had −1.11 standard deviations lower GPAs compared to children without ADHD. This difference remained substantial after adjusting for demographic factors (−0.87), comorbid mental disorders (−0.82), early school performance (−0.54), and when comparing full siblings (−0.60). The relative ADHD deficit was 22% larger for girls than for boys and 39% larger for children with highly educated parents than for children of parents without completed high school, but the absolute deficit was smaller. Conclusion The ADHD deficit in school performance was large and not easily attributable to other factors. Because the ADHD deficit was large in all school subjects, interventions should ideally address factors that affect school performance broadly, although targeting theoretical subjects specifically may be most effective given limited resources.

• Grøsland, Mari; Reme, Bjørn-Atle & Gjefsen, Hege Marie (2022). Impact of Omicron on sick leave across industries: A population-wide study. Scandinavian Journal of Public Health. ISSN 1403-4948. doi: 10.1177/14034948221123163. Full text in Research Archive
• Kravdal, Øystein; Wörn, Jonathan & Reme, Bjørn-Atle (2022). Mental health benefits of cohabitation and marriage: A longitudinal analysis of Norwegian register data. Population Studies. ISSN 0032-4728. doi: 10.1080/00324728.2022.2063933. Full text in Research Archive Show summary

  The aim is to examine how mental health is affected by cohabitation and marriage. Individual fixed-effects models are estimated from Norwegian register data containing information about consultations with a general practitioner because of mental health conditions in 2006–19. Mental health, as indicated by annual number of consultations, improves over several years before cohabitation. For those marrying their cohabiting partner, there is a weak further reduction in consultations until the wedding, but no decline afterwards. In other words, formalization of the union does not seem to confer additional mental health benefits. However, marriage may be considered a marker of favourable earlier development in mental health. In contrast, there is further improvement after direct marriage, as well as stronger improvement over the years just preceding direct marriage. Patterns are quite similar for women and men. Overall, the results suggest that the mental health benefits of cohabitation and marriage are similar.

• Cappelen, Alexander Wright; Mollerstrom, Johanna; Reme, Bjørn-Atle & Tungodden, Bertil (2022). A Meritocratic Origin of Egalitarian Behaviour. The Economic Journal. ISSN 0013-0133. 132(646), p. 2101–2117. doi: 10.1093/ej/ueac008. Full text in Research Archive
• Nordmo, Magnus; Kinge, Jonas Minet; Reme, Bjørn-Atle; Flatø, Martin; Suren, Pål & Wörn, Jonathan [Show all 9 contributors for this article] (2022). The educational burden of disease: a cohort study. The Lancet Public Health. ISSN 2468-2667. 7(6), p. e549–e556. doi: 10.1016/S2468-2667(22)00059-7. Full text in Research Archive Show summary

  Background Students with health disorders might be at risk of disengaging from education, which can reinforce socioeconomic inequalities in health. We aimed to evaluate the associations between 176 diseases and injuries and later school performance in Norwegian adolescents and to estimate the importance of each disorder using a novel measure for the educational burden of disease (EBoD). Methods We used diagnostic information from government-funded health services for all Norwegian inhabitants who were born between Jan 1, 1995, and Dec 31, 2002, were registered as living in Norway at age 11–16 years, and were participating in compulsory education. School performance was assessed as grade point average at the end of compulsory education at age 16 years. We used a linear regression of school performance on disease in a fixed-effects sibling comparison model (113 411 families). The association (regression coefficients) between disease and school performance was multiplied by disease prevalence to estimate the proportional EBoD among 467 412 individuals participating in compulsory education. Findings Overall, although most diseases were not meaningfully associated with grade point average (regression coefficients close to 0), some were strongly associated (eg, intellectual disability regression coefficients –1·2 for boys and –1·3 for girls). The total educational disease burden was slightly higher for girls (53·5%) than for boys (46·5%). Mental health disorders were associated with the largest educational burden among adolescents in Norway (total burden 44·6%; boys 24·6% vs girls 20·0%), of which hyperkinetic disorder contributed to 22·1% of the total burden (boys 14·6% vs girls 7·5%). Among somatic diseases, those with unknown causes and possibly mental causes were associated with the largest educational burden. Interpretation The EBoD concept could provide a simple metric to guide researchers and policy makers. Because mental health disorders form a large component of the educational burden, investment in mental health might be particularly important for improving educational outcomes in adolescents.

• Reme, Bjørn-Atle; Røhr, Helene Lie & Sæthre, Morten (2021). Inattention in Contract Markets: Evidence from a Consolidation of Options in Telecom. Management science. ISSN 0025-1909. 68(2), p. 1019–1038. doi: 10.1287/mnsc.2021.3975. Full text in Research Archive
• Kingsbury, Mila; Reme, Bjørn-Atle; Skogen, Jens Christoffer; Sivertsen, Børge; Øverland, Simon Nygaard & Cantor, Nathan [Show all 9 contributors for this article] (2020). Differential associations between types of social media use and university students' non-suicidal self-injury and suicidal behavior. Computers in Human Behavior. ISSN 0747-5632. 115. doi: 10.1016/j.chb.2020.106614. Full text in Research Archive Show summary

  Objective To examine differential associations between types of social media use and non-suicidal self-injury (NSSI) and suicidal behaviors. Methods Participants were N = 40,065 Norwegian college and university students, age 18–25, from the 2018 Students' Health and Wellbeing (SHoT) study. Students reported on their use of social media for seven specific activities, which we categorized into active and passive non-social use, passive social use, active public social, and active private social use. We also considered students' tendency for negative social comparisons on social media. Outcomes were past-year NSSI, NSSI ideation, suicidal ideation, and suicide attempt. Covariates were age, gender, total daily screen time and financial stress. Results Results of multiple logistic regression revealed differential associations between types of social media use and outcomes. Notably, active social private use (e.g., messaging friends) was associated with decreased odds of all outcomes, whereas active social public use (e.g., status updates) was associated with increased odds of NSSI ideation, NSSI, and suicide attempt. Social comparison was associated with increased odds of all outcomes. Conclusion Our results suggest that specific types of social media use are differentially associated with NSSI and suicidal outcomes among university students.

• Reme, Bjørn-Atle (2019). Competition in Markets with Quality Uncertainty and Network Effects. Review of Network Economics. 18(4), p. 205–242. doi: 10.1515/rne-2019-0061. Full text in Research Archive
• Reme, Bjørn-Atle & Sørgard, Lars (2016). Sequential negotiations: Substitutes versus complements. Journal of Institutional and Theoretical Economics. ISSN 0932-4569. 172(4), p. 639–644. doi: 10.1628/093245616X14605537965102. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2016). Leadership and incentives. Management science. ISSN 0025-1909. 62(7), p. 1944–1953. doi: 10.1287/mnsc.2015.2225. Full text in Research Archive Show summary

  We study how leader compensation affects public goods provision. We report from a lab experiment with four treatments, where the base treatment was a standard public goods game with simultaneous contribution decisions, and the three other treatments allowed participants to volunteer to be the leader in their group and make their contribution before the others. In the three leader treatments, we manipulated the level of compensation given to the leader. Our main finding is that a moderate compensation to the leader is beneficial; it increases the average contribution relative to both a situation where the leader is not compensated and a situation without a leader. A further increase in the leader compensation, however, is detrimental to public goods provision; it attracts more free riders and creates a social crowding-out effect. Finally, we report from a survey showing that the social crowding-out effect is also present in the population at large. We argue that the main findings of the paper are important in many real-life settings where we would like to use economic incentives to encourage people to lead by example.

• Mollerstrom, Johanna; Reme, Bjørn-Atle & Sørensen, Erik Øiolf (2015). Luck, choice and responsibility - An experimental study of fairness views. Journal of Public Economics. ISSN 0047-2727. 131, p. 33–40. doi: 10.1016/j.jpubeco.2015.08.010. Full text in Research Archive Show summary

  Weconduct laboratory experimentswhere third-party spectators have the opportunity to redistribute Resources between two agents, thereby eliminating inequality and offsetting the consequences of controllable and uncontrollable luck. Some spectators go to the limits and equalize either all or no inequalities, but many follow an interior allocation rule. These interior allocators regard an agent's choices as more important than the cause of her low income and do not always compensate bad uncontrollable luck. Instead, they condition such compensation on the agent's decision regarding controllable luck exposure, even though the two types of luck are independent. This allocation rule is previously unaccounted for by the fairness views in the literature. Moreover, its policy implications are fundamentally different in that it extends individual responsibility for choices made to also apply to areas that were not affected by these choices.

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• Reme, Bjørn-Atle (2026). Legemiddelindustriens produktivitetsparadoks. Full text in Research Archive Show summary

  Når legemiddelindustrien og produsenter av medisinsk teknologi fremmer produktivitetsargumentet, argumenterer de i realiteten for økte budsjetter til seg selv.

• Aas, Eline; Kinge, Jonas Minet; Burger, Emily Annika; Pedersen, Kine; Iversen, Tor & Godager, Geir [Show all 14 contributors for this article] (2025). Feil tallgrunnlag kan koste liv i helsetjenesten. Full text in Research Archive
• Wörn, Jonathan; Delalic, Lamija & Reme, Bjørn-Atle (2025). Blant barn som mister en forelder, er det flere som får utfordringer med skole og jobb senere. doi: https:/www.fhi.no/nyheter/2025/blant-barn-som-mister-en-forelder--er-det-flere-som-far-utfordringer-med-skole-og-jobb-senere/. Full text in Research Archive
• Wörn, Jonathan & Reme, Bjørn-Atle (2025). Sykdom i familien og innvirkninger på pårørende. Full text in Research Archive
• Fiva, Jon H.; Lind, Jo Thori; Reme, Bjørn-Atle & Øien, Henning (2025). Sick of Politics? Full text in Research Archive
• Fiva, Jon H.; Lind, Jo Thori; Reme, Bjørn-Atle & Øien, Henning (2025). Sick of Politics? Full text in Research Archive
• Fiva, Jon H.; Lind, Jo Thori; Reme, Bjørn-Atle & Øien, Henning (2025). Sick of Politics? Full text in Research Archive
• Fiva, Jon H.; Lind, Jo Thori; Reme, Bjørn-Atle & Øien, Henning (2025). Sick of Politics? CESifo Working Papers. ISSN 1617-9595. doi: https:/www.ifo.de/en/cesifo/publications/2025/working-paper/sick-politics?fbclid=IwY2xjawKQQiNleHRuA2FlbQIxMABicmlkETFJUzlYMkQyMlFXN0lIcm9ZAR6zJBfB-TsLGcfA5PQi8xqJLC6dYZcfNtDywqRjqO1eIwlP3YbPJwxdgpacfg_aem_3YCXf2A9Wuimg9o9TgkZTA. Full text in Research Archive
• Reme, Bjørn-Atle & Wörn, Jonathan (2024). Parental death during childhood and the likelihood of NEET - status as young adult. Full text in Research Archive
• Reme, Bjørn-Atle; Rotevatn, Torill Alise & Wörn, Jonathan (2024). Sickness in the family: A register-based study on disease clustering. Full text in Research Archive
• Reme, Bjørn-Atle & Wörn, Jonathan (2024). Parental death in childhood: long-term impacts on probability of NEET-status across socioeconomic status. Full text in Research Archive
• Torvik, Fartein Ask; Flatø, Martin; Reme, Bjørn-Atle & Stoltenberg, Camilla (2023). Derfor forsker FHI på gutter i skolen. p. 30–30. Full text in Research Archive
• Beck, Kathryn Christine; Reme, Bjørn-Atle; Røhr, Helene Lie; Flatø, Martin & Stoltenberg, Camilla (2023). Nederlag i skolen går hardest ut over guttene. Full text in Research Archive
• Wörn, Jonathan & Reme, Bjørn-Atle (2023). Parental death during childhood: long-run effects on labor market participation. Full text in Research Archive
• Flatø, Martin; Reme, Bjørn-Atle; Stoltenberg, Camilla & Torvik, Fartein Ask (2023). Nyanser i gutteforskningen. Morgenbladet. ISSN 0805-3847. Full text in Research Archive
• Reme, Bjørn-Atle (2023). Inntekt og helse. Magma forskning og viten. ISSN 1500-0788. doi: 10.23865/magma.v26.1430. Full text in Research Archive
• Torvik, Fartein Ask; Stoltenberg, Camilla; Flatø, Martin; Sunde, Hans Fredrik; Reisel, Liza & Reme, Bjørn-Atle [Show all 7 contributors for this article] (2023). Gutter, skole og utenforskap. Full text in Research Archive
• Christine, Beck Kathryn; Røhr, Helene Lie; Reme, Bjørn-Atle & Flatø, Martin (2022). Distressing Testing: A Propensity Score Analysis of High Stakes Exam Failure and Mental Health. Full text in Research Archive
• Reme, Bjørn-Atle; Wörn, Jonathan; Godøy, Anna Aasen; Hart, Rannveig Kaldager; Bratsberg, Bernt Magne & Raaum, Oddbjørn (2021). Arbeidsløshet og helse. In Tvedten, Hilde Marie; Vikum, Eirik Frønæs; Holtermann, Merete Kile & Larsen, Vilde Bergstad (Ed.), Folkehelserapportens temautgave 2021. Folkehelsen etter covid-19. Pandemiens konsekvenser for ulike grupper i befolkningen. Folkehelseinstituttet. ISSN 9788284062440. p. 29–36. Full text in Research Archive Show summary

  Som en følge av tiltakene for å begrense spredningen av SARSCoV-2 har store deler av befolkningen opplevd endringer i arbeidssituasjonen. Mange har i tillegg blitt permittert og andre har mistet jobben. Har det fått konsekvenser for helsen i befolkningen?

• Lind, Jo Thori; Bjelland, Johannes; Kotsadam, Andreas; Reme, Bjørn-Atle & Sundsøy, Pål Roe (2018). Quantifying socio-economic segregation in in large-scale social networks using mobile phone metadata. Full text in Research Archive
• Lind, Jo Thori; Bjelland, Johannes; Kotsadam, Andreas; Reme, Bjørn-Atle & Sundsøy, Pål Roe (2018). Quantifying socio-economic segregation in in large-scale social networks using mobile phone metadata (. Full text in Research Archive
• Sæthre, Morten; Reme, Bjørn-Atle & Røhr, Helene Lie (2017). The Poking Effect: Price Changes, Information and Inertia in the Market for Mobile Subscription. Full text in Research Archive Show summary

  We study consumer inertia in the mobile subscription market, focusing on the decision of whether or not to switch to a competing provider. To identify the effect of price changes on the propensity to switch, we exploit tariff changes faced by close to 270,000 consumers of a large telecom provider. We document that the propensity to switch increases for consumers whose costs increase under the new tariffs. However, consumers whose costs decrease are also more likely to switch. In addition, we find that the propensity to switch is highest when consumers are informed of the upcoming change – one month prior to the tariff changes – not when the change is implemented. These results indicate the existence of choice inertia. To separate the effect of consumers’ attention from their reaction to the actual price change, we estimate a structural model of consumer choice of subscription with inattention. We find that when consumers are poked with the information of the upcoming tariff change, their attention more than doubles. This leads many consumers to switch provider earlier than they otherwise would, explaining why they leave even though their terms within their current company improves.

• Reme, Bjørn-Atle (2016). Performance,luck and inequality: an experimental investigation of fairness preferences under uncertainty. Full text in Research Archive
• Reme, Bjørn-Atle (2016). Customer poking and churn — an empirical study. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2013). Pay Less - Get Better Leaders. Full text in Research Archive
• Mollerstrom, Johanna & Reme, Bjørn-Atle (2013). Luck, Choice and Responsibility - An Empirical Investigation of Fairness Views. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle & Falch, Ranveig (2013). Schrödingers katt. [TV]. NRK. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2012). Leading by example: The effect of leadership compensation in a public goods experiment. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2012). Leading by example: The effect of leadership compensation in a public goods experiment. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2012). Kompensasjon av ledere og eksempelets makt. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2012). Leading by example: The effect of leadership compensation in a public goods experiment. Full text in Research Archive
• Mollerstrom, Johanna & Reme, Bjørn-Atle (2012). Understanding the democracy effect – an experimental approach. Full text in Research Archive
• Mollerstrom, Johanna & Reme, Bjørn-Atle (2012). Choice, luck, and responsibility. Full text in Research Archive
• Mollerstrom, Johanna & Reme, Bjørn-Atle (2012). Luck, Choice and Responsibility - An Experimental Study of Fairness Views. Full text in Research Archive
• Mollerstrom, Johanna & Reme, Bjørn-Atle (2012). Luck, Choice and Responsibility - An Experimental Study of Fairness Views. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2011). Leading by example - evidence from a public goods experiment. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2011). Leading by example: The effect of leadership compensation in a public goods experiment. Full text in Research Archive
• Andersen, Maria Lyster; Reme, Bjørn-Atle & Wörn, Jonathan (2025). Thematic Issue of the Public Health Report 2025 – Mental Health of Children and Adolescents; Chapter 5: Social Inequalities in Mental Health Among Children and Adolescents. Folkehelseinstituttet. Full text in Research Archive Show summary

  Barn av foreldre med lav inntekt eller utdanning har økt risiko for å oppleve psykiske helseproblemer. Vi ser størst sosial ulikhet hos barn med ADHD, en diagnose som er vanlig i ung alder og blant gutter.

• Bergsaker, Marianne A Riise; Bratsberg, Bernt; Daae, Anita Odveig; Flottorp, Signe Agnes; Forland, Frode & Furuseth, Ellen [Show all 31 contributors for this article] (2021). Folkehelserapportens temautgave 2021. Folkehelsen etter covid-19. Pandemiens konsekvenser for ulike grupper i befolkningen. Folkehelseinstituttet. ISSN 9788284062440. Full text in Research Archive
• Cappelen, Alexander Wright; Mollerstrom, Johanna; Reme, Bjørn-Atle & Tungodden, Bertil (2019). A Meritocratic Origin of Egalitarian Behavior. Institutt for samfunnsøkonomi. Full text in Research Archive Show summary

  The meritocratic fairness ideal implies that inequalities in earnings are regarded as fair only when they reflect differences in performance. Consequently, implementation of the meritocratic fairness ideal requires complete information about individual performances, but in practice, such information is often not available. We study redistributive behavior in the common, but previously understudied, situation where there is uncertainty about whether inequality is reflecting performance or luck. We show theoretically that meritocrats in such situations can become very egalitarian in their behavior, and that the degree to which this happens depends on how they trade off the probability of making mistakes and the size of mistakes that they risk making when redistributing under uncertainty. Our laboratory experiments show, in line with our model, that uncertainty about the source of inequality provides a strong egalitarian pull on the behavior of meritocrats. In addition, the external validity of our framework, and the results from the laboratory, are supported in two general population surveys conducted in the United States and Norway.

• Reme, Bjørn-Atle; Røhr, Helene Lie & Sæthre, Morten (2018). The Poking Effect: Price Changes, Information, and Inertia in the Market for Mobile Subscriptions. Norges Handelshøyskole. Full text in Research Archive Show summary

  We study consumer inertia in the mobile subscription market, focusing on the decision of whether to switch to a competing provider. To identify the extent of inertia, we exploit price changes faced by 270,000 consumers of a large telecom provider. We document that the propensity to switch provider after the price change increases among consumers whose costs decrease with the new prices. Furthermore, we find that the increase is largest right after consumers are informed of the upcoming change—during the two months prior to the tariff change—as opposed to when the price change is implemented. From these findings, we infer what we call a poking effect; the information of an upcoming price change causes consumers to engage in searches for alternative offers, leading to increased switching.We supplement the analysis with a survey and find indications that the poking effect is due to consumer inattention. To separate the effect on attention from the reaction to the actual price change, we estimate a model of consumer choice with limited attention. We find that when consumers are poked, it increases the share of consumers becoming attentive to competing offers. This leads many consumers to switch providers earlier than they would otherwise, explaining why they leave even though their terms with their current company improve.

• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2014). Leadership and incentives. Institutt for samfunnsøkonomi, Norges Handelshøyskole. Full text in Research Archive
• Cappelen, Alexander Wright; Reme, Bjørn-Atle; Sørensen, Erik Øiolf & Tungodden, Bertil (2013). Leadership and incentives. Department of Economics, Norwegian School of Economics. Full text in Research Archive Show summary

  We study whether compensating people who volunteer to be leaders in a public goods game creates a social crowding-out effect of moral motivation among the others in the group. We report from an experiment with four treatments, where the base treatment is a standard public goods game with simultaneous contribution decisions, while the three other treatments allowed participants to volunteer to be an “early contributor” in their group. In the three leader treatments, we manipulate the level of compensation given to the leader. Our main finding is that a moderate compensation to the leader is highly beneficial, it increases the average contribution by almost 80%. A high compensation, however, is detrimental to public good provision. We show that paying a moderate compensation to the leaders strikes the right balance between the need for recruiting leaders and avoiding a large social crowding-out effect. We argue that the main findings of the paper are important in many real life settings where we would like to use economic incentives to encourage people to lead by example.

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