Opportunities and challenges in public-private partnerships to reduce social inequality in health in upper-middle-income and high-income countries: a systematic review and meta-synthesis.

OBJECTIVES: There is a need for novel approaches to address the complexity of social inequality in health. Public-private partnerships (PPPs) have been proposed as a promising approach; however, knowledge on lessons learnt from such partnerships remain unclear. This study synthesises evidence on opportunities and challenges of PPPs focusing on social inequality in health in upper-middle-income and high-income countries. DESIGN: A systematic literature review and meta-synthesis was conducted using the Mixed Methods Appraisal Tool for quality appraisal. DATA SOURCES: PubMed, PsychInfo, Embase, Sociological Abstracts and SocIndex were searched for studies published between January 2013 and January 2023. ELIGIBILITY CRITERIA: Studies were eligible if they applied a quantitative, qualitative, or mixed methods design and reported on lessons learnt from PPPs focusing on social inequality in health in upper-middle-income and high-income countries. Studies had to be published in either English, Danish, German, Norwegian or Swedish. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and appraised the quality of the included studies. A meta-synthesis with a descriptive intent was conducted and data were grouped into opportunities and challenges. RESULTS: A total of 16 studies of varying methodological quality were included. Opportunities covered three themes: (1) creating synergies, (2) clear communication and coordination, and (3) trust to sustain partnerships. Challenges were identified as reflected in the following three themes: (1) scarce resources, (2) inadequate communication and coordination, and (3) concerns on distrust and conflicting interest. CONCLUSIONS: Partnerships across public, private and academic institutions hold the potential to address social inequality in health. Nevertheless, a variety of important lessons learnt are identified in the scientific literature. For future PPPs to be successful, partners should be aware of the availability of resources, provide clear communication and coordination, and address concerns on distrust and conflicting interests among partners. PROSPERO REGISTRATION NUMBER: CRD42023384608.

Barriers and facilitators to return to work following cardiovascular disease: a systematic review and meta-synthesis of qualitative research.

OBJECTIVES: Return to work is a key rehabilitation goal, however, people recovering from cardiovascular disease (CVD) often struggle with returning to work. The aim of this study was to conduct a systematic review and meta-synthesis of the existing qualitative evidence on barriers and facilitators to return to work experienced by people with CVD. METHODS: A systematic literature search was conducted in PubMed, Embase, Web of Science, PsycINFO, Scopus and CINAHL in August 2022. The reference lists of the included articles were searched. The Critical Appraisal Skills Programme was used for quality appraisal and a meta-synthesis was employed. FINDINGS: This review includes 15 studies of overall high methodological quality. Barriers covered four themes: physical limitations, psychological and relational factors, the working context and support within health and social care systems. Facilitators were related to five themes: return to normality, enhancing well-being, financial concerns, the working context and support within health and social care systems. CONCLUSION: Our findings highlight that return to work following CVD is a complex process influenced by individual factors, as well as work-related factors, factors in the health and social care systems and social security policies and regulations. To improve return to work, this review illustrates a need for individualised, multidisciplinary and coordinated vocational rehabilitation programmes that accommodate potential barriers to re-employment. Similarly, this review highlights how vocational rehabilitation programmes should ensure individualised information and support early in the rehabilitation process, as well as the importance of engaging relevant stakeholders, such as employers, in making individualised return-to-work plans.

Association Between Urban Regeneration and Healthcare-Seeking Behavior of Affected Residents: A Natural Experiment in two Multi-Ethnic Deprived Housing Areas in Denmark.

Area regeneration of deprived neighborhoods is being used to reduce health inequality, socioeconomic deprivation and ethnic segregation. This quasi-experimental study examines if long-term graded exposure to urban regeneration is associated with primary healthcare-seeking behavior among residents. We compared general practitioner (GP) contacts from 2015-2020 in two adjacent, deprived social housing areas, one exposed to area regeneration. Populations were into Western and non-Western males and females aged 15 years and older (N = 3,960). Mean annual GP contact frequency for each group were estimated and a difference-in-difference (DiD) analysis was conducted with adjustments for propensity scores based on baseline characteristics. GP contact frequency increased for all groups across time with a systematically higher level and faster increase in the control groups. In particular, the mean difference between the exposed and control area for Western women increased from -4.67 to -5.76 annual contacts across the period. The mean differences in contact frequency increased for all groups but results of the DiD analyses were insignificant. In conclusion, an increasing gap in GP contact frequency, with the highest levels in the control area, was observed for all comparisons across time. More long-term research is needed to understand how the increasing gaps evolve.

The association between social integration and neighborhood dissatisfaction and unsafety: a cross-sectional survey study among social housing residents in Denmark.

BACKGROUND: Social integration and perceived neighborhood environment are recognized as important social determinants of health. However, little is known about the association between social integration and perceived neighborhood environment among underrepresented population groups, such as residents in disadvantaged neighborhoods, in public health research. The aim of this study is to: 1) Describe the levels of social integration and 2) Investigate the association between social integration and neighborhood dissatisfaction and unsafety among middle-aged and older social housing residents. METHODS: A multilingual face-to-face interviewer-administrated survey questionnaire was conducted among 206 residents aged 45 years and above (response rate: 34.1%) of various nationalities in disadvantaged socioeconomic positions in a social housing area in Denmark. The assessment of social integration was based on cohabitation status, frequency of face-to-face and non-face-to-face interaction with social relations and participation in local association activities. Neighborhood dissatisfaction measured the level of dissatisfaction with the neighborhood, and neighborhood unsafety assessed the level of unsafety being outdoors in the neighborhood. Descriptive statistics were conducted to illustrate respondent characteristics and the distribution of social integration among the study population. Logistic regression models were applied to analyze associations between social integration and neighborhood dissatisfaction and unsafety, adjusted for age, sex, country of origin, educational attainment and employment status. RESULTS: In total, 23.8% of the respondents reported low levels of social integration. A medium level of social integration was associated with higher odds of neighborhood dissatisfaction (OR: 2.36; 95% CI: 1.04-5.38) compared to the highest level of integration. A low frequency of face-to-face interaction was associated with higher odds of neighborhood dissatisfaction (OR: 2.65; 95% CI: 1.16-6.06) and neighborhood unsafety (OR: 2.41; 95% CI: 1.04-5.57) compared to the highest frequency of face-to-face interaction. CONCLUSIONS: Almost one-fourth of respondents reported low levels of social integration. A medium level of social integration was associated with neighborhood dissatisfaction. A low frequency of face-to-face interaction was associated with neighborhood dissatisfaction and unsafety. The results suggest that targeted health promotion interventions designed to foster face-to-face interaction, hold potential to reduce neighborhood dissatisfaction and unsafety among residents in disadvantaged neighborhoods.

Polypharmacy occurrence and the related risk of premature death among older adults in Denmark: A nationwide register-based cohort study.

BACKGROUND: Polypharmacy, defined as the concurrent use of ≥5 medications, increases the risk of drug-drug and drug-disease interactions as well as non-adherence to drug therapy. This may have negative health consequences particularly among older adults due to age-related pharmacokinetic and pharmacodynamic changes. This study aims to uncover the occurrence of polypharmacy among older adults in Denmark and investigate how polypharmacy relates to mortality. METHOD: This nationwide register-based study included 1,338,058 adults aged 65+ years between January 2013 and December 2017 in Denmark. Polypharmacy prevalence was measured at time of inclusion while incidence and the association between polypharmacy and mortality were measured over the five-year follow-up using Cox regression. In an attempt to adjust for confounding by indication, propensity scores with overlap weighting were introduced to the regression model. RESULTS: At time of inclusion, polypharmacy prevalence was 29% and over the five years follow-up, 47% of the remaining adults transitioned into polypharmacy. Identified risk factors included multimorbidity (2+ morbidities: HR = 3.51; 95% CI = 3.48-3.53), age (95+ years: HR = 2.85; 95% CI = 2.74-2.96), socioeconomic factors (Highest income quartile: HR = 0.81; 95% CI = 0.80-0.81), region of birth region (Non-western migrants: HR = 0.77; 95% CI = 0.75-0.79), marital status (Divorced: HR = 1.10; 95% CI = 1.10-1.12) and year of inclusion (2017: HR = 1.19; 95% CI = 1.19-1.22). Further analyses showed that polypharmacy involves many different drug cocktails with medication for the cardiovascular system (95%), blood and blood-forming organs (69%), alimentary tract and metabolism (61%) and nervous system (54%) contributing the most. After adjustment for propensity scores with OW, both polypharmacy (HR = 3.48, CI95% = 3.41-3.54) and excessive polypharmacy (HR = 3.48, CI95% = 3.43-3.53) increased the risk of death substantially. CONCLUSION: A considerable proportion of older adults in Denmark were exposed to polypharmacy dependent on health status, socio-economic status, and societal factors. The associated three- to four-fold mortality risk indicate a need for further exploration of the appropriateness of polypharmacy among older adults.

Civil Servants and Non-Western Migrants' Perceptions on Pathways to Health Care in Serbia-A Grounded Theory, Multi-Perspective Study.

(1) Background: Informal patient payments continue to persist in the Serbian health care system, exposing vulnerable groups to private spending on health care. Migrants may in particular be subject to such payments, as they often experience barriers in access to health care. Little is known about migrants paying informally to access health care in Serbia. The study aims to explore pathways of accessing health care, including the role of informal patient payments, from the perspectives of civil servants and non-western migrants in Serbia. (2) Methods: Respondents (n = 8 civil servants and n = 6 migrants) were recruited in Belgrade in 2018, where semi-structured interviews were conducted. The interviews were analysed applying the grounded theory methodological steps. (3) Results: Data reveal different pathways to navigate the Serbian health care system, and ultimately whether paying informally occurs. Migrants appear less prone to paying informally and receive the same or better-quality health care. Locals experience the need to pay informal patient payments, quasi-formal payments and to bring medicine, materials or equipment when in health facilities. (4) Conclusions: Paying informally or using private care in Serbia appear to have become common. Despite a comprehensive health insurance coverage, high levels of out-of-pocket payments show barriers in accessing health care. It is highly important to not confuse the cultural beliefs with forced spending on health care and such private spending should be reduced to not push people into poverty.

Targeting preventive home visits to older adults in disadvantaged communities: Perspectives of professionals.

This study explored the implementation of multidimensional preventive home visits targeted to older adults living in a disadvantaged community in Denmark. The intervention was adapted to include the following key components: involvement of community members in recruitment processes; a combination of individual and group-based dissemination; adaptation of materials to overcome language barriers; and diversity-sensitivity training for professionals. The study took place over 12 months between August 2016 and August 2017 and used various data sources: registry-based data, participant observations, combined with individual and focus group interviews with the target population (n = 22) and relevant health care professionals (n = 8). Here, we report on findings pertaining to implementation barriers and facilitators as seen from the perspective of professionals. Socioeconomic vulnerability was prominent, and uptake of health care services was low, indicating under-utilisation. Implementation facilitators and barriers were identified including potentials in nurturing local partnerships and proximity during recruitment; overcoming language barriers; offering diversity-sensitivity training for professionals; and a need for a more multidisciplinary, comprehensive scope of preventive visits for diverse older adults in disadvantaged communities. Thus, more focus on participatory, comprehensive and community-based health promotion are needed to ensure healthy ageing in the context of social inequality and ethnic diversity.

Providing targeted healthcare services for immigrants with complex health needs.

INTRODUCTION: Providing targeted healthcare for immigrants with complex needs is an innovative approach to reducing health inequities. This study explores sociodemographic characteristics, symptoms and morbidity patterns of patients attending one such pioneering clinic. METHODS: This was a cross-sectional survey based on 408 patients seen from 1 January 2014 to 20 November 2017. Data on socio-demographics, referral patterns, migration background, symptoms and multimorbidity were collected using a standardised screening questionnaire. Baseline blood test results were included for a subpopulation (n = 178). Data were analysed using descriptive statistics and logistic regression analysis. RESULTS: The patients, among whom 83% (n = 334) were women, represented 43 nationalities and had a mean age of 49 years. A total of 19% (n = 78) had no formal schooling. More than 70% (n = 287) reported an (oral and written) interpreter need despite most (63%) having resided in Denmark for > 20 years. Reported symptoms were often pain-related, and 87% (n = 355) reported ≥ 5 symptoms. Multi-morbidity (≥ 2 reported diagnoses) was seen in 73% (n = 298) of the patients. Women had a significantly lower odds ratio (OR) of having > 5 symptoms (OR = 0.44; 95% confidence interval (CI): 0.21-0.92) and an insignificantly lower risk of multi-morbidity (OR = 0.76; 95% CI: 0.40-1.43) than men; no significant differences were seen according to migrant status. CONCLUSIONS: The patients presented with a complex disease burden, language and a disadvantaged socioeconomic status highlighting the need for targeted health services for vulnerable immigrant groups in order to reduce inequities in health. FUNDING: Department of Infectious Diseases, Hvidovre Hospital. TRIAL REGISTRATION: none.

Social Relations, Community Engagement and Potentials: A Qualitative Study Exploring Resident Engagement in a Community-Based Health Promotion Intervention in a Deprived Social Housing Area.

Emerging evidence points towards a lower quality of life, fragile social relations and suboptimal health behavior and status of residents living in social housing areas characterized by ethnic diversity and socioeconomic deprivation. Community-based health promotion interventions developed in collaboration with the target group and adjusted to the local context can affect the acceptance of and engagement in such interventions. However, few studies have investigated the potential of community-based interventions in deprived social housing areas. This study explores residents' perspectives on engagement in a community-based health promotion intervention focusing on enhancing social relations. The study builds on qualitative methods including participant observations combined with pre- and post-intervention interviews with a selected group of residents (n = 9). Data were thematically analyzed with focuses on participation in an everyday life context, concepts of othering, and territorial stigmatization. Engagement in the intervention was motivated by the need to establish and enhance social relations, and to explore the world outside the housing area. However, barriers including cultural and language differences among residents, and competing contextual factors, challenged engagement. We conclude that participatory community-based interventions have a potential to enhance social relations in deprived social housing areas. However, adequate support and efforts to overcome the identified barriers are needed.

Health, well-being and social relations in a changing neighbourhood: protocol for a prospective, multimethods study of the consequences of large structural changes in an ethnic diverse social housing area in Denmark.

INTRODUCTION: Residential areas constitute an important arena for health, well-being and social relations. Structural interventions such as demolition and area renewal have been used to reduce inequality in health and well-being in disadvantaged areas. However, the effects of larger structural interventions are inconclusive. In a longitudinal perspective, this study aims to analyse how large-scale structural changes in an ethnic diverse social housing area are associated with the residents' health, well-being and social relations. METHODS AND ANALYSIS: In this multimethods study, we examine this aim among middle-aged and older residents in a multiethnic social housing area in a Danish municipality by the inclusion of comprehensive survey (in 2018, 2019 and 2020), register (yearly 2015-2025) and qualitative (2018-2020) data. Municipal Health Profile survey data from 2017 and 2021 will be used for comparison. The area will undergo large structural changes in the built environment during 2018-2021. A 'natural experiment' (n=6000) compares differences in health and social outcomes across the study period between the study area and a similar neighbouring area not undergoing structural changes. Through user engagement in the design of the study, throughout the different phases of the study and in the two co-created interventions embedded in the study design, a focus on empowerment and recognition of the resources and perspectives of residents are encouraged. ETHICS AND DISSEMINATION: The study is registered in the University of Copenhagen's record of biobanks and research projects containing personal data and will be conducted in accordance with the principles of the Helsinki Declaration. Residential and municipal representatives and local non-governmental organisations are engaged in the design and execution of the study to ensure the usefulness, reflexive interpretation of data, and relevance of interventions. Results will be published in international peer-reviewed scientific journals, presented at conferences and as short reports through the use of both written and visual outputs.

Improving Dietary Behavior Among Ethnic Minority Women in Denmark: A Feasibility Study Based on a Participatory and Culturally Adapted Intervention.

The Danish Heart Foundation and the non-governmental organization Neighborhood Mothers have co-developed a culturally adapted intervention seeking to promote healthy dietary behaviour among ethnic minority women. This feasibility study explores the potential of the intervention to reach ethnic minority women using health promotion initiatives. Participants attended instructor courses or cooking events, where culturally adapted, healthy recipes were introduced and meals prepared. Feasibility was explored using a mixed-method approach. Surveys were completed by 59 volunteers and 150 participants at five instructor courses and 21 cooking events. Individual interviews and focus group discussions were conducted with volunteers and participants after completion of the intervention. After the intervention, 61% of the 150 participants had high levels of knowledge about dietary recommendations, 96% intended to cook healthy dishes in the future and 84% intended to incorporate measuring equipment into their daily cooking routine. Participants with a high level of knowledge reported intention to change dietary behaviour more often than participants with lower levels of knowledge. Interviews confirmed that the participants cooked healthy dishes after participating, and incorporated knowledge about healthy food practices into their daily cooking. Few participants used measuring equipment. The intervention proved to be feasible as a health promotion initiative targeting a hard-to-reach population.

Community-based interventions to enhance healthy aging in disadvantaged areas: perceptions of older adults and health care professionals.

BACKGROUND: The number of older adults with different ethnic and socioeconomic background is steadily increasing. There is a need for community-based health promotion interventions for older adults that are responsive to ethnic and socioeconomic diversity among target populations. The aim of this study is to explore encounters between older adults living in disadvantaged areas and health care professionals in the context of community-based health promotion. METHODS: Qualitative methods were used involving interviews and focus groups with older adults (n = 22) and municipal health care professionals (n = 8), and multiple observations were conducted. Data were analyzed thematically. RESULTS: Findings show a gap between health promotion services and older adults due to a perception of services as being neither accessible nor acceptable in the context of complex health and psychosocial needs. Health care professionals reported trust, proximity and presence as fundamental factors for improving acceptability and accessibility of health promotion services. CONCLUSIONS: There is a need to develop participatory approaches to engage older adults who live in disadvantaged areas in municipal health promotion services and to ensure that these services are relevant to these groups.

Social relations and healthcare utilisation among middle-aged and older people: study protocol for an implementation and register-based study in Denmark.

BACKGROUND: While previous research establishes an association between social relations, health and use of healthcare services among older people, how to implement this knowledge in real-life settings has received much less attention. This study will explore the relationship between social relations, health and use of healthcare services in a Danish mid-life population sample. In addition, the study will explore individual and contextual factors affecting the implementation of a group-based life story intervention aimed at establishing and strengthening social relations among older people at nursing homes in Denmark. METHODS/DESIGN: A combined quantitative register-based approach and a qualitative implementation approach will be applied in this study. First, we will quantitatively analyse the relationship between social relations, health status and use of healthcare services among middle-aged people in Denmark by linking survey data on social relations, loneliness, self-perceived health and disease status from the Copenhagen Aging and Midlife Biobank (CAMB) (n = 7191) with national registries through the Public Health Database on use of healthcare services and demographic and socioeconomic factors. Second, we will qualitatively analyse individual and contextual factors affecting the implementation process of the group-based life story intervention based on semi-structured interviews (n = 16), observations and field notes with and among intervention stakeholders, i.e., participants and group leaders facilitating the intervention. DISCUSSION: The results of this study are expected to improve knowledge about mechanisms through which social relations are associated with health status and use of healthcare services and to inform the implementation of future interventions targeting social relations among older people at nursing homes. TRIAL REGISTRATION: The study has been registered and approved by the Danish Data Protection Agency. Seperate approvals have been attained for the qualitative data (Approval No. SUND-2016-08), and for the quantitative data in the CAMB database which has also received approval from the local ethical committee (approval No.H-A-2008-126 and No. 2013-41-1814, respectively).

Recruitment of ethnic minorities for public health research: An interpretive synthesis of experiences from six interlinked Danish studies.

AIMS: This paper examines the importance of recruitment site in relation to the recruitment of ethnic minorities into health research. It presents a synthesis of experiences drawn from six interlinked Danish studies which applied different methods and used healthcare facilities and educational settings as sites for recruitment. METHODS: Inspired by interpretive reviewing, data on recruitment methods from the different studies were synthesized with a focus on the various levels of recruitment success achieved. This involved an iterative process of comparison, analysis and discussion of experiences among the researchers involved. RESULTS: Success in recruitment seemed to depend partly on recruitment site. Using healthcare facilities as the recruitment site and healthcare professionals as gatekeepers was less efficient than using schools and employees from educational institutions. Successful study designs also depended on the possibility of singling out specific locations with a high proportion of the relevant ethnic minority target population. CONCLUSIONS: The findings, though based on a small number of cases, indicate that health professionals and healthcare institutions, despite their interest in high-quality health research into all population groups, fail to facilitate research access to some of the most disadvantaged groups, who need to be included in order to understand the mechanisms behind health disparities. This happens despite the genuine wish of many healthcare professionals to help facilitate such research. In this way, the findings indirectly emphasize the specific challenge of accessing more vulnerable and sick groups in research studies.

Allergen immunotherapy for the prevention of allergy: A systematic review and meta-analysis.

BACKGROUND: There is a need to establish the effectiveness, cost-effectiveness, and safety of allergen immunotherapy (AIT) for the prevention of allergic disease. METHODS: Two reviewers independently screened nine international biomedical databases. Studies were quantitatively synthesized using random-effects meta-analyses. RESULTS: A total of 32 studies satisfied the inclusion criteria. Overall, meta-analysis found no conclusive evidence that AIT reduced the risk of developing a first allergic disease over the short term (RR = 0.30; 95% CI: 0.04-2.09) and no randomized controlled evidence was found in relation to its longer-term effects for this outcome. There was, however, a reduction in the short-term risk of those with allergic rhinitis developing asthma (RR = 0.40; 95% CI: 0.30-0.54), with this finding being robust to a pre-specified sensitivity analysis. We found inconclusive evidence that this benefit was maintained over the longer term: RR = 0.62; 95% CI: 0.31-1.23. There was evidence that the risk of new sensitization was reduced over the short term, but this was not confirmed in the sensitivity analysis: RR = 0.72; 95% CI: 0.24-2.18. There was no clear evidence of any longer-term reduction in the risk of sensitization: RR = 0.47; 95% CI: 0.08-2.77. AIT appeared to have an acceptable side effect profile. CONCLUSIONS: AIT did not result in a statistically significant reduction in the risk of developing a first allergic disease. There was, however, evidence of a reduced short-term risk of developing asthma in those with allergic rhinitis, but it is unclear whether this benefit was maintained over the longer term. We are unable to comment on the cost-effectiveness of AIT.

Drawing on healthcare professionals' ethnicity: lessons learned from a Danish community pharmacy intervention for ethnic minorities.

AIMS: To present and discuss implementation experiences regarding the involvement of community pharmacists with ethnic minority backgrounds in a medication review intervention for ethnic minority poly-pharmacy patients in Denmark. METHODS: Data sources include 1) reflection notes from an introductory seminar with pharmacists and the cross-disciplinary research team and 2) five individual interviews and one focus group interview with pharmacists. Data were thematically coded and synthesised to identify underlying rationales and challenges encountered when involving professionals with ethnic minority backgrounds in interventions for ethnic minorities. RESULTS: Informants perceived the need for interventions targeted at ethnic minority poly-pharmacy patients, and highlighted the potential of involving professionals with diverse ethnic backgrounds in such interventions. However, implementation created challenges, because the professional identity of the pharmacists reduced their options for serving as peers with the same ethnic background. Furthermore, issues related to organisational difficulties and overcoming language barriers in the intervention impacted on the potential of involving professionals with ethnic minority backgrounds. CONCLUSIONS: Involving healthcare professionals with ethnic minority backgrounds in encounters with ethnic minorities holds potential for the adaptation of services to ethnically diverse populations, thus improving access to and quality of care. However, it is important to ensure sufficient personal and organisational support and to acknowledge the delicate balance between simultaneously serving as a peer and as a professional.

Refugee children have fewer contacts to psychiatric healthcare services: an analysis of a subset of refugee children compared to Danish-born peers.

PURPOSE: Studies show a high level of mental health problems among refugee children. This study examined whether a subset of refugee children living in Denmark accessed psychiatric healthcare services more than those born in the country. METHODS: This study compared 24,427 refugee children from Asia, The Middle East, Sub-Saharan Africa and former Yugoslavia, who obtained residency in Denmark between 1 January 1993 and 31 December 2010 with 146,562 Danish-born children, matched 1:6 on age and sex. The study looked at contacts with psychiatric hospitals as well as psychologists and psychiatrists in private practice. RESULTS: Between 1 January 1996 and 30 June 2012, 3.5 % of the refugee children accessed psychiatric healthcare services compared to 7.7 % of the Danish-born children. The rate ratio of having any first-time psychiatric contact was 0.42 (95 % CI 0.40-0.45) among refugee boys and 0.35 (95 % CI 0.33-0.37) among refugee girls, compared to Danish-born children. Figures were similar for those accessing private psychologists or psychiatrists, emergency room, inpatient and outpatient services. CONCLUSIONS: Refugee children used fewer psychiatric healthcare services than Danish-born children. This may indicate that refugee children experience barriers in accessing psychiatric healthcare systems and do not receive adequate assessment of their mental health and subsequent referral to specialist services.

Assessment of rehabilitation needs in colorectal cancer treatment: Results from a mixed audit and qualitative study in Denmark.

Background Systematic assessments of cancer patients' rehabilitation needs are a prerequisite for devising appropriate survivorship programs. Little is known about the fit between needs assessment outlined in national rehabilitation policies and clinical practice. This study aimed to explore clinical practices related to identification and documentation of rehabilitation needs among patients with colorectal cancer at Danish hospitals. Material and methods A retrospective clinical audit was conducted utilizing data from patient files randomly selected at surgical and oncology hospital departments treating colorectal cancer patients. Forty patients were included, 10 from each department. Semi-structured interviews were carried out among clinical nurse specialists. Audit data was analyzed using descriptive statistics, qualitative data using thematic analysis. Results Documentation of physical, psychological and social rehabilitation needs initially and at end of treatment was evident in 10% (n = 2) of surgical patient trajectories and 35% (n = 7) of oncology trajectories. Physical rehabilitation needs were documented among 90% (n = 36) of all patients. Referral to municipal rehabilitation services was documented among 5% (n = 2) of all patients. Assessments at surgical departments were shaped by the inherent continuous assessment of rehabilitation needs within standardized fast-track colorectal cancer surgery. In contrast, the implementation of locally developed assessment tools inspired by the distress thermometer (DT) in oncology departments was challenged by a lack of competencies and funding, impeding integration of data into patient files. Conclusion Consensus must be reached on how to ensure more systematic, comprehensive assessments of rehabilitation needs throughout clinical cancer care. Fast-track surgery ensures systematic documentation of physical needs, but the lack of inclusion of data collected by the DT in oncological departments questions the efficacy of assessment tools and points to a need for distinguishing between surgical and oncological settings in national rehabilitation policies.

Aging and health among migrants in a European perspective.

Population aging and the associated changes in demographic structures and healthcare needs is a key challenge across Europe. Healthy aging strategies focus on ensuring the ability to maintain health, quality of life and independent living at old age. Concurrent to the process of population aging, the demographics of Europe are affected by increased migration resulting in substantial ethnic diversity. In this paper, we narratively review the health profile of the growing proportion of aging migrants in Europe, outline key factors shaping health among this diverse group and consider ways of addressing their healthcare needs. Although factors shaping aging processes are largely similar across populations, migrant-specific risk factors exist. These include exposure to health risks before and during migration; a more disadvantaged socioeconomic position; language barriers and low health literacy; cultural factors influencing health-seeking behaviours; and psychosocial vulnerability and discrimination affecting health and quality of life. Overall, migrants experience the same morbidity and mortality causes as the native populations, but with different relative importance, severity and age of onset and with substantial differences within and between migrant groups. Little is known regarding health behaviours among aging migrants, although differences in cancer screening behaviours have been identified. Indications of widening health differentials between migrants and native populations with age and informal barriers to quality healthcare for aging migrants are causes of concern. In conclusion, there is a need for attention to migration alongside other determinants of healthy aging. The diversity in individual characteristics, life course processes and contextual factors shaping aging processes among migrants point to the need for a sensitive and comprehensive approach to policies, practices and research within the field of healthy aging. This is important to accommodate for the needs of the growing number of aging migrants in Europe and counter inequities in health and well-being at old age.