Differences in postpartum mental healthcare among women with identified needs: The role of migration status.

AIMS: The aim of this study was to examine the association between women's migrant status (majority, immigrant, descendant) and use of postpartum mental healthcare and investigate whether migration characteristics are associated with mental healthcare use. METHODS: Retrospective cohort study. We included all mothers of children born between 2002 and 2018 in 34 municipalities of Denmark who had an identified mental health need as clinically assessed by a child health visitor (CHV) or by a score of 11 or more on the Edinburgh Postpartum Depression Scale (EPDS). Women were followed until the first mental healthcare received 2 years' postpartum, death or emigration. Using Cox regression models, we estimated the time to mental healthcare by migrant status and explored the role of migration characteristics. RESULTS: A total of 29% of women (n = 45,573) had a mental health need identified by the CHV, and 7% (n = 4968) had an EPDS ⩾ 11. Immigrants accounted for 19.5%, and descendants for 4.7% of the sample. Immigrants were at lower risk of using mental healthcare than the majority group (CHV: hazard ratio adjusted (HRa) 0.75 (0.70-0.79), EPDS: HRa 0.67 (0.58-0.78)), as were descendants (CHV: HRa 0.77 (0.70-0.86), EPDS: HRa 0.69 (0.55-0.88)). Among migrants, those not refugees, newly arrived, whose partners were immigrants or descendants, and those originally from Africa showed a lower risk of using postpartum mental healthcare. CONCLUSIONS: Our findings emphasize the need to strengthen access to mental healthcare for immigrants and descendants experiencing postpartum mental health concerns and consider migration characteristics as indicators of potential inequalities in access to maternal mental healthcare.

Motor development problems in infancy predict mental disorders in childhood: a longitudinal cohort study.

The purpose of this study is to examine whether motor development problems in infancy predicted mental disorders later in childhood, taking a wide array of potential confounding variables into consideration. This longitudinal study included an unselected study population of 33238 newborn children from the Copenhagen area, Denmark. Data on the predictor variable, motor development problems at 8-10 months of age, were obtained from the community health nurses' systematic evaluation of the child's motor development during a home visit and stored in the Child Health Database. Data on outcome, diagnosed mental disorders before the age of 8 years, were obtained from the Danish National Patient Register. Potential confounding variables were obtained from the Child Health Database, the National Birth Register and the Civil Registration System. The prevalence of motor development problems at 8-10 months of age was 19.3%; the incidence of any diagnosed mental disorder from 11 months of age to the 8th birthday was 4.0%. Motor development problems were associated with an increased risk of being diagnosed with a mental disorder before the 8th birthday, adjusted odds ratio (AOR) 1.47 (1.29-1.67). Motor development problems were associated with later neurodevelopmental disorders, AOR 1.77 (1.52-2.06), in particular autism spectrum disorders, AOR 1.63 (1.31-2.03), hyperactivity/attention deficit disorders, AOR 1.29 (1.03-1.61) and disorders of intellectual disability, AOR 3.28 (2.39-4.49). CONCLUSION: Motor development problems as early at 8-10 months of age were predictive of neurodevelopmental disorders before the 8th birthday. The findings call for clinical attention and more research on preventive potentials in the community child health care. WHAT IS KNOWN: • Children with ASD, ADHD and ID have high prevalence of early motor development problems. WHAT IS NEW: • Motor development problems in infancy predicted neurodevelopmental disorders before the 8th birthday. • This observation could improve early identification and prevention of mental health problems in childhood.

Effect of the multicomponent healthy high school intervention on meal frequency and eating habits among high school students in Denmark: a cluster randomized controlled trial.

BACKGROUND: Previous studies have shown that multicomponent interventions may improve meal frequency and eating habits in children, but evidence among young people is limited. This study evaluated the effect of the Healthy High School (HHS) intervention on daily intake of breakfast, lunch, water, fruit, and vegetables at 9-month follow-up. METHODS: The study included first-year students (≈16 years) attending high school in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (operating as usual) (N = 15). The intervention was designed to promote well-being (primary outcome) by focusing on healthy habits including meals, stress prevention, and strong peer relations. It included a curriculum, structural and organisational initiatives, a workshop, and a smartphone application. Students completed self-administered online questionnaires at the beginning of the school year and nine months later. To account for clustering of data, we used multilevel logistic regression analyses to estimate odds ratios (OR). We applied an intention-to-treat approach with multiple imputations of missing data. RESULTS: At baseline 4577 of 5201 students answered the questionnaire and 4512 at follow-up. In both groups the proportion of students eating breakfast decreased from approximately 50% to 40% from baseline to follow-up, and lunch frequency decreased from approximately 50% to 47%. Daily water intake, intake of fresh fruit and intake of vegetables remained unchanged from baseline to follow-up. There were no significant between group differences on any of the outcomes at first follow-up: breakfast: OR = 0.85 (95% CI: 0.65;1.10), lunch: OR = 0.96 (95% CI: 0.75;1.22), water intake: OR = 1.14 (95% CI: 0.92;1.40), intake of fresh fruit: (OR = 1.07, 95% CI: 0.84;1.37), vegetables: (OR = 1.01, 95% CI: 0.77;1.33). CONCLUSION: No evidence of an effect of the HHS intervention was found for any of the outcomes. Future studies are warranted to explore how health promoting interventions can be integrated in further education to support educational goals. Moreover, how to fit interventions to the lives and wishes of young people, by also including systems outside of the school setting. TRIAL REGISTRATION: ISRCTN, ISRCTN43284296 . Registered 28 April 2017 - retrospectively registered.

The Infant Health Study - Promoting mental health and healthy weight through sensitive parenting to infants with cognitive, emotional, and regulatory vulnerabilities: protocol for a stepped-wedge cluster-randomized trial and a process evaluation within municipality settings.

BACKGROUND: Child mental health problems are a major public health concern associated with poor mental and physical health later in development. The study evaluates a new community-based intervention to promote sensitive parenting and reduce enduring mental health problems and unhealthy weight among vulnerable infants aged 9-24 months. METHODS: We use a step-wedge cluster randomized controlled trial design conducted within a home visiting program offered by community health nurses to infant families in Denmark. Sixteen municipalities are randomly allocated to implement the intervention starting at three successive time points from May 1, 2022 to January 1, 2023. A total of 900-1000 families will be included. A standardized program, Psykisk Udvikling og Funktion (PUF), is used to identify infants with major problems of eating, sleep, emotional or behavioral regulation or developmental problems. The intervention builds on the Video-Feedback Intervention to Promote Positive Parenting (VIPP) program, adapted to the PUF-context and named the VIPP-PUF. Children will be followed up at ages 18 and 24 months. Primary outcome measure is the Strengths and Difficulties Questionnaire (SDQ) at child age 24 months. The other outcome measures include body mass index z-scores, the Ages and Stages Questionnaire Social-Emotional (ASQ:SE2); the Child Behavior Checklist (CBCL 1½ -5); Eating behavior Questionnaires; the Being a Mother-questionnaire (BaM13); the Parental Stress Scale (PSS); and the WHO-5 well-being index (WHO-5). Data on child and family factors are obtained from National registries and the Child Health Database. Quantitative measures are applied to examine the effectiveness of the VIPP-PUF intervention and the implementation process. Qualitative measures include interviews with CHNs, parents and municipality stakeholders to explore factors that may influence the adherence and effectiveness of the intervention. DISCUSSION: The study examines a service-setting based intervention building on the promotion of sensitive parenting to vulnerable infants. We use a mixed methods approach to evaluate the intervention, taking into account the influences of COVID-19 pandemic running since March 2020. Overall, the study has potential to add to the knowledge on the possibilities of prevention within the municipality child health care to reduce the risk of mental health problems and unhealthy weight in early childhood. TRIAL REGISTRATION: www.ClinicalTrials.gov ; ID NCT04601779 ; Protocol ID 95-110-21307. Registered 25 June 2021.

Underweight among adolescents in Denmark: prevalence, trends (1998-2018), and association of underweight with socioeconomic status.

BACKGROUND: Underweight among adolescents is an important clinical and public health issue. It is associated with adverse health outcomes throughout the life-span and may reflect food poverty, unhealthy eating habits, or some underlying health conditions. OBJECTIVE: To study prevalence and trends in underweight among adolescents 1998-2018, to examine social inequality in underweight, and whether social inequality changed over time. METHODS: Data were derived from 6 cross-sectional school surveys from The Health Behaviour in School-aged Children study in Denmark. The study included 11-, 13-, and 15-year-old schoolchildren in random samples of schools in 1998, 2002, 2006, 2010, 2014, and 2018 (n = 22,177). Underweight was determined by body mass index-for-age thinness grade 2-3 (the Cole and Lobstein method). Socioeconomic status was determined using occupational social class (the Danish OSC Measurement). RESULTS: The overall prevalence of underweight was 3.1% among boys and 5.3% among girls (P < 0.0001) and decreased by age (P < 0.0001) among both boys and girls. The prevalence of underweight was almost stable from 1998 to 2018. There was no observed absolute or relative social inequality in the prevalence of underweight among boys or girls. CONCLUSION: The prevalence of underweight in 11- to 15-year-olds was significantly higher among girls than boys. The prevalence remained stable from 1998 to 2018. There was no significant association between SES and prevalence of underweight. It is important to elucidate the underlying causes of underweight such as malnutrition, eating disorders, eating problems, loss of appetite, chronic diseases, insufficient knowledge of nutrients effects on bodily functions, and persistent pain.

Underweight among adolescents is an important clinical and public health issue as it may reflect food poverty, unhealthy eating habits, or some underlying health problem. The aim was to study prevalence and trends in underweight among adolescents 1998­2018 and to examine social inequality in underweight. We used data from 6 cross-sectional school surveys from Denmark. Across all surveys, the number of participants was 22,177 11-, 13-, and 15-year-old students. The prevalence of thinness grades 2 and 3 were taken as indicators of underweight and were 3.1% among boys and 5.3% among girls. This prevalence was almost stable from 1998 to 2018. Contrary to overweight, which is usually more prevalent in lower socioeconomic groups, underweight was not associated with socioeconomic status. There were 2 exceptions: the prevalence of underweight among girls was highest in those from high socioeconomic groups in1998, while the prevalence among boys was highest in those from low socioeconomic groups in 2018. Underweight conditions in adolescents need careful medical examinations to elucidate the underlying causes of underweight, for example, malnutrition, eating disorders, eating problems, loss of appetite, voluntary uptake of fad diets, chronic disease, insufficient knowledge of nutrients that impact their bodily functions, mental health problems, and persistent pain.

Chronic backpain among adolescents in Denmark: trends 1991-2018 and association with socioeconomic status.

Chronic backpain among adolescents is important because the prevalence is high, above 10%, and more than 10% of all adolescents experience impacts on important day-to-day activities. Chronic backpain tracks into adulthood and is associated with several health problems. The objective was to study trends in the prevalence of chronic backpain among adolescents 1991-2018, to examine the association with socioeconomic status (SES), and whether this association changed over time. The study used data from eight comparable cross-sectional school surveys of nationally representative samples of 11-15-year-olds in 1991, 1994, 1998, 2002, 2006, 2010, 2014, and 2018, which constitute the Danish arm of the international Health Behaviour in School-aged Children (HBSC) study. The participation rate was 74.6% of the eligible study population, n = 29,952. Chronic backpain was defined as self-reported backpain daily or several days a week during the last 6 months. The prevalence of chronic backpain was 11.1%, significantly increasing from 8.9% in 1991 to 11.7% in 2018. The OR for chronic backpain was 1.20 (95% CI: 1.10-1.31) in middle, and 1.56 (95% CI: 1.41-1.73) in low compared to high SES. Sensitivity analyses with two other cut-points for backpain frequency showed similar associations.Conclusion: Chronic backpain is common among adolescents and the prevalence increased from 1991 to 2018. The prevalence was highest in lower SES families. We recommend increased efforts to prevent chronic backpain. What is Known: • Chronic backpain among adolescents is common, has a high burden of disability, is associated with several health problems, and tracks into adulthood. What is New: • The prevalence of chronic backpain among adolescents in Denmark increased from 8.9% in 1991 to 11.7% in 2018. • The prevalence was highest among adolescents from lower SES families.

Social inequality in parent-infant relations: Epidemiological study of community nurse records.

Background: Some studies suggest that favourable socioeconomic circumstances are associated with better parent-child relations but the documentation of such an association is limited and inconsistent. Few studies focused on infancy, few studies relied on objective measurement of parent-infant relations, and few studies included more than one measurement of parent-infant relations in the first year of life. Aims: To report the prevalence of objectively measured problems in parent-infant relations during the first year of life and to examine the association between socioeconomic circumstances and parent-infant relations in an unselected community sample of infants. Methods: Cross-sectional study of a community sample of children from birth to 10 months in 15 municipalities in Denmark, n = 11,765. The exposure variables were population register data about socioeconomic circumstances: (a) parents' education, (b) family composition, (c) parents' origin, and (d) parents' occupational status. The outcome variable was the health visitor's concerns about the parent-infant relation assessed at four home visits from birth to 10 months after delivery. Results: The proportion of children with concerns about the parent-infant relation was 10.5%, 7.8% at one home visit and 2.8% at two or more home visits. Logistic regression analyses showed that all four indicators of socioeconomic circumstances were associated with concerns about the parent-infant relation in the first year of life. Conclusions: The risk of problematic parent-infant relations were significantly elevated among, children of immigrant parents, and children of parents with shorter education and not in education or work.

Disparities in postpartum depression screening participation between immigrant and Danish-born women.

BACKGROUND: Qualitative studies suggest that immigrant women experience barriers for postpartum depression (PPD) screening. This study examines the prevalence of participation in PPD screening in the universal home-visiting programme in Denmark, in relation to migrant status and its association with acculturation factors, such as length of residence and age at migration. METHODS: The sample consists of 77 694 births from 72 292 mothers (2015-18) that participated in the programme and were registered in the National Child Health Database. Lack of PPD screening using the Edinburgh Postpartum Depression Scale (EPDS) was examined in relation to migrant group and acculturation factors. We used Poisson regression with cluster robust standard errors to estimate crude and adjusted relative risk. RESULTS: In total, 27.8% of Danish-born women and 54.7% of immigrant women lacked screening. Compared with Danish-born women, immigrant women in all groups were more likely to lack PPD screening (aRR ranging from 1.81 to 1.90). Women with low acculturation were more likely to lack screening. Women who migrated as adults [aRR = 1.27 (95% CI 1.16, 1.38)] and women who had resided in Demark for <5 years [aRR = 1.37 (95% CI 1.28, 1.46)] were more likely to lack screening. CONCLUSIONS: Immigrant women in Denmark, particularly recent immigrants, are at increased risk of not being screened for PPD using the EPDS. This can lead to under-recognition of PPD among immigrant women. More work is needed to understand how health visitors recognize the mental health needs of immigrant women who are not screened, and whether this gap results in reduced use of mental health services.

Recurrent abdominal pain among adolescents: trends and social inequality 1991-2018.

OBJECTIVES: The association between socioeconomic status and recurrent abdominal pain (RAP) among adolescents is an understudied issue. No study has examined whether such an association changes over time. The aim was to examine trends in RAP among adolescents in Denmark from 1991 to 2018, to examine whether there was social inequality in RAP and whether this inequality varied over time. METHODS: The study used data from the Danish part of the international Health Behaviour in School-aged Children (HBSC) study of nationally representative samples of 11-, 13- and 15-year-olds. This study pooled data from eight comparable surveys from 1991 to 2018, overall participation rate 88.0%, n=30,048. The definition of RAP was self-reported stomach-ache daily or several days per week during the past six months. We reported absolute inequality as prevalence difference in RAP between low and high socioeconomic status and relative inequality as odds ratio for RAP by socioeconomic status. RESULTS: In the entire study population, 5.6% reported RAP, 3.1% among boys and 7.8% among girls. There was a significant increase in RAP from 1991 to 2018 among boys and girls, test for trend, p<0.0001. The prevalence of RAP was significantly higher in low than high socioeconomic status, OR=1.63 (95% CI: 1.42-1.87). The absolute social inequality in RAP fluctuated with no consistent increasing or decreasing pattern. CONCLUSIONS: The prevalence of RAP increased from 1991 to 2018. The prevalence was significantly higher among girls than among boys, and significantly higher in low socioeconomic status families. Professionals should be aware of RAP as common and potentially serious health problems among children and adolescents. In addition to clinical examination it is important to focus on improving the child's quality of life, reduce parents' and children's concerns about the seriousness of the condition, and consider supplements to medicine use.

Intake of sugar sweetened soft drinks among adolescents: Trends and social inequality in Denmark 2002-2018.

BACKGROUND: Intake of sugar sweetened soft drinks (SSSD) has decreased among adolescents, but trends in social inequality in SSSD intake are unknown. AIM: Examine trends in social inequality in SSSD intake among adolescents in Denmark during 2002-2018. METHODS: Five Health Behaviour in School-aged Children surveys with data on SSSD intake and parents' occupational social class (OSC) from nationally representative samples of 11, 13 and 15 year olds, n =20,112. RESULTS: The overall prevalence of daily SSSD intake decreased from 10.1% in 2002 to 6.4% in 2018. The prevalence decreased in both high OSC (from 8% to 5%) and middle OSC (from 10% to 6%) but remained around 12% in low OSC. The odds ratio (OR) estimates of low compared with high OSC increased over the years around an overall OR of 2.01 (1.74-2.34). CONCLUSIONS: Danish adolescents' SSSD intake decreased during 2002-2018 and was higher the lower the parents' OSC. Thus, social inequality increased during 2002-2018.

Difficulties falling asleep among adolescents: Social inequality and time trends 1991-2018.

Sleep problems in adolescence are increasingly common, and associated with adverse health and psychological outcomes. Adolescents' sleep problems may be related to the family's socioeconomic status, but studies are few and no study has examined whether social inequality in sleep problems changes as sleep problems become increasingly common. This study examined trends in difficulties falling asleep among adolescents in Denmark, whether this sleep problem was associated with socioeconomic status, and whether this association changed from 1991 to 2018. The study applied data from eight comparable surveys among 11-15 year olds in Denmark 1991-2018, the Danish arm of the international Health Behaviour in School-aged Children study, N = 30,002. The prevalence of daily difficulties falling asleep increased from 7.0% to 13.4% in 1991-2018 with higher frequencies among girls and younger adolescents. The odds ratio (95% confidence interval) for daily difficulties was 1.14 (1.05-1.24) in middle and 1.52 (1.37-1.69) in low compared with high socioeconomic status. The absolute social inequality in difficulties falling asleep was persistent in 1991-2018 whereas the relative social inequality may have decreased. The increasing prevalence and the social inequality in difficulties falling asleep among adolescents is a serious public health concern that calls for more attention and efforts.

Persistent social inequality in low intake of vegetables among adolescents, 2002-2014.

OBJECTIVE: To examine the trend in social inequality in low intake of vegetables among adolescents in Denmark from 2002 to 2014 using occupational social class (OSC) as socio-economic indicator. DESIGN: Repeated cross-sectional school surveys including four waves of data collection in 2002-2014. The analyses focused on absolute social inequality (difference between high and low OSC in low vegetable intake) as well as relative social inequality (OR for low vegetable intake by OSC). SETTING: The nationally representative Health Behaviour in School-aged Children (HBSC) study in Denmark. SUBJECTS: The study population was 11-15-year olds (n 17 243). RESULTS: Low intake of vegetables was defined as less than weekly intake measured by food frequency items. OSC was measured by student reports of parents' occupation. The proportion of participants who reported eating vegetables less than once weekly was 8·9 %, with a notable decrease from 11·9 % in 2002 to 5·9 % in 2014. The OR (95 % CI) for less than weekly vegetable intake was 2·28 (1·98, 2·63) in the middle compared with high OSC and 3·12 (2·67, 3·66) in the low compared with high OSC. The absolute social inequality in low vegetable intake decreased from 2002 to 2014 but the relative social inequality remained unchanged. CONCLUSIONS: The study underscores that it is important to address socio-economic factors in future efforts to promote vegetable intake among adolescents. The statistical analyses of social inequality in vegetable intake demonstrate that it is important to address both absolute and relative social inequality as these two phenomena may develop differently.

Curricular activities and change in determinants of fruit and vegetable intake among adolescents: Results from the Boost intervention.

Knowledge of the association between implementation of different intervention components and the determinants they are tailored to change may contribute to evaluating the effects and working mechanisms of multi-component interventions. This study examined 1) the effect of a Danish multi-component school-based intervention (2010 - 2011) on key determinants of adolescents' fruit and vegetable intake and 2) if dose of curricular activities was positively associated with change in these determinants. Using multi-level linear and logistic regression analyses stratified by gender and socioeconomic position, we analyzed survey data from the cluster-randomized Boost study targeting Danish 13-year-olds' fruit and vegetable intake. We examined 1) differences in knowledge of recommendations, taste preferences and situational norms between students from 20 intervention (n = 991) and 20 control (n = 915) schools at follow-up; and 2) associations between curriculum dose received and delivered (student and teacher data aggregated to school- and class-level) and these determinants among students at intervention schools only. At follow-up, more students from intervention than control schools knew the recommendation for vegetable intake (OR 1.56, CI:1.18, 2.06) and number of fruits liked (taste preferences) increased by 0.22 (CI:0.04, 0.41). At class-level, curriculum dose received was positively associated with proportion of students knowing the recommendation for vegetable intake (OR 1.06, CI:1.002, 1.13). In stratified analyses, this association was only significant among students from high social class (OR 1.17, CI:1.04, 1.31). The Boost intervention succeeded in improving students' taste preferences for fruit and knowledge of recommendation for vegetable intake, but only the latter determinant was positively associated with curriculum dose. Trial registration: ISRCTN11666034.

Trends from 2002 to 2010 in Daily Breakfast Consumption and its Socio-Demographic Correlates in Adolescents across 31 Countries Participating in the HBSC Study.

Breakfast is often considered the most important meal of the day and children and adolescents can benefit from breakfast consumption in several ways. The purpose of the present study was to describe trends in daily breakfast consumption (DBC) among adolescents across 31 countries participating in the HBSC survey between 2002 to 2010 and to identify socio-demographic (gender, family affluence and family structure) correlates of DBC. Cross-sectional surveys including nationally representative samples of 11-15 year olds (n = 455,391). Multilevel logistic regression analyses modeled DBC over time after adjusting for family affluence, family structure and year of survey. In all countries, children in two-parent families were more likely to report DBC compared to single parent families. In most countries (n = 19), DBC was associated with family affluence. Six countries showed an increase in DBC (Canada, Netherland, Macedonia, Scotland, Wales, England) from 2002. A significant decrease in DBC from 2002 was found in 11 countries (Belgium Fr, France, Germany, Croatia, Spain, Poland, Russian Federation, Ukraine, Latvia, Lithuania and Norway), while in 5 countries (Portugal, Denmark, Finland, Ireland, Sweden) no significant changes were seen. Frequency of DBC among adolescents in European countries and North America showed a more uniform pattern in 2010 as compared to patterns in 2002. DBC increased significantly in only six out of 19 countries from 2002 to 2010. There is need for continued education and campaigns to motivate adolescents to consume DBC. Comparing patterns across HBSC countries can make an important contribution to understanding regional /global trends and to monitoring strategies and development of health promotion programs.

Breakfast frequency among adolescents: associations with measures of family functioning.

OBJECTIVE: To investigate (i) associations between adolescents' frequency of breakfast and family functioning (close relations to parents, quality of family communication and family support) and (ii) if any observed associations between breakfast frequency and family functioning vary by sociodemographic factors. DESIGN: School-based cross-sectional study. Students completed a web-based questionnaire. Associations were estimated by multilevel multivariate logistic regression. SETTING: Danish arm of the Health Behaviour in School-aged Children study, 2014. SUBJECTS: Adolescents aged 13 and 15 years (n 3054) from a random sample of forty-one schools. RESULTS: Nearly one-quarter of the adolescents had low breakfast frequency. Low breakfast frequency was associated with low family functioning measured by three dimensions. The OR (95 % CI) of low breakfast frequency was 1·81 (1·40, 2·33) for adolescents who reported no close relations to parents, 2·28 (1·61, 3·22) for adolescents who reported low level of quality of family communication and 2·09 (1·39, 3·15) for adolescents who reported low level of family support. Joint effect analyses suggested that the odds of low breakfast frequency among adolescents with low family functioning compared with high family functioning were highest among adolescents being girls, immigrants and living in other than a traditional family structure. CONCLUSIONS: Low breakfast frequency was associated with low family functioning measured by close relations to parents, quality of family communication and family support. Further, analyses suggested that the associations were more pronounced among girls, immigrants and adolescents from other family structure than traditional. The study highlights the importance of the family setting in promoting regular breakfast frequency among adolescents.

Lunch frequency among adolescents: associations with sociodemographic factors and school characteristics.

OBJECTIVE: To investigate: (i) how lunch frequency of adolescents varies between schools and between classes within schools; (ii) the associations between frequency of lunch and individual sociodemographic factors and school characteristics; and (iii) if any observed associations between lunch frequency and school characteristics vary by gender and age groups. DESIGN: Cross-sectional study in which students and school headmasters completed self-administered questionnaires. Associations were estimated by multilevel multivariate logistic regression. SETTING: The Danish arm of the Health Behaviour in School-Aged Children study 2010. SUBJECTS: Students (n 4922) aged 11, 13 and 15 years attending a random sample of seventy-three schools. RESULTS: The school-level and class-level variations in low lunch frequency were small (intraclass correlation coefficient <2·1 %). At the individual level, low lunch frequency was most common among students who were boys, 13- and 15-year-olds, from medium and low family social class, descendants of immigrants, living in a single-parent family and in a reconstructed family. School-level analyses suggested that having access to a canteen at school was associated with low lunch frequency (OR=1·47; 95% CI 1·14, 1·89). Likewise not having an adult present during lunch breaks was associated with low lunch frequency (OR=1·44; 95% CI 1·18, 1·75). Cross-level interactions suggested that these associations differed by age group. CONCLUSIONS: Lunch frequency among Danish students appears to be largely influenced by sociodemographic factors. Additionally, the presence of an adult during lunch breaks promotes frequent lunch consumption while availability of a canteen may discourage frequent lunch consumption. These findings vary between older and younger students.

Main meal frequency measures in the Health Behaviour in School-aged Children study: agreement with 7-day 24-h recalls.

OBJECTIVES: To estimate agreement between questionnaire-based frequency measures from the Health Behaviour in School-aged Children study (HBSC) and 7-day 24-h recall measures of breakfast, lunch and evening meals among 11-15-year-olds, and examine whether disagreement between the two methods varied by socio-demographic factors. METHODS: In one week 11-15-year-old Danish students completed HBSC questionnaires including meal frequency items. The following week they completed daily 24-h recall questionnaire about their meals (response rate 88.4 %, n = 412). RESULTS: Good to moderate agreement for the breakfast measure: per cent agreement 0.70-0.87, kappa 0.43-0.65. Fair agreement for the lunch measure: per cent agreement 0.53-0.84, kappa 0.26-0.54. High per cent agreement for the evening meal measure (0.83-0.95) but poor kappa agreement (0.14-0.19). Being immigrant predicted disagreement between the two methods for week day breakfast OR (95 % CI) 2.17 (1.16-4.04) and lunch 2.44 (1.33-4.48). CONCLUSIONS: We found good to moderate agreement between frequency and 7-day 24-h recall measures for breakfast, a fair agreement for lunch and for evening meal the two agreement methods provided different results. Migration status predicted disagreement between the two methods.

The role of curriculum dose for the promotion of fruit and vegetable intake among adolescents: results from the Boost intervention.

BACKGROUND: Multi-component interventions combining educational and environmental strategies have proved effective in increasing children and adolescents' fruit and vegetable intake. However such interventions are complex and difficult to implement and several studies report poor implementation. There is a need for knowledge on the role of dose for behaviour change and for assessment of intervention dose to avoid conclusions that intervention components which are not implemented are ineffective. This study aimed to examine 1) the association between dose of a class curriculum and adolescents' fruit and vegetable intake in a school-based multi-component intervention, 2) if gender and socioeconomic position modify this association. METHODS: We carried out secondary analysis of data from intervention schools in the cluster-randomized Boost study targeting 13-year-olds' fruit and vegetable intake. Teacher- and student data on curriculum dose delivered and received were aggregated to the school-level and class-level (only possible for student data). We analysed the association between curriculum dose and students' (n 995) self-reported fruit and vegetable intake (24-h recall questionnaire) after finalization of the intervention using multi-level analyses. Potential moderation was examined by analyses stratified by gender and socioeconomic position. RESULTS: Average dose received at class-level was significantly associated with students' fruit and vegetable intake (10 g (CI: 0.06, 20.33) per curricular activity received). In stratified analyses the association remained significant among boys only (14 g (CI: 2.84, 26.76) per curricular activity received). The average dose delivered and received at the school-level was not significantly associated with students' intake. CONCLUSIONS: We found a dose-response relationship between number of curricular activities received and adolescents' fruit and vegetable intake. The results indicate that curriculum dose received only mattered for promotion of fruit and vegetable intake among boys. Future studies should explore this gender difference in larger samples to guide the planning of school-based curricular interventions with regards to the optimal number of curricular activities required to promote behavioural change in subgroups with low fruit and vegetable intake at baseline. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11666034.

Perceived problems with computer gaming and Internet use are associated with poorer social relations in adolescence.

OBJECTIVES: Young people's engagement in electronic gaming and Internet communication have caused concerns about potential harmful effects on their social relations, but the literature is inconclusive. The aim of this paper was to examine whether perceived problems with computer gaming and Internet communication are associated with young people's social relations. METHODS: Cross-sectional questionnaire survey in 13 schools in the city of Aarhus, Denmark, in 2009. Response rate 89%, n = 2,100 students in grades 5, 7, and 9. Independent variables were perceived problems related to computer gaming and Internet use, respectively. Outcomes were measures of structural (number of days/week with friends, number of friends) and functional (confidence in others, being bullied, bullying others) dimensions of student's social relations. RESULTS: Perception of problems related to computer gaming were associated with almost all aspects of poor social relations among boys. Among girls, an association was only seen for bullying. For both boys and girls, perceived problems related to Internet use were associated with bullying only. CONCLUSIONS: Although the study is cross-sectional, the findings suggest that computer gaming and Internet use may be harmful to young people's social relations.