Gunnar Inghe: A founding father of Scandinavian social medicine and still highly relevant.

Gunnar Inghe (1910-1977) was a founding father of Scandinavian social medicine and the first editor of the Scandinavian Journal of Social Medicine. He worked as a physician for social care clients in Stockholm from 1944 to 1961 and was professor in social medicine from 1961 to 1975. We (F.D. and U.J.) were his last two PhD students. As we were recollecting the 50-year history of the Scandinavian Journal of Public Health in 2022, it became evident to us how relevant Gunnar Inghe's work, 45 years after his death, still is for today's social medicine, population health research and policy in Scandinavia. We shall explain why with five examples of Inghe's work: reproductive health, health of paupers, foundation of the discipline, international solidarity and collaboration between medical and social care.

Agribusiness and the COVID-19 syndemic: The unsustainable pathways.

It has been suggested that it would be more appropriate to term the COVID-19 pandemic a syndemic, as the infection interacts synergistically with pre-existing chronic conditions such as obesity. Both conditions occur with steep socio-economic inequalities, and Brazil is suffering a heavy burden from both. What and who drives the clustering and interaction of these disorders? In this commentary, we examine the pathways leading to the COVID-19 syndemic. Deforestation, declining biodiversity and factory farming are promoting the emergence of new pathogens. Widespread use of pesticides influences immune, endocrine and metabolic systems. The ingestion of ultra-processed food promotes malnutrition and obesity in a country where at the same time poverty and food insecurity is rising. Brazilian agribusiness is focused on the production and global export of agricultural commodities, mainly for animal food and meat production. It is made possible through a combination of expanded land use, with deforestation in Amazonas and other Brazilian biomes, and the intensification of land use and cultivation of genetically modified crops with fertilizers and pesticides. This development is not sustainable for either population health or the environment.

Underlying pathways of social inequality in tooth loss: the mediating role of sugary beverages and diabetes.

BACKGROUND: Previous studies show social inequality in tooth loss, but the underlying pathways are not well understood. The aim was to investigate the mediated proportion of sugary beverages (SBs) and diabetes and the association between educational level and tooth loss, and to investigate whether the indirect effect of SBs and diabetes varied between educational groups in relation to tooth loss. METHODS: Data from 47,109 Danish men and women aged 50 years or older included in the Danish Diet, Cancer and Health Study was combined with data from Danish registers. Using natural effect models, SBs and diabetes were considered as mediators, and tooth loss was defined as having <15 teeth present. RESULTS: In total, 10,648 participants had tooth loss. The analyses showed that 3% (95% confidence interval 2-4%) of the social inequality in tooth loss was mediated through SBs and diabetes. The mediated proportion was mainly due to differential exposure to SBs and diabetes among lower educational groups. CONCLUSIONS: The findings show that SBs and diabetes to a minor degree contribute to tooth-loss inequalities. The explanation indicates that individuals in lower educational groups have higher consumption of SBs and more often suffer from diabetes than higher educational groups.

Planning for health equity in the crossfire between science and policy.

The persistence of health inequalities means that many public health professionals face an ongoing task to develop and update policies to tackle them. However, although the inequalities might be unchanged, the political priorities in the many policy areas involved are changing and the ambition to reduce the health divide is constantly facing strong forces pushing in the opposite direction. Recent proposals to re-think health inequalities need to be treated with caution because they are disconnected from what is needed for policy-making in this area. From our experience of 35 years in developing strategies to tackle health inequalities, we still see many entry points with space for local and national improvements, but it is crucial to ask the right questions. The aim of this Commentary is to present a new framework of eight questions that might provide a helpful structure for the necessary dialogue between researchers and policy-makers. Even if answers are not yet available for all of them, we believe that discussing them for a specific population in a specific political context will be fruitful to inform policy on the ground.

A health inequality impact assessment from reduction in overweight and obesity.

BACKGROUND: In recent years, social differences in overweight and obesity (OWOB) have become more pronounced. Health impact assessments provide population-level scenario evaluations of changes in disease prevalence and risk factors. The objective of this study was to simulate the health effects of reducing the prevalence of overweight and obesity in populations with short and medium education. METHODS: The DYNAMO-HIA tool was used to conduct a health inequality impact assessment of the future reduced disease prevalence (ischemic heart disease (IHD), diabetes, stroke, and multi-morbidity) and changes in life expectancy for the 2040-population of Copenhagen, Denmark (n = 742,130). We simulated an equalized weight scenario where the prevalence of OWOB in the population with short and medium education was reduced to the levels of the population with long education. RESULTS: A higher proportion of the population with short and medium education were OWOB relative to the population with long education. They also had a higher prevalence of cardiometabolic diseases. In the equalized weight scenario, the prevalence of diabetes in the population with short education was reduced by 8-10% for men and 12-13% for women. Life expectancy increased by one year among women with short education. Only small changes in prevalence and life expectancy related to stroke and IHD were observed. CONCLUSION: Reducing the prevalence of OWOB in populations with short and medium education will reduce the future prevalence of cardiometabolic diseases, increase life expectancy, and reduce the social inequality in health. These simulations serve as reference points for public health debates.

The relevance of public health research for practice: A 30-year perspective.

The Nordic context where public health responsibility is strongly devolved to municipalities raises specific demands on public health research. The demands for causal inference of disease aetiology and intervention efficacy is not different, but in addition there is a need for population health science that describes local prevalence, distribution and clustering of determinants. Knowledge of what interventions and policies work, for whom and under what conditions is essential, but instead of assuming context independence and demanding high external validity it is important to understand how contextual factors linked to groups and places modify both effects and implementation. More implementation studies are needed, but the infrastructure for that research in terms of theories and instruments for monitoring implementation is needed. Much of this was true also 30 years ago, but with increasing spending on both public health research and practice, the demands are increasing that major improvement of population health and health equity are actually achieved.

Governing health equity in Scandinavian municipalities: The inter-sectorial challenge.

AIMS: Local governments in the Scandinavian countries are increasingly committed to reduce health inequity through 'health equity in all policies' (HEiAP) governance. There exists, however, only very sporadic implementation evidence concerning municipal HEiAP governance, which is the focus of this study. METHODS: Data are based on qualitative thematic network analysis of 20 interviews conducted from 2014 to 2015 with Scandinavian political and administrative practitioners. RESULTS: We identify 24 factors located within three categories; political processes, where insufficient political commitment to health equity goals outside of the health sector and inadequate economic prioritization budget curbs implementation. Concerning evidence, there is a lack of epidemiological data, detailed evidence of health equity interventions as well as indicators relevant for monitoring implementation. Concerted administrative action relates to a lack of vertical support and alignment from the national and the regional level to the local level. Horizontally within the municipality, insufficient coordination across policy sectors inhibits effective health equity governance. CONCLUSIONS: A shift away from 'health in all policies' based on a narrow health concept towards 'health equity for all policies' based on a broader concept such as 'sustainability' can improve ownership of health equity policy goals across municipal sectors.

Joint Effect of Alcohol Consumption and Educational Level on Alcohol-related Medical Events: A Danish Register-based Cohort Study.

BACKGROUND: Alcohol-related mortality is more pronounced in lower than in higher socioeconomic groups in Western countries. Part of the explanation is differences in drinking patterns. However, differences in vulnerability to health consequences of alcohol consumption across socioeconomic groups may also play a role. We investigated the joint effect of alcohol consumption and educational level on the rate of alcohol-related medical events. METHODS: We pooled seven prospective cohorts from Denmark that enrolled 74,278 men and women age 30-70 years (study period, 1981 to 2009). We measured alcohol consumption at baseline using self-administrated questionnaires. Information on highest attained education 1 year before study entry and hospital and mortality data on alcohol-related medical events were obtained through linkage to nationwide registries. We performed analyses using the Aalen additive hazards model. RESULTS: During follow-up (1,085,049 person-years), a total of 1718 alcohol-related events occurred. The joint effect of very high alcohol consumption (>21 [>28] drinks per week in women [men]) and low education on alcohol-related events exceeded the sum of their separate effects. Among men, we observed 289 (95% confidence interval = 123, 457) extra events per 100,000 person-years owing to education-alcohol interaction (P < 0.001). Similarly, among women, we observed 239 (95% confidence interval = 90, 388) extra events per 100,000 person-years owing to this interaction (P < 0.001). CONCLUSIONS: High alcohol consumption is associated with a higher risk of alcohol-related medical events among those with low compared with high education. This interaction may be explained by differences in vulnerability and drinking patterns across educational groups.See video abstract at, http://links.lww.com/EDE/B267.

Job mobility and health in the Danish workforce.

AIMS: The globalized economy has stimulated mobility in the labour market in many countries and Denmark has one of the highest rates of mobility between workplaces among the OECD countries. This raises the question of the potential health effects of mobility and the effect of disease on mobility. METHODS: This study was register-based with a longitudinal design using data on the entire Danish population in 1992-2006. The data included mobility between employers and workplaces and seven different diseases based on admissions to hospital and drug prescriptions. RESULTS: After adjusting for relevant confounders, an exposure-response relationship was seen between mobility and the incidence of ischaemic heart disease, stroke, duodenal ulcer, anxiety/depression and, most strongly, with alcohol-related disorders. The effects were not very strong, however, with odds ratios varying from 1.2 to 1.6. As expected, no effect was seen for colorectal cancer. We also found an effect of both somatic and mental disorders on mobility, but not for the two cancer types. Mobility did not seem to prevent being out of the labour force after diagnosis. CONCLUSIONS: Frequent mobility in the labour market increases the risk of cardiovascular disease, common mental disorders and alcohol-related disorders and these diagnoses also seem to increase the risk of subsequent mobility.

Risk factors for not completing health interventions and the potential impact on health inequalities between educational groups - a mixed method study from Denmark.

BACKGROUND: Individual-based interventions aim to improve patient self-management of chronic disease and to improve lifestyle among people at high risk, to reduce the prevalence of diseases contributing to health inequality. The present study investigates risk factors for uncompleted health interventions, via a combination of quantitative and qualitative methods. METHODS: From a health centre in Copenhagen, questionnaire data on educational level, gender, age, and cohabitation status from 104 participants in health interventions were used to examine risks for dropout. Qualitative telephone interviews further investigated risk factors among 17 participants who were registered as uncompleted. RESULTS: Our findings show that there is a significantly higher prevalence of uncompleted courses among participants below age 60 (OR 3.38, 95 % CI 1.08; 10.55) and an insignificantly higher prevalence among people with low education (OR 1.82, 95 % CI 0.66; 5.03). Qualitative elaboration of these findings points to low self-control in jobs and a higher degree of comorbidity and treatment of diseases among the lower educated as determinants for not completing, but not lower motivation or less positive attitude toward the intervention itself. CONCLUSIONS: This study indicates a social difference in dropout, and if dropout is to be prevented, there is a need to acknowledge factors such as organization of the intervention, lack of job flexibility, and comorbidity. If these factors are not addressed, people with low socioeconomic status will most likely have reduced opportunities for making healthy choices, in this case, completing the intervention, and this may increase health inequality.

Risk of breast cancer in relation to combined effects of hormone therapy, body mass index, and alcohol use, by hormone-receptor status.

BACKGROUND: Alcohol consumption, increased body mass index (BMI), and hormone therapy are risk factors for postmenopausal breast cancer, but their combined effects are not well understood. Because hormone therapy is effective for the relief of menopausal symptoms, the identification of "high-risk" users is important for therapeutic reasons. We investigated interactions between hormone therapy use and alcohol-use/high BMI status in relation to invasive breast cancer risk, both overall and according to estrogen receptor (ER) status. METHODS: Two Danish prospective cohorts were pooled, including 30,789 women ages 50+ years (study period 1981 to 2009). Information on risk factors was obtained in baseline questionnaires. We performed analyses using the Aalen additive hazards model. Serum estradiol and testosterone measurements were obtained in a subsample of approximately 1000 women. RESULTS: During 392,938 person-years of follow-up, 1579 women developed invasive breast cancer. Among nonusers of hormone therapy, the risk of breast cancer was slightly increased with overweight/obesity and increasing alcohol consumption. Compared with normal-weight nonusers, the risk of breast cancer was higher in hormone therapy users across all BMI strata (P for interaction = 0.003). A markedly higher risk of breast cancer was also observed for alcohol combined with hormone therapy use compared with abstinent nonusers (P for interaction = 0.02). These effects were primarily restricted to ER-positive cases. Combined effects of hormone therapy/high BMI and hormone therapy/alcohol on serum estradiol and testosterone supported the hypothesis of a hormonal pathway linking these exposures to breast cancer. CONCLUSION: These analyses suggest an increased risk of breast cancer associated with hormone therapy use-a risk that may be particularly strong among women consuming alcohol.

The effect of breast cancer on personal income three years after diagnosis by cancer stage and education: a register-based cohort study among Danish females.

BACKGROUND: The purpose of this study was to investigate whether there is an association between stage of incident breast cancer (BC) and personal income three years after diagnosis. The analysis further considered whether the association differed among educational groups. METHODS: The study was based on information from Danish nationwide registers. A total of 7,372 women aged 30-60 years diagnosed with BC, 48% with metastasis, were compared to 213,276 controls. Generalised linear models were used to estimate the effect of a cancer diagnosis on personal gross income three years after diagnosis, stratified by education and stage of cancer. The models were adjusted for income two years prior to cancer diagnosis and demographic, geographic and co-morbidity covariates. RESULTS: Adjusting for income two years prior to cancer diagnosis and other baseline covariates (see above), cancer had a minor effect on personal income three years after diagnosis. The effect of metastatic BC was a statistically significant reduction in income three years after diagnosis of -3.4% (95% CI -4.8;-2.0), -2.8% (95% CI -4.3;-1.3) and -4.1 (95% CI -5.9;-2.3) among further, vocational and low educated women, respectively. The corresponding estimates for the effect of localised BC were -2.5% (95% CI -3.8; -1.2), -1.6% (95% CI -3.0; -0.2) and -1.7% (95% CI -3.7; 0.3); the latter estimate (for the low-educated) was not statistically different from zero. We found no statistically significant educational gradient in the effect of cancer stage on income. CONCLUSIONS: In a Danish context, the very small negative effect of BC on personal income may be explained by different types of compensation in low- and high-income groups. The public income transfers are equal for all income groups and cover a relatively high compensation among low-income groups. However, high-income groups additionally receive pay-outs from private pension and insurance schemes, which typically provide higher coverage for high-income workers.

Health promotion in primary and secondary schools in Denmark: time trends and associations with schools' and students' characteristics.

BACKGROUND: Schools are important arenas for interventions among children as health promoting initiatives in childhood is expected to have substantial influence on health and well-being in adulthood. In countries with compulsory school attention, all children could potentially benefit from health promotion at the school level regardless of socioeconomic status or other background factors. The first aim was to elucidate time trends in the number and types of school health promoting activities by describing the number and type of health promoting activities in primary and secondary schools in Denmark. The second aim was to investigate which characteristics of schools and students that are associated with participation in many (≥3) versus few (0-2) health promoting activities during the preceding 2-3 years. METHODS: We used cross-sectional data from the 2006- and 2010-survey of the Health Behaviour in School-aged Children study. The headmasters answered questions about the school's participation in health promoting activities and about school size, proportion of ethnic minorities, school facilities available for health promoting activities, competing problems and resources at the school and in the neighborhood. Students provided information about their health-related behavior and exposure to bullying which was aggregated to the school level. A total of 74 schools were available for analyses in 2006 and 69 in 2010. We used chi-square test, t-test, and binary logistic regression to analyze time trends and differences between schools engaging in many versus few health promoting activities. RESULTS: The percentage of schools participating in ≥3 health promoting activities was 63% in 2006 and 61% in 2010. Also the mean number of health promoting activities was similar (3.14 vs. 3.07). The activities most frequently targeted physical activity (73% and 85%) and bullying (78% and 67%). Schools' participation in anti-smoking activities was significantly higher in 2006 compared with 2010 (46% vs. 29%). None of the investigated variables were associated with schools' participation in health promoting activities. CONCLUSION: In a Danish context, schools' participation in health promotion was rather stable from 2006 to 2010 and unrelated to the measured characteristics of the schools and their students.

Combined effects of socioeconomic position, smoking, and hypertension on risk of ischemic and hemorrhagic stroke.

BACKGROUND AND PURPOSE: Combined effects of socioeconomic position and well-established risk factors on stroke incidence have not been formally investigated. METHODS: In a pooled cohort study of 68 643 men and women aged 30 to 70 years in Denmark, we examined the combined effect and interaction between socioeconomic position (ie, education), smoking, and hypertension on ischemic and hemorrhagic stroke incidence by the use of the additive hazards model. RESULTS: During 14 years of follow-up, 3613 ischemic strokes and 776 hemorrhagic strokes were observed. Current smoking and hypertension were more prevalent among those with low education. Low versus high education was associated with greater ischemic, but not hemorrhagic, stroke incidence. The combined effect of low education and current smoking was more than expected by the sum of their separate effects on ischemic stroke incidence, particularly among men: 134 (95% confidence interval, 49-219) extra cases per 100 000 person-years because of interaction, adjusted for age, cohort study, and birth cohort. There was no clear evidence of interaction between low education and hypertension. The combined effect of current smoking and hypertension was more than expected by the sum of their separate effects on ischemic and hemorrhagic stroke incidence. This effect was most pronounced for ischemic stroke among women: 178 (95% confidence interval, 103-253) extra cases per 100 000 person-years because of interaction, adjusted for age, cohort study, and birth cohort. CONCLUSIONS: Reducing smoking in those with low socioeconomic position and in those with hypertension could potentially reduce social inequality stroke incidence.

Education and cause-specific mortality: the mediating role of differential exposure and vulnerability to behavioral risk factors.

BACKGROUND: Differential exposures to behavioral risk factors have been shown to play an important mediating role on the education-mortality relation. However, little is known about the extent to which educational attainment interacts with health behavior, possibly through differential vulnerability. METHODS: In a cohort study of 76,294 participants 30 to 70 years of age, we estimated educational differences in cause-specific mortality from 1980 through 2009 and the mediating role of behavioral risk factors (smoking, alcohol intake, physical activity, and body mass index). With the use of marginal structural models and three-way effect decomposition, we simultaneously regarded the behavioral risk factors as intermediates and clarified the role of their interaction with educational exposure. RESULTS: Rate differences in mortality comparing participants with low to high education were 1,277 (95% confidence interval = 1,062 to 1,492) per 100,000 person-years for men and 746 (598 to 894) per 100,000 person-years for women. Smoking was the strongest mediator for cardiovascular disease, cancer, and respiratory disease mortality when conditioning on sex, age, and cohort. The proportion mediated through smoking was most pronounced in cancer mortality as a combination of the pure indirect effect, owing to differential exposure (men, 42% [25% to 75%]; women, 36% [17% to 74%]) and the mediated interactive effect, owing to differential vulnerability (men, 18% [2% to 35%], women, 26% [8% to 50%]). The mediating effects through body mass index, alcohol intake, or physical activity were partial and varied for the causes of deaths. CONCLUSION: Differential exposure and vulnerability should be addressed simultaneously, as these mechanisms are not mutually exclusive and may operate at the same time.

Cost-effectiveness of changes in alcohol taxation in Denmark: a modelling study.

INTRODUCTION: Excessive alcohol consumption is a public health problem in many countries including Denmark, where 6% of the burden of disease is due to alcohol consumption, according to the new estimates from the Global Burden of Disease 2010 study. Pricing policies, including tax increases, have been shown to effectively decrease the level of alcohol consumption. METHODS: We analysed the cost-effectiveness of three different scenarios of changed taxation of alcoholic beverages in Denmark (20% and 100% increase and 10% decrease). The lifetime health effects are estimated as the difference in disability-adjusted life years between a Danish population that continues to drink alcohol at current rates and an identical population that changes their alcohol consumption due to changes in taxation. Calculation of cost offsets related to treatment of alcohol-related diseases and injuries, was based on health care system costs from Danish national registers. Cost-effectiveness was evaluated by calculating cost-effectiveness ratios (CERs) compared to current practice. RESULTS: The two scenarios of 20% and 100% increased taxation could avert 20,000 DALY and 95,500 DALY respectively, and yield cost savings of -€119 million and -€575 million, over the life time of the Danish population. Both scenarios are thus cost saving. The tax decrease scenario would lead to 10,100 added DALY and an added cost of €60 million. For all three interventions the health effects build up and reach their maximum around 15-20 years after implementation of the tax change. CONCLUSION: Our results show that decreased taxation will lead to an increased burden of disease and related increases in health care costs, whereas both a doubling of the current level of alcohol taxation and a scenario where taxation is only increased by 20% can be cost-saving ways to reduce alcohol related morbidity and mortality. Our results support the growing evidence that population strategies are cost-effective and should be considered for policy making and prevention of alcohol abuse.

Effect of socioeconomic position on patient outcome after hysterectomy.

OBJECTIVE: To investigate the association between socioeconomic position (assessed by education, employment and income) and complications following hysterectomy and assess the role of lifestyle, co-morbidity and clinical conditions on the relationship. DESIGN: Register-based cohort study. SETTING AND POPULATION: The study included nearly all Danish women (n = 22 150) registered with a benign elective hysterectomy in the Danish Hysterectomy Database in 2004-2008. METHODS: Data were analyzed using logistic regression models estimating the odds ratio with 95% confidence intervals. MAIN OUTCOME MEASURES: Complications following hysterectomy. RESULTS: Seventeen percent of the women experienced complications in relation to the hysterectomy. Women with less than high school education and unemployed women had higher odds of infection, complications and readmission than women with more than high school education and employed women. Furthermore, unemployed women had higher odds of hospitalization >4 days than women in employment. Lifestyle factors (smoking and body mass index) and co-morbidity status seemed to explain most of the social differences. However, an association between women with less than high school education and all complications remained unexplained. Furthermore, differences in lifestyle and co-morbidity status only partially explained the higher odds of infection, complications and hospitalization >4 days for unemployed than employed women. CONCLUSION: Women with a low socioeconomic position have significantly higher odds of complications following hysterectomy compared with women with a high socioeconomic position. Unhealthy lifestyle and presence of co-morbidity in women with low socioeconomic position partially explains the differences in complications.

Assessment of health impacts of decreased smoking prevalence in Copenhagen: Application of the DYNAMO-HIA model.

AIMS: Tobacco smoking is among the leading risk factors for chronic disease and early death in developed countries, including Denmark, where smoking causes 14% of the disease burden. In Denmark, many public health interventions, including smoking prevention, are undertaken by the municipalities, but models to estimate potential health effects of local interventions are lacking. The aim of the current study was to model the effects of decreased smoking prevalence in Copenhagen, Denmark. METHODS: The DYNAMO-HIA model was applied to the population of Copenhagen, by using health survey data and data from Danish population registers. We modelled the effects of four intervention scenarios aimed at different target groups, compared to a reference scenario. The potential effects of each scenario were modelled until 2040. RESULTS: A combined scenario affecting both initiation rates among youth, and cessation and re-initiation rates among adults, which reduced the smoking prevalence to 4% by 2025, would have large beneficial effects on incidence and prevalence of smoking-related diseases and mortality. Health benefits could also be obtained through interventions targeting only cessation or re-initiation rates, whereas an intervention targeting only initiation among youth had marginal effects on morbidity and mortality within the modelled time frame. CONCLUSIONS: By modifying the DYNAMO-HIA model, we were able to estimate the potential health effects of four interventions to reduce smoking prevalence in the population of Copenhagen. The effect of the interventions on future public health depended on population subgroup(s) targeted, duration of implementation and intervention reach.