Development of a program theory for osteoporosis patient education in Denmark: a qualitative study based on realist evaluation.

BACKGROUND: Osteoporosis patient education is offered in many countries worldwide. When evaluating complex interventions like these, it is important to understand how and why the intervention leads to effects. This study aimed to develop a program theory of osteoporosis patient education in Danish municipalities with a focus on examining the mechanisms of change i.e. what is about the programs that generate change. METHODS: The program theory was developed in an iterative process. The initial draft was based on a previous published systematic review, and subsequently the draft was continually refined based on findings from observations (10 h during osteoporosis patient education) and interviews (individual interviews with six employees in municipalities and three health professionals at hospitals, as well as four focus group interviews with participants in patient education (in total 27 informants)). The transcribed interviews were analyzed using thematic analysis and with inspiration from realist evaluation the mechanisms as well as the contextual factors and outcomes were examined. RESULTS: Based on this qualitative study we developed a program theory of osteoporosis patient education and identified four mechanisms: motivation, recognizability, reassurance, and peer reflection. For each mechanism we examined how contextual factors activated the mechanism as well as which outcomes were achieved. For instance, the participants' motivation is activated when they meet in groups, and thereafter outcomes such as more physical activity may be achieved. Recognizability is activated by the participants' course of disease, which may lead to better ergonomic habits. Reassurance may result in more physical activity, and this mechanism is activated in newly diagnosed participants without previous fractures. Peer reflection is activated when the participants meet in groups, and the outcome healthier diet may be achieved. CONCLUSIONS: We developed a program theory and examined how and why osteoporosis patient education is likely to be effective. Understanding these prerequisites is important for future implementation and evaluation of osteoporosis patient education.

Effectiveness of the multi-component intervention 'Focus' on reducing smoking among students in the vocational education setting: a cluster randomized controlled trial.

BACKGROUND: Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students' smoking. METHODS: A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation. RESULTS: Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention. CONCLUSION: This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved. TRIAL REGISTRATION: https://www.isrctn.com/ISRCTN16455577 , date of registration 14/06/2018.

Mortality among persons experiencing musculoskeletal pain: a prospective study among Danish men and women.

BACKGROUND: Musculoskeletal (MSK) pain affects many people worldwide and has a great impact on general health and quality of life. However, the relationship between MSK pain and mortality is not clear. This study aimed to investigate all-cause and cause-specific mortality in relation to self-reported MSK pain within the last 14 days, including spread of pain and pain intensity. METHODS: This prospective cohort study included a representative cohort of 4806 men and women aged 16+ years, who participated in a Danish MSK survey 1990-1991. The survey comprised questions on MSK pain, including spread of pain and pain intensity. These data were linked with the Danish Register of Causes of Death to obtain information on cause of death. Mean follow-up was 19.1 years. Cox regression analyses were performed with adjustment for potential confounders. RESULTS: In the study population (mean age 44.5 years; 47.9% men), 41.0% had experienced MSK pain within the last 14 days and 1372 persons died during follow-up. For both sexes, increased all-cause mortality with higher spread and intensity of MSK pain was observed; a high risk was observed especially for men with strong pain (HR = 1.66; 95% CI:1.09-2.53) and women with widespread pain (HR = 1.49; 95% CI:1.16-1.92). MSK pain within last 14 days yielded c-statistics of 0.544 and 0.887 with age added. Moreover, persons with strong MSK pain had an increased cardiovascular mortality, persons with moderate pain and pain in two areas had an increased risk of cancer mortality, and persons with widespread pain had an increased risk of respiratory mortality. CONCLUSIONS: Overall, persons experiencing MSK pain had a higher risk of mortality. The increased mortality was not accounted for by potential confounders. However, when evaluating these results, it is important to take the possibility of unmeasured confounders into account as we had no information on e.g. BMI etc. SIGNIFICANCE: The present study provides new insights into the long-term consequences of MSK pain. However, the discriminatory accuracy of MSK pain was low, which indicates that this information cannot stand alone when predicting mortality risk.

Total sitting time, leisure time physical activity and risk of hospitalization due to low back pain: The Danish Health Examination Survey cohort 2007-2008.

AIMS: This study aimed to test the hypotheses that a high total sitting time and vigorous physical activity in leisure time increase the risk of low back pain and herniated lumbar disc disease. METHODS: A total of 76,438 adults answered questions regarding their total sitting time and physical activity during leisure time in the Danish Health Examination Survey 2007-2008. Information on low back pain diagnoses up to 10 September 2015 was obtained from The National Patient Register. The mean follow-up time was 7.4 years. Data were analysed using Cox regression analysis with adjustment for potential confounders. Multiple imputations were performed for missing values. RESULTS: During the follow-up period, 1796 individuals were diagnosed with low back pain, of whom 479 were diagnosed with herniated lumbar disc disease. Total sitting time was not associated with low back pain or herniated lumbar disc disease. However, moderate or vigorous physical activity, as compared to light physical activity, was associated with increased risk of low back pain (HR = 1.16, 95% CI: 1.03-1.30 and HR = 1.45, 95% CI: 1.15-1.83). Moderate, but not vigorous physical activity was associated with increased risk of herniated lumbar disc disease. CONCLUSIONS: The results suggest that total sitting time is not associated with low back pain, but moderate and vigorous physical activity is associated with increased risk of low back pain compared with light physical activity.

Perceived Sexual Difficulties and Sexual Counseling in Men and Women Across Heart Diagnoses: A Nationwide Cross-Sectional Study.

BACKGROUND: Ischemic heart disease and heart failure often lead to sexual difficulties in men, but little is known about the sexual difficulties in women and patients with other heart diagnoses or the level of information patients receive about the risk of sexual difficulties. AIM: To investigate perceived sexual difficulties and associated factors in a mixed population of men and women newly diagnosed with heart disease and provide insight into sexual counseling and information given by health care professionals. METHODS: This article reports on a cross-sectional, questionnaire study sent to a randomly selected sample of men and women newly diagnosed with heart failure, ischemic heart disease, atrial fibrillation, or heart valve surgery. Eligible patients were identified by diagnosis using the Danish National Patient Register, which contains all diagnoses. OUTCOMES: Sexual difficulties were self-reported using single-item questions, and factors associated with sexual difficulties were collected from the survey and national registers. RESULTS: The study population consisted of 1,549 men and 807 women (35-98 years old) with heart failure (n = 243), ischemic heart disease (n = 1,036), heart valve surgery (n = 375), and atrial fibrillation (n = 702). Sexual difficulties were reported by 55% of men and 29% of women. In a multiple regression analysis, difficulties in men were associated with being older (≥75 years old; odds ratio [OR] = 1.97, 95% CI = 1.13-3.43), having heart failure (OR = 2.07, 95% CI = 1.16-3.71), diabetes (OR = 1.80, 95% CI = 1.15-2.82), hypertension (OR = 1.43, 95% CI = 1.06-1.93), receiving ß-blockers (OR = 1.37, 95% CI = 1.02-1.86), or having anxiety (OR = 2.25, 95% CI = 1.34-3.80) or depression (OR = 2.74, 95% CI = 1.38-5.43). In women, difficulties were significantly associated with anxiety (OR = 3.00, 95% CI = 1.51-5.95). A total of 48.6% of men and 58.8% of women did not feel informed about sexuality, and 18.1% of men and 10.3% of women were offered sexual counseling. CLINICAL IMPLICATIONS: Heart disease increases the risk of sexual difficulties and there is a need for improved information and counseling about sex and relationships for patients. STRENGTHS AND LIMITATIONS: This large nationwide survey of men and women combined a survey with administrative data from national registries. However, this study used non-validated single-item questions to assess sexual difficulties without addressing sexual distress. CONCLUSION: More than half the men and one fourth the women across common heart diagnoses had sexual difficulties. No difference was found among diagnoses, except heart failure in men. Despite guidelines recommending sexual counseling, sexual difficulties were not met by sufficient information and counseling. Rundblad L, Zwisler AD, Johansen PP, et al. Perceived Sexual Difficulties and Sexual Counseling in Men and Women Across Heart Diagnoses: A Nationwide Cross-Sectional Study. J Sex Med 2017;14:785-796.

Point-of-Care Phalangeal Bone Mineral Density Measurement Can Reduce the Need of Dual-Energy X-Ray Absorptiometry Scanning in Danish Women at Risk of Fracture.

Identifying persons with a high risk of osteoporotic fractures remains a challenge. DXA uptake in women with elevated risk of osteoporosis seems to be depending on distance to scanning facilities. This study aimed to investigate the ability of a small portable scanner in identifying women with reduced bone mineral density (BMD), and to define triage thresholds for pre-selection. Total hip and lumbar spine BMD was measured by dual-energy X-ray absorptiometry and phalangeal BMD by radiographic absorptiometry in 121 Danish women with intermediate or high 10-year fracture probability (aged 61-81 years). Correlation between the two methods was estimated using correlation coefficient (r) and Bland-Altman plots. A moderate correlation between phalangeal BMD versus total hip (r = 0.47) and lumbar spine (r = 0.51), and an AUC on 0.80 was found. The mean difference between phalangeal T score and total hip T score/lumbar spine T score was low, and ranged from -0.26 SD to -0.31 SD depending on site and reference database used for calculation of T scores, but, large variation was seen at an individual level. When applying a triage approach approx. one-third of all DXA scan could be avoided and only 6 % of women in the low-risk group would be false negatives.

The risk-stratified osteoporosis strategy evaluation study (ROSE): a randomized prospective population-based study. Design and baseline characteristics.

The risk-stratified osteoporosis strategy evaluation study (ROSE) is a randomized prospective population-based study investigating the effectiveness of a two-step screening program for osteoporosis in women. This paper reports the study design and baseline characteristics of the study population. 35,000 women aged 65-80 years were selected at random from the population in the Region of Southern Denmark and-before inclusion-randomized to either a screening group or a control group. As first step, a self-administered questionnaire regarding risk factors for osteoporosis based on FRAX(®) was issued to both groups. As second step, subjects in the screening group with a 10-year probability of major osteoporotic fractures ≥15% were offered a DXA scan. Patients diagnosed with osteoporosis from the DXA scan were advised to see their GP and discuss pharmaceutical treatment according to Danish National guidelines. The primary outcome is incident clinical fractures as evaluated through annual follow-up using the Danish National Patient Registry. The secondary outcomes are cost-effectiveness, participation rate, and patient preferences. 20,904 (60%) women participated and included in the baseline analyses (10,411 in screening and 10,949 in control group). The mean age was 71 years. As expected by randomization, the screening and control groups had similar baseline characteristics. Screening for osteoporosis is at present not evidence based according to the WHO screening criteria. The ROSE study is expected to provide knowledge of the effectiveness of a screening strategy that may be implemented in health care systems to prevent fractures.

Shaping the Social: design of a settings-based intervention study to improve well-being and reduce smoking and dropout in Danish vocational schools.

BACKGROUND: The social environment at schools is an important setting to promote educational attainment, and health and well-being of young people. However, within upper secondary education there is a need for evidence-based school intervention programmes. The Shaping the Social intervention is a comprehensive programme integrating social and educational activities to promote student well-being and reduce smoking and dropout in upper secondary vocational education. The evaluation design is reported here. METHODS/DESIGN: The evaluation employed a non-randomised cluster controlled design, and schools were selected to either implement the intervention or continue with normal practice for comparison. In the baseline survey conducted 2011-2012, 2,329 students from four intervention schools and 3,371 students from six comparison schools answered a computer-based questionnaire during class, representing 73% and 81% of eligible students, and 22% of all technical/agricultural vocational schools in Denmark. Follow-up assessment was conducted 10 weeks after baseline and at the same time teachers of the intervention classes answered a questionnaire about implementation. School dropout rates will be tracked via national education registers through a 2-year follow-up period. DISCUSSION: Shaping the Social was designed to address that students at Danish vocational schools constitute a high risk population concerning health behaviour as well as school dropout by modifying the school environment, alongside developing appropriate evaluation strategies. To address difficulties in implementing settings-based interventions, as highlighted in prior research, the strategy was to involve intervention schools in the development of the intervention. Baseline differences will be included in the effectiveness analysis, so will the impact of likely mediators and moderators of the intervention. TRIALS REGISTRATION: ISRCTN57822968. Date of registration: 16/01/2013.

How can we strengthen students' social relations in order to reduce school dropout? An intervention development study within four Danish vocational schools.

BACKGROUND: This article describes the rationale and contents of an intervention program aimed at strengthening students' social relations in order to reduce dropout from vocational schools in Denmark. Taking its theoretical cue from the concept of 'social participation', a qualitative study was performed to investigate the specific relationships between the social environment within the schools and the institutional structures in order to analyse reasons for school dropout and their relation to well-being, cigarette smoking and substance use. METHODS: The development study was based on ethnographic methods, including 22 qualitative interviews with students 17-19 years old and fieldwork with participant observations at four vocational schools over 40 days, including informal interviews and discussion meetings with managers, teachers, counselors and students. As part of the fieldwork, four additional qualitative interviews and four group interviews were conducted with students 16-25 years old. RESULTS: The qualitative data collection resulted in seven major themes to be addressed in the intervention: social relations, sole focus on professional skills, institutionalized individualization, importance of the introduction period, physical surroundings and schedules, tobacco and cannabis use and communication about drug use. The program addressing these themes incorporates suggestions that are meant to improve how teachers welcome new students, to enable greater integration of social and educational activities and to enhance the capacity of teachers and counselors to deal with drug use problems among students. CONCLUSION: The development of new intervention programs might benefit from adopting a theoretical and methodological perspective that enables a closer exploration of the everyday social practices in which interventions are embedded. Thus, we aimed to create a comprehensive intervention that worked through organizational changes in everyday school practices. Intervention programs must be planned in dialogue and collaboration with practitioners in the field to ensure the pertinence and usability of the program.

Survey nonresponse among ethnic minorities in a national health survey--a mixed-method study of participation, barriers, and potentials.

OBJECTIVES: The participation rate in the Danish National Health Survey (DNHS) 2010 was significantly lower among ethnic minorities than ethnic Danes. The purpose was to characterize nonresponse among ethnic minorities in DNHS, analyze variations in item nonresponse, and investigate barriers and incentives to participation. DESIGN: This was a mixed-method study. Logistic regression was used to analyze nonresponse using data from DNHS (N = 177,639 and chi-square tests in item nonresponse analyses. We explored barriers and incentives regarding participation through focus groups and cognitive interviews. Informants included immigrants and their descendants of both sexes, with and without higher education. RESULTS: The highest nonresponse rate was for non-Western descendants (80.0%) and immigrants 25 (72.3%) with basic education. Immigrants and descendants had higher odds ratios (OR = 3.07 and OR = 3.35, respectively) for nonresponse than ethnic Danes when adjusted for sex, age, marital status, and education. Non-Western immigrants had higher item nonresponse in several question categories. Barriers to non-participation related to the content, language, format, and layout of both the questionnaire and the cover letter. The sender and setting in which to receive the questionnaire also influenced answering incentives. We observed differences in barriers and incentives between immigrants and descendants. CONCLUSIONS: Nonresponse appears related to linguistic and/or educational limitations, to alienation generated by the questions' focus on disease and cultural assumptions, or mistrust regarding anonymity. Ethnic minorities seem particularly affected by such barriers. To increase survey participation, questions could be sensitized to reflect multicultural traditions, and the impact of sender and setting considered.

Fracture risk prediction using phalangeal bone mineral density or FRAX(®)?-A Danish cohort study on men and women.

In this prospective study, we investigated the ability of Fracture Risk Assessment Tool (FRAX), phalangeal bone mineral density (BMD), and age alone to predict fractures using data from a Danish cohort study, Danish Health Examination Survey 2007-2008, including men (n = 5206) and women (n = 7552) aged 40-90 yr. Data were collected using a self-administered questionnaire and by phalangeal BMD measurement. Information on incident and prevalent fractures, rheumatoid arthritis, and secondary osteoporosis was retrieved from the Danish National Patient Registry. Survival analyses were used to examine the association between low, intermediate, and high risk by phalangeal T-score or FRAX and incident fractures, and receiver operating characteristic curves were obtained. Mean follow-up time was 4.3 yr, and a total of 395 persons (3.1%) experienced a fracture during follow-up. The highest rate of major osteoporotic fractures was observed in persons with a high combined risk (FRAX ≥20% and T-score ≤-2.5; women: 32.7 and men: 27.6 per 1000 person-yr). This group also had the highest risk of hip fractures (women: 8.1 and men: 7.2 per 1000 person-yr). FRAX and T-score in combination analyzed as continuous variables performed overall best in the prediction of major osteoporotic fractures. In predicting hip fractures, there was a tendency of T-score performing worse than the other methods.

Maternal use of hormonal contraception and risk of childhood autism spectrum disorders: A Parental Exposures and Child Health (PECH) cohort study.

A recent hypothesis suggests that maternal hormonal contraception use has contributed to the increasing incidence of autism spectrum disorders (ASD). We used a nationwide population-based cohort (the PECH cohort) including 1,056,149 Danish children born in the period January 1, 1998, to December 31, 2014, to assess associations between maternal hormonal contraception use and childhood ASD (end of follow-up: December 31, 2017). Maternal hormonal contraception use was grouped as "recent use" (≤ 3 months before pregnancy start or during pregnancy), "previous use" (>3 months before pregnancy start) and "never use", except for few products. Incidence rate ratios (IRRs) were estimated using Poisson regression. During follow-up of nearly 12 million person-years, 19,996 children were diagnosed with ASD. A slightly higher IRR was observed for maternal recent use of any hormonal contraception, compared to previous use. This association was largely driven by the non-oral progestin-only products, and associations were especially seen for infantile autism and other/unspecified ASD. An increased IRR of infantile autism was also observed for recent use of the oral progestin-only products, compared to previous use. Our results suggest that maternal use of hormonal contraception may be associated with ASD risk in children, especially for the progestin-only products.

Ten-year follow-up of fracture risk in a systematic population-based screening program: the risk-stratified osteoporosis strategy evaluation (ROSE) randomised trial.

Background: Osteoporotic fractures pose a growing public health concern. Osteoporosis is underdiagnosed and undertreated, highlighting the necessity of systematic screening programs. We aimed to evaluate the effectiveness of a two-step population-based osteoporotic screening program. Methods: This ten-year follow-up of the Risk-stratified Osteoporosis Strategy Evaluation (ROSE) randomized trial tested the effectiveness of a screening program utilizing the Fracture Risk Assessment Tool (FRAX) for major osteoporotic fractures (MOF) to select women for dual-energy x-ray absorptiometry (DXA) scan following standard osteoporosis treatment. Women residing in the Region of Southern Denmark, aged 65-80, were randomised (single masked) into a screening or a control group by a computer program prior to inclusion and subsequently approached with a mailed questionnaire. Based on the questionnaire data, women in the screening group with a FRAX value ≥15% were invited for DXA scanning. The primary outcome was MOF derived from nationwide registers. ClinicalTrials.gov: NCT01388244, status: Completed. Findings: All randomised women were included February 4, 2010-January 8, 2011, the same day as approached to participate. During follow-up, 7355 MOFs were observed. No differences in incidences of MOF were identified, comparing the 17,072 women in the screening group with the 17,157 controls in the intention-to-treat analysis (IRR 1.01, 0.95; 1.06). However, per-protocol, women DXA-scanned exhibited a 14% lower incidence of MOF (IRR 0.86, 0.78; 0.94) than controls with a FRAX value ≥15%. Similar trends were observed for hip fractures, all fractures, and mortality. Interpretation: While the ROSE program had no overall effect on osteoporotic fracture incidence or mortality it showed a preventive effect for women at moderate to high risk who underwent DXA scans. Hence the overall effect might have been diluted by those who were not at an intervention level threshold risk or those who did not show up for DXA. Using self-administered questionnaires as screening tools may be inefficient for systematic screening due to the low and differential screening uptake. Funding: INTERREG and the Region of Southern Denmark.

Workforce affiliation in primary and secondary prevention Implantable Cardioverter Defibrillator patients - a nationwide Danish study.

BACKGROUND AND AIM: There are a paucity of studies investigating workforce affiliation in connection with first-time ICD-implantation. This study explored workforce affiliation and risk markers associated with not returning to work in patients with ICDs. METHODS: Using the nationwide Danish registers, patients with a first-time ICD-implantation between 2007-2017 and of working age (30-65 years) were identified. Descriptive statistic and logistic regression models were used to describe workforce affiliation and to estimate risk markers associated with not returning to work, respectively. All analyses were stratified by indication for implantation (primary and secondary prevention). RESULTS: Of the 4,659 ICD-patients of working age, 3,300 patients (71%) were members of the workforce (employed, on sick leave or unemployed) (primary: 1428 (43%); secondary:1872 (57%)). At baseline, 842 primary and 1477 secondary prevention ICD-patients were employed. Of those employed at baseline, 81% primary and 75% secondary prevention ICD-patients returned to work within one-year, whereof more than 80% remained employed the following year. Among patients receiving sick leave benefits at baseline, 25% were employed after one-year. Risk markers of not returning to work were 'younger age' in primary prevention ICD-patients, while 'female sex', 'LVEF ≤40', 'lower income' and '≥3 comorbidities' were risk markers in secondary prevention ICD-patients. Lower educational level was a risk marker in both patient groups. CONCLUSIONS: High return-to-work proportions following ICD-implantation, with a subsequent high level of employment maintenance were found. Several significant risk markers of not returning to work were identified including 'lower educational level', that posed a risk in both patient groups.Trial registration number: Capital Region of Denmark, P-2019-051.

Association of patient-reported psychosocial healthcare and risk of readmissions and mortality in patients with ischemic heart disease: A population-based cohort study.

OBJECTIVE: Psychosocial risk factors are common in patients with ischemic heart disease (IHD) and linked to poor prognosis. Psychosocial healthcare is recommended in international guidelines and has demonstrated positive effects, primarily on psychosocial symptoms. We examined the association between patient-reported psychosocial healthcare and hospital readmissions and mortality in patients with IHD. METHODS: A population-based cohort study with register-based follow-up. Patient-reported psychosocial healthcare was measured by seven items in a survey sent to a random sample of patients with incident IHD in Denmark in 2014. We used multivariable Cox proportional hazards models and Poisson regression to examine the association between psychosocial healthcare and readmissions and all-cause mortality. RESULTS: In total, 1083 (57%) patients were followed up to 4½ years. Low psychosocial support was reported by 53.4%, medium by 26.2% and high by 20.4% patients. The hazard of acute cardiac readmission for patients reporting low psychosocial healthcare was 2.08 higher than for patients reporting high psychosocial healthcare (95%CI:1.01-4.30). No association was found with time to first all-cause readmission. The acute cardiac readmission rate was 3.24 (95%CI:1.66-6.29) and 4.23 (95%CI:2.15-8.33) times higher among patients reporting low and medium psychosocial healthcare compared to high, and the all-cause readmission rate was 1.30 (95%CI:1.16-1.46) and 1.32 (95%CI:1.17-1.49) times higher. The hazard of death was 2.86 (95%CI:1.23-6.69) and 2.88 (95%CI:1.18-7.04) times higher among patients reporting low and medium psychosocial healthcare compared to high. CONCLUSION: In patients with IHD, a high level of patient-reported psychosocial healthcare was significantly associated with reduced hospital readmissions and all-cause mortality.

Perception of pharmacological prevention and subsequent non-adherence to medication in patients with ischaemic heart disease: a population-based cohort study.

OBJECTIVE: A patient-focused approach is advocated to embody risk of non-adherence to medication and subsequent adverse clinical outcomes following ischaemic heart disease (IHD). This study aimed to explore how patient perceived information on pharmacological prevention was associated with subsequent non-adherence to medication (measured by non-initiation, non-implementation and non-persistence) in patients with incident IHD. DESIGN: Cohort study. SETTING: Denmark. PARTICIPANTS: Register-based cohort of 829 patients with incident IHD in 2013. MEASURES: Perception covered whether patients' experienced being adequately informed about their pharmacological prevention. Information on such was obtained from a survey and divided into 'Well informed', 'Moderately informed' and 'Poorly informed'. Information on baseline characteristics, and reimbursed prescriptions of medication (antiplatelets, statins, ACE-inhibitors/angiotensin receptor blockers and ß-blockers) during follow-up were obtained by linkage to nationwide public registers. Non-initiation and non-implementation of medication, measured as proportion of days covered, were analysed by Poisson regression. Non-persistence to medication, measured as risk of discontinuation, was analysed by multivariable Cox proportional hazard regression. PRIMARY AND SECONDARY OUTCOME MEASURES: Non-implementation and non-persistence to medication up to 365 days of follow-up were primary outcomes. Secondary outcomes included non-initiation as well as non-implementation and non-persistence to medication at 180 days of follow-up. RESULTS: A dose-response association was in general found between perception of pharmacological prevention and risk of non-implementation and non-persistence. For example, the hazard of non-persistence to antiplatelets was 1.18 (95% CI 0.71 to 1.96) times higher for patients reporting 'Moderately informed' and 1.89 (95% CI 1.10 to 3.25) times higher for patients reporting 'Poorly informed', compared with patients reporting 'Well informed of perception of pharmacological prevention' up to 365 days of follow-up. CONCLUSION: Lower levels of perception of pharmacological prevention were associated with subsequent non-implementation and non-persistence to medication in patients with incident IHD.

The development of a health-promoting employment intervention with physical activity for young people Not in Education, Employment or Training (NEET): NEXT STEP-on the path to education and job.

BACKGROUND: In the EU, approx. 16.5% of the 20-34-year-olds are Not in Education, Employment or Training (NEET). Research shows that good health is an important progression factor towards employment, and daily physical activity as well as participation in sports has a positive effect on physical and mental health as well as in the development of life skill. However, there is an absence of studies investigating what role physical activity can play in the employment efforts. The aim of this study is to investigate experiences with physical activity in employment interventions and to describe the development of a health-promoting employment intervention with physical activity for young people aged 18-30 years who are NEET. METHODS: The study combined an evidence-based approach with practice-based experiences. It included a Mapping of Danish employment interventions with physical activity for young people NEET, an overview of national reports and international literature, a workshop with leaders and employees from Danish municipalities, and fieldwork in four municipalities. Key findings were grouped thematically and were transformed into intervention content in a close dialog with relevant researchers and practitioners. RESULTS: In general, physical activity was assessed as a meaningful method when working with young people NEET. A range of positive experiences was highlighted, including successful experiences, surplus of mental resources, new ways of meeting, and new social relations. Based on these findings, a 16-week health-promoting employment intervention, NEXT STEP, was developed with the following intervention components: (1) fixed boundaries, (2) body and physical activity, (3) social relations and network, and (4) life skills and future. NEXT STEP is designed to be implemented in Danish job centers. CONCLUSION: The study found the great potential of including physical activity in employment interventions for young people NEET. The planning and development of the intervention have reinforced a comprehensive evaluation; however, the first intervention in its entirety is ready for testing in a randomized feasibility trial.

Cardiac rehabilitation for patients with heart failure: association with readmission and mortality risk.

AIMS: To examine the temporal trends and factors associated with national cardiac rehabilitation (CR) referral and compare the risk of hospital readmission and mortality in those referred for CR versus no referral. METHODS AND RESULTS: This cohort study includes all adult patients alive 120 days from incident heart failure (HF) identified by the Danish Heart Failure Registry (n = 33 257) between 2010 and 2018. Multivariable logistic regression models were used to assess the association between CR referral and patient factors and acute all-cause hospital readmission and mortality at 1 year following HF admission. Overall, 46.7% of HF patients were referred to CR, increasing from 31.7% in 2010 to 52.2% in 2018. Several factors were associated with lower odds of CR referral: male sex [odds ratio (OR): 0.85; 95% confidence interval: 0.80-0.89], older age, unemployment, retirement, living alone, non-Danish ethnic origin, low educational level, New York Heart Association (NYHA) class IV vs. I (OR: 0.75; 0.60-0.95), left ventricular ejection fraction >40%, and comorbidity (stroke, chronic kidney disease, atrial fibrillation/flutter, and diabetes). Myocardial infarction, arthritis, coronary artery bypass grafting, percutaneous coronary intervention, valvular surgery, NYHA class II, and use of angiotensin-converting enzyme inhibitors were associated with higher odds of CR referral. CR referral was associated with lower risk of acute all-cause readmission (OR: 0.92; 0.87-0.97) and all-cause mortality (OR: 0.65; 0.58-0.72). CONCLUSION: Although increased over time, only one in two HF patients in Denmark were referred to CR in 2018. Strategies are needed to reduce referral disparities, focusing on subgroups of patients at highest risk of non-referral.

Non-Persistence with Medication as a Mediator for the Social Inequality in Risk of Major Adverse Cardiovascular Events in Patients with Incident Acute Coronary Syndrome: A Nationwide Cohort Study.

AIM: Low socioeconomic status is associated with higher risk of major adverse cardiovascular events (MACE) among patients with incident acute coronary syndrome (ACS). We examined whether non-persistence with antiplatelet and statin therapy mediated the income- and educational-related inequality in risk of MACE. METHODS: Using national registers, all Danish patients diagnosed with incident ACS from 2010 to 2017 were identified. The primary outcome (MACE) comprised all-cause death, cardiac death and cardiac readmission. Risk of MACE was handled by discrete time analyses using inverse probability of treatment weights. The mediator variable comprised non-persistence to a combined 2-dimensional measure of statin and antiplatelet treatment. The mediation analysis was evaluated by population average effects. RESULTS: The study population was 45,874 patients, of whom 16,958 (37.0%) were non-persistent with medication and 16,365 (35.7%) suffered MACE during the median follow-up of 3.5 years. Compared to patients with low income, the adjusted hazard ratio of MACE was lowered by 33% (HR: 0.67, 95% CI: 0.61-0.72) in men and by 34% (HR: 0.66, 95% CI: 0.61-0.72) in women with high income, respectively. Similar results were observed according to level of education. A socioeconomic difference in risk of non-persistence was found in men but not women and only in relation to income. The lower risk of non-persistence observed in high-income men mediated the lower risk of MACE by 12.6% (95% CI: 11.1-14.1%) compared with low-income men. CONCLUSION: Non-persistence with medication mediated some of the income-related inequality in risk of MACE in men, but not women, with incident ACS.

Reducing smoking in youth by a smoke-free school environment: A stratified cluster randomized controlled trial of Focus, a multicomponent program for alternative high schools.

Youth smoking remains a major challenge for public health. Socioeconomic position influences the initiation and maintenance of smoking, and alternative high school students are at particularly high risk. The school environment is an important setting to promote health, however there is a lack of evidence-based school intervention programs. This article presents the Focus study, which aims to test the implementation and effectiveness of a school-based intervention integrating1 a comprehensive school smoking policy [i.e. smoke-free school hours (SFSH)]2, a course for school staff in short motivational conversations3, school class-based teaching material4, an edutainment session5, a class-based competition, and6 access to smoking cessation support. Together these intervention components address students' acceptability of smoking, social influences, attitudes, motivation, and opportunities for smoking. The setting is alternative high schools across Denmark, and the evaluation design is based on a stratified cluster randomized controlled trial comparing the intervention group to a control group. Outcome data is collected at baseline, midway, and at the end of the intervention period. Moreover, a detailed process evaluation, using qualitative and quantitative methods, is conducted among students, teachers, and school principals. The results from this trial will provide important knowledge on the effectiveness of a smoke-free school environment. The findings will lead to a better understanding of which policies, environments, and cognitions, contribute to preventing and reducing cigarette use among young people in a diverse and high-risk school setting, and illuminate which complementary factors are significant to achieve success when implementing SFSH.