Tingbjerg Changing Diabetes: experiencing and navigating complexity in a community-based health promotion initiative in a disadvantaged neighbourhood in Copenhagen, Denmark.

As a response to the complexity of reducing health inequity there has been a rise in community-based health promotion interventions adhering to the principles of complexity thinking. Such interventions often work with adaptive practice and constitute themselves in complex webs of collaborations between multiple stakeholders. However, few efforts have been made to articulate how complexity can be navigated and addressed by stakeholders in practice. This study explores how partners experience and navigate complexity in the partnership behind Tingbjerg Changing Diabetes (TCD), a community-based intervention addressing health and social development in the disadvantaged neighborhood of Tingbjerg in urban Copenhagen. The study provides important insights on the role of context and how it contributes complexity in community-based health promotion.The study is based on 18 months of ethnographic fieldwork in the local community including participant observations and 9 in-depth interviews with key partner representatives. Findings show that complexity in TCD can be characterized by unpredictability in actions and outcomes, undefined purpose and direction, and differing organizational logics. Factors that support partners' navigation in complexity include connectivity, embracing a flexible intervention framework, autonomy, and quick responsiveness. The study showcases the interdependency between the intervention and the context of the disadvantaged neighborhood of Tingbjerg and encourages stakeholders and researchers to embrace the messiness of complexity, and to pay attention to ways through which messiness and unpredictability can be handled.

Patient Knowledge and Trust in Health Care. A Theoretical Discussion on the Relationship Between Patients' Knowledge and Their Trust in Health Care Personnel in High Modernity.

In this paper we aim to discuss a theoretical explanation for the positive relationship between patients' knowledge and their trust in healthcare personnel. Our approach is based on John Dewey's notion of continuity. This notion entails that the individual's experiences are interpreted as interrelated to each other, and that knowledge is related to future experience, not merely a record of the past. Furthermore, we apply Niklas Luhmann's theory on trust as a way of reducing complexity and enabling action. Anthony Giddens' description and analysis of the high modern society provides a frame for discussing the preconditions for patient-healthcare personnel interaction. High modernity is dominated by expert systems and demands trust in these. We conclude that patient knowledge and trust in healthcare personnel is related because both knowledge and trust are future- and action-oriented concepts. The traits of high modernity provides opportunities and challenges as the personnel can and must perform discretion. This discretion must be made in a context where knowledge is considered uncertain and preliminary.

Health educational background as a predictor of non-participation in national colorectal cancer screening: A cross-sectional population study among 886,088 invited Danes.

Health information knowledge may affect attitude toward colorectal cancer screening, but the participation of health educated citizens are unknown. Therefore, we investigated non-participation in a sample of 886,088 invited participants, based on educational length, type, and level. Logistic regression analyses were conducted to estimate the odds of non-participation in Danish men and women based on educational type and length. Models were adjusted for age, income, marital status and immigration status. Information was derived from National registers. Men with long educational length level had increased odds of non-participation if their education was within the field of medicine/medical science (OR 1.87) or belonged to other long health educations, but not in nursing and health care, compared to other long educations after full model adjustment. Women with long educational length level had increased odds of non-participation if they were educated in the field of medicine/medical science (OR 1.47), whereas they had decreased odds in the fields of nursing and health care and other long health educations, compared to other long educations after full model adjustment. Men within short educational length level did not have different odds of nonparticipation, after full model adjustments, whereas women within short health educations were at increased odds in the youngest age group and at decreased odds in the eldest age group. Having an education in the field of medicine/medical science is associated with non-participation in colorectal cancer screening in Denmark 2014-2015. Opposite, an educational background in nursing and health care increased participation in women, but not in men.

Perceived stress as a risk factor of unemployment: a register-based cohort study.

BACKGROUND: Although unemployment and high levels of perceived stress have been associated in cross-sectional studies, the direction of causation is unknown. We prospectively examined if high levels of perceived everyday life stress increased the risk of subsequent unemployment and further if differences existed between socioeconomic status-groups. METHODS: We included 9335 18-64-year-old employed respondents of a health survey (North Denmark Health Profile 2010) in which Cohen's Perceived Stress Scale was used to assess the level of perceived stress. Data were linked individually to national administrative registers. Cox proportional hazards model was used to investigate the association between perceived stress quintiles and risk of unemployment during 98 weeks of follow-up. Analyses were further performed in subgroups defined by education and income. RESULTS: In total, 224 people (10.4%) of the high stress group became unemployed during follow-up, which was higher than the lower stress groups. After adjusting for gender, age, education and income, the risk of unemployment was 1.64 (95% CI: 1.28;2.11) in the high stress group compared to the low stress group. After adjusting for gender and age, a similar trend was observed across different education levels and among the lower income groups, but no higher risk of unemployment due to perceived stress was found among the higher income groups. However, there was no statistically significant interaction between perceived stress and income level (p = 0.841) or perceived stress and education level (p = 0.587). CONCLUSION: Perceived everyday life stress nearly doubled the risk of subsequent unemployment in a working population. No statistically significant interactions between SES and perceived stress were found. This indicates that stress prevention among the working population should not solely focus on stress in the workplace but also include stress from everyday life.

The indirect and direct pathways between physical fitness and academic achievement on commencement in post-compulsory education in a historical cohort of Danish school youth.

BACKGROUND: Some studies have found positive associations between physical fitness and academic achievements. Pupils' academic achievements should indicate scholastic abilities to commence a post-compulsory education. However, the effect magnitude of physical fitness and academic achievements on commencement in post-compulsory education is unknown. We examined the pathways between physical fitness and academic achievement on pupils' commencement in post-compulsory education. METHODS: This historical cohort study followed 530 girls and 554 boys from the Danish municipality of Aalborg in the period 2008-2014, 13 to 15 years old in 2010. Physical fitness was assessed through a watt-max cycle ergometer test represented as VO2max (mL·kg-1·min-1). Academic achievement, commencement status and information on covariates were obtained from Danish nationwide registers. Causal inference based mediation analysis was used to investigate the indirect and direct pathways by separating the total effect of physical fitness on post-compulsory education commencement. RESULTS: Adjusting for sex, age, ethnicity and socioeconomic status, the overall mediation analysis showed an odds ratio (OR) of 1.87 (95% confidence interval (CI): 1.30; 2.73) for the total effect, corresponding to an increase in odds of post-compulsory education commencement when the physical fitness was increased by 10 units of VO2max. The separated total effect showed a natural direct OR of 1.36 (95% CI: 0.93; 1.98) and a natural indirect (i.e., through academic achievement) OR of 1.37 (95% CI: 1.20; 1.57). Thus, 51% (95% CI: 27%; 122%) of the effect of physical fitness on post-compulsory education commencement was mediated through academic achievement. CONCLUSION: Physical fitness had a positive effect on post-compulsory education commencement. A substantial part of this effect was mediated through academic achievement.

Socioeconomic inequality and mortality--a regional Danish cohort study.

BACKGROUND: Socioeconomic inequalities in mortality pose a serious impediment to enhance public health even in highly developed welfare states. This study aimed to improve the understanding of socioeconomic disparities in all-cause mortality by using a comprehensive approach including a range of behavioural, psychological, material and social determinants in the analysis. METHODS: Data from The North Denmark Region Health Survey 2007 among residents in Northern Jutland, Denmark, were linked with data from nationwide administrative registries to obtain information on death in a 5.8-year follow-up period (1(st) February 2007- 31(st) December 2012). Socioeconomic position was assessed using educational status as a proxy. The study population was assigned to one of five groups according to highest achieved educational level. The sample size was 8,837 after participants with missing values or aged below 30 years were excluded. Cox regression models were used to assess the risk of death from all causes according to educational level, with a step-wise inclusion of explanatory covariates. RESULTS: Participants' mean age at baseline was 54.1 years (SD 12.6); 3,999 were men (45.3%). In the follow-up period, 395 died (4.5%). With adjustment for age and gender, the risk of all-cause mortality was significantly higher in the two least-educated levels (HR = 1.5, 95%, CI = 1.2-1.8 and HR = 3.7, 95% CI = 2.4-5.9, respectively) compared to the middle educational level. After adjustment for the effect of subjective and objective health, similar results were obtained (HR = 1.4, 95% CI = 1.1-1.7 and HR = 3.5, 95% CI = 2.0-6.3, respectively). Further adjustment for the effect of behavioural, psychological, material and social determinants also failed to eliminate inequalities found among groups, the risk remaining significantly higher for the least educated levels (HR = 1.4, 95% CI = 1.1-1.9 and HR = 4.0, 95% CI = 2.3-6.8, respectively). In comparison with the middle level, the two highest educated levels remained statistically insignificant throughout the entire analysis. CONCLUSION: Socioeconomic inequality influenced mortality substantially even when adjusted for a range of determinants that might explain the association. Further studies are needed to understand this important relationship.

Individual social capital and survival: a population study with 5-year follow-up.

BACKGROUND: The concept of social capital has received increasing attention as a determinant of population survival, but its significance is uncertain. We examined the importance of social capital on survival in a population study while focusing on gender differences. METHODS: We used data from a Danish regional health survey with a five-year follow-up period, 2007-2012 (n = 9288, 53.5% men, 46.5% women). We investigated the association between social capital and all-cause mortality, performing separate analyses on a composite measure as well as four specific dimensions of social capital while controlling for covariates. Analyses were performed with Cox proportional hazard models by which hazard ratios and 95% confidence intervals were calculated. RESULTS: For women, higher levels of social capital were associated with lower all-cause mortality regardless of age, socioeconomic status, health, and health behaviour (HR = 0.586, 95% CI = 0.421-0.816) while no such association was found for men (HR = 0.949, 95% CI = 0.816-1.104). Analysing the specific dimensions of social capital, higher levels of trust and social network were significantly associated with lower all-cause mortality in women (HR = 0.827, 95% CI = 0.750-0.913 and HR = 0.832, 95% CI = 0.729-0.949, respectively). For men, strong social networks were associated with a higher risk of all-cause mortality (HR = 1.132, 95% CI = 1.017-1.260). Civic engagement had a similar effect for both men (HR = 0.848, 95% CI = 0.722-0.997) and women (HR = 0.848, 95% CI = 0.630-1.140). CONCLUSIONS: We found differential effects of social capital in men compared to women. The predictive effects on all-cause mortality of four specific dimensions of social capital varied. Gender stratified analysis and the use of multiple indicators to measure social capital are thus warranted in future research.

"I think we should wait and see": A qualitative study of call-takers' decision-making in consultations with patients suffering unrecognized myocardial infarction.

OBJECTIVES: Call-takers face a complex situation when assessing medical problems in emergency medical services calls. Patients with myocardial infarction experiencing atypical symptoms risk misinterpretation. We examined development in call-takers' decision-making process in telephone consultations with patients having imminent myocardial infarction. METHODS: Recording of 38 calls among 19 patients (two per patient) who contacted Copenhagen Emergency Medical Services (Denmark) at least twice within one week before myocardial infarction diagnosis. The penultimate and last call were compared using qualitative content analysis. RESULTS: Call-takers' assessment of the condition changed from unclear symptom picture and dismissal of heart disease in penultimate call to severe condition, not heart-related, and possible heart disease in last call. Call-takers recommended watchful waiting in the penultimate call. Both calls involved response negotiation, while caution regarding misinterpretation was only seen in the penultimate call. CONCLUSION: Call-takers used different decision-making approaches when the caller's symptom descriptions appeared unclear and not corresponding with the medical understanding of severe conditions. Call-takers did not negotiate the condition's assessment but engaged in discussions about the response choice. PRACTICE IMPLICATIONS: A protocol to negotiate response choice with callers having unclear clinical conditions should be developed. Clarifying watchful waiting as a recommendation may assist call-takers' decision-making.

Spaces of participation: Exploring the characteristics of conducive environments for citizen participation in a community-based health promotion initiative in a disadvantaged neighborhood.

Research has shown that community participation in health programmes is vital to ensure positive health outcomes and sustainable solutions. This is often challenged by difficulties to engage socially disadvantaged population groups. Through ethnographic fieldwork in a community initiative in a disadvantaged neighbourhood in Copenhagen, Denmark, we explored which factors contributed to a conducive environment for participation. Data material consists of observation notes taken during fieldwork in a community hub from January 2020 until August 2021 and 19 semi-structured interviews with professional stakeholders and participants. We applied the analytical concept of space to elucidate how the organizational, social, and physical environments played important roles in ensuring possibilities for participation. We termed these environments Spaces of Participation. Our results highlight the importance of ensuring spaces that are flexible, informal, and responsive when engaging those who are hard to reach.

Our Healthy Community Conceptual Framework and Intervention Model for Health Promotion and Disease Prevention in Municipalities.

This paper introduces the conceptual framework and intervention model of Our Healthy Community (OHC), a new, coordinated, and integrated approach towards health promotion and disease prevention in municipalities. The model is inspired by systems-based approaches and employs a supersetting approach for engaging stakeholders across sectors in the development and implementation of interventions to increase health and well-being among citizens. The conceptual model includes a combination of a bottom-up approach emphasizing involvement of citizens and other community-based stakeholders combined with a top-down approach emphasizing political, legal, administrative, and technical support from a variety of councils and departments in local municipality government. The model operates bidirectionally: (1) by pushing political and administrative processes to promote the establishment of conducive structural environments for making healthy choices, and (2) by involving citizens and professional stakeholders at all levels in co-creating processes of shaping their own community and municipality. An operational intervention model was further developed by the OHC project while working with the OHC in two Danish municipalities. The operational intervention model of OHC comprises three main phases and key actions to be implemented at the levels of local government and community: (1) Local government: Situational analysis, dialogue, and political priorities; (2) Community: Thematic co-creation among professional stakeholders; and (3) Target area: Intervention development and implementation. The OHC model will provide municipalities with new tools to improve the citizens' health and well-being with available resources. Health promotion and disease prevention interventions are developed, implemented, and anchored in the local community by citizens and local stakeholders at municipal and local community levels using collaboration and partnerships as leverage points.

"I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction.

OBJECTIVES: Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers. METHODS: Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied. RESULTS: Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see". CONCLUSION: Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response. PRACTICE IMPLICATIONS: Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

"Like a rainy weather inside of me": Qualitative content analysis of telephone consultations concerning back pain preceding out-of-hospital cardiac arrest.

INTRODUCTION: Cardiac arrest patients presenting with back pain are at risk of not receiving the appropriate help when calling emergency medical services. In telephone consultations regarding patients with back pain preceding an out-of-hospital cardiac arrest, we investigated how communication between caller and call-taker influenced the call-taker's interpretation of back pain descriptions and decision-making about choice of response. METHOD: The study was conducted using 20 recorded phone calls from 17 patients who contacted the Copenhagen Emergency Medical Services (Denmark) reporting back pain up to 24 hours before an out-of-hospital cardiac arrest. Qualitative content analysis was applied. RESULTS: Two main categories emerged: (1) reasons, including subcategories: reported conditions, descriptions of conditions, patient's interpretation of condition and patient's own remedial actions; and (2) considerations, including subcategories: assessment of the severity, call-taker's interpretation of the condition, arguments for chosen response and conditions not facilitating further communication by the call-taker. CONCLUSION: In telephone consultations regarding patients with back pain preceding an out-of-hospital cardiac arrest the communication was influenced by the communicative preconditions of the call-taker. Communication in consultations where ambulances were not dispatched was characterized by complex descriptions of symptoms not easily fitting into the health system's interpretations of conditions warranting an urgent response.

Tingbjerg Changing Diabetes: a protocol for a long-term Supersetting initiative to promote health and prevent type 2 diabetes among people living in an ethnically and socioeconomically diverse neighbourhood in Copenhagen, Denmark.

INTRODUCTION: Type 2 diabetes is an escalating public health problem closely related to socioeconomic position. There is increased risk of type 2 diabetes in disadvantaged neighbourhoods where education, occupation and income levels are low. Meanwhile, studies show positive health outcomes of participatory community interventions pointing towards the need for increased health promotion and prevention of type 2 diabetes in local communities. This study protocol describes Tingbjerg Changing Diabetes (TCD), a community-based health promotion and type 2 diabetes prevention initiative in Tingbjerg, a disadvantaged neighbourhood in Copenhagen, Denmark. METHODS AND ANALYSIS: TCD is a long-term, complex intervention, implemented in three phases from 2014 to 2032, focusing on partnership formation (phase 1, 2014-2019), developing and implementing action for health (phase 2, 2019-2030) and diffusion of knowledge (phase 3, 2022-2032). The Supersetting principles act as guidelines for development and implementation of all intervention activities of TCD, involving several population groups in a variety of everyday life settings. The implementation of TCD draws on Community Action Research design and methodologies. TCD's evaluation and research strategy is interdisciplinary, pragmatic and multimethod, unfolding at three levels of operation: (A) evaluating activities, (B) researching cross-cutting topics, and (C) researching methods and approaches. ETHICS AND DISSEMINATION: TCD has been approved by the Danish Data Protection Agency. Accordingly, the initiative is carried out in adherence to rules and regulations of the Danish Data Protection Agency. As data contain no personal identifiable or sensitive data, no clearance from the Danish National Ethical Review Board can be obtained according to Danish regulations. Citizen, local agents and stakeholders are engaged in the design and execution of TCD to ensure usefulness, reflexive interpretation of data, relevance and iterative progression of interventions. Results will be published in international peer-reviewed scientific journals, presented at conferences and through public media including TCD home page, podcasts and videos.

The Mediating Effect of Pupils' Physical Fitness on the Relationship Between Family Socioeconomic Status and Academic Achievement in a Danish School Cohort.

INTRODUCTION: Family socioeconomic status influences pupils' academic achievements, and studies have established positive associations between physical fitness and academic achievements. However, whether physical fitness mediates the relationship remains unknown. OBJECTIVE: We investigated if pupils' physical fitness mediates the pathway between family socioeconomic status and academic achievement using causal inference-based mediation analysis. METHODS: This study included 527 girls and 552 boys between 13 and 15 years of age from the Danish municipality of Aalborg. Physical fitness was measured through VO2max tests in 2010 and demographic data were obtained from nationwide registers. Family socioeconomic status was classified into four levels ranging from 1 to 4, where level 1 represents the lowest and level 4 the highest based on either family income or education. RESULTS: Controlling for sex, ethnicity, age, and parents' cohabitation status, all total effects display higher academic achievement with increased family socioeconomic status. Splitting the effects, the direct effects reveal the existence of other pathways not involving physical fitness. The indirect effects established physical fitness as a mediator showing that pupils from family socioeconomic status levels one, three, and four changes grade by - 0.13 [95% confidence interval (CI) - 0.26, - 0.01], 0.07 (95% CI 0.00, 0.14), and 0.24 (95% CI 0.14, 0.34), respectively, compared to socioeconomic status level two. The corresponding proportions mediated are 18% (95% CI 1, 57), 6% (95 CI 0, 13), and 12% (95% CI 7, 18) when family socioeconomic status is based on education. Classifying family socioeconomic status on income, pupils from family socioeconomic status levels one, three, and four show grade changes of - 0.07 (95% CI - 0.16, 0.02), 0.22 (95% CI 0.13, 0.32), and 0.26 (95% CI 0.15, 0.37), respectively, compared to socioeconomic status level two. The corresponding proportions mediated are 12% (95% CI - 6, 41), 30% (95% CI 16, 54), and 20% (95% CI 12, 32). CONCLUSION: In conclusion, pupils' physical fitness partially mediated the pathway between family socioeconomic status and academic achievement.

Association Between Physical Fitness and Academic Achievement in a Cohort of Danish School Pupils.

BACKGROUND: Time spent on physical activity in elementary school has been altered to improve core academics. However, little is known about the relationship between physical fitness and academic achievement. We examined the association between physical fitness and academic achievement and investigated the influence of parental socioeconomic status and ethnicity. METHODS: Participants were 542 girls and 577 boys aged 13 to 15 residing in the Danish municipality of Aalborg. A watt-max cycle ergometer test was completed to evaluate physical fitness as represented by VO2 max (mL·kg(-1) ·min(-1) ). Academic achievement was measured 1 school year later through a series of mandatory exams within the humanities, sciences, and all obligatory defined exams. Parental income and education were drawn from nationwide registers. Linear regression models were used to investigate the association. RESULTS: Adjusting for ethnicity and parental socioeconomic status, the effect size of the humanities was 0.08 grad/VO2 max (95% Cl: 0.05 to 0.11) for girls and 0.06 grad/VO2 max (95% Cl:0.03 to 0.08) for boys. The effect size of the sciences was 0.09 grad/VO2 max (95% Cl:0.05 to 0.13) for girls and 0.06 grad/VO2 max (95% Cl:0.03 to 0.09) for boys. The effect size of the defined exams was 0.09 grad/VO2 max (95% Cl:0.06 to 0.11) for girls and 0.06 grad/VO2 max (95% Cl:0.03 to 0.08) for boys. CONCLUSION: We found a statistically significant positive association between physical fitness and academic achievement after adjusting for ethnicity and parental socioeconomic status.