Public health educational comprehensiveness: The strategic rationale in establishing networks among schools of public health.

The establishment and continuing development of a sufficient and competent public health workforce is fundamental for the planning, implementation, evaluation, effect and ethical validity of public health strategies and policies and, thus, for the development of the population's health and the cost-effectiveness of health and public health systems and interventions. Professional public health strategy-making demands a background of a comprehensive multi-disciplinary curriculum including mutually, dynamically coherent competences - not least, competences in sociology and other behavioural sciences and their interaction with, for example, epidemiology, biostatistics, qualitative methods and health promotion and disease prevention. The size of schools and university departments of public health varies, and smaller entities may run into problems if seeking to meet the comprehensive curriculum challenge entirely by use of in-house resources. This commentary discusses the relevance and strength of establishing comprehensive curriculum development networks between schools and university departments of public health, as one means to meet the comprehensiveness challenge. This commentary attempts to consider a two-stage strategy to develop complete curricula at the bachelor and master's as well as PhD levels.

The Role of European Schools and University Departments of Public Health in the 2020 COVID-19 Response, European Region, 2020.

Objective: The main objective was to examine, how European Schools of Public Health (SPHs) responded to the COVID-19 pandemic through 2020, across the main activity domains of the SPHs. Methods: A cross-sectional survey based on an online questionnaire concerning the anti-COVID-19 activities from 1st March to 31st October 2020 of the 117 members of the Association of Schools of Public Health in the European Region (ASPHER). The questionnaire asked about 33 sub-themes within the four main themes of teaching, health communication to the public, research, and consultancy/advice. Results: Fifty-nine SPHs (50%) completed the questionnaire. Seventy-nine per cent of participants were involved in COVID-19 related teaching; health communication to the public, 76%; research, 80%; consultancy/advice, 81%. Eight out of ten participants had been involved in all of the four main themes. Conclusion: The study demonstrated a substantial body of COVID-19 related work by SPHs in Europe, and an outstanding potential to deliver crucial knowledge and skills to support the governance and the public health systems necessary to combat COVID-19.

Adherence to guidelines in people with screen-detected type 2 diabetes, ADDITION, Denmark.

OBJECTIVE: In people with screen-detected type 2 diabetes in primary care, (1) to assess adherence to guidelines, recommending consultation with the GP every three months and treatment initiation with an ACE inhibitor or an angiotensin-II receptor antagonist when systolic BP was > 120 mmHg and/or diastolic BP was > 80 mmHg, and (2) to identify predictors for adherence. DESIGN: Prospective follow-up of a fixed cohort of patients. SETTING: Fifty-four Danish general practices. SUBJECTS AND MAIN OUTCOME MEASURES: A total of 361 people with screen-detected type 2 diabetes were followed up for 410 days to assess planned consultations with their GP and recording of BP. Some 226 people, with BP recorded above guideline threshold(s) and where treatment was not already initiated, were followed for up to 410 days to monitor prescription redemption. RESULTS: At 3, 6, 9 and 12 months 80%, 77%, 74%, and 73% of the cohort attended a consultation. A total of 89% of the cohort attended two of the four planned consultations. The probability of redeemed prescriptions for an ACE inhibitor or an angiotensin-II receptor antagonist according to the guideline during the first year following diagnosis was 51%. High initial BP was associated with prescription redemption. No other analysed individual or organisational characteristics were found to be associated with treatment initiation. CONCLUSION: The consultation attendance was reasonably high, and treatment initiation with an ACE inhibitor or an angiotensin-II receptor antagonist according to the guideline was found in half of the cases. High initial BP increased the probability of treatment initiation.

Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend.

BACKGROUND: Cardiac rehabilitation (CR) is well documented, in randomised trials, to reduce mortality risk after myocardial infarction (MI). Selection of healthy patients for CR is a relatively unexplored problem. Our aims were to identify predictors of CR-attendance and to describe the prognosis as concerns mortality, re-admission and invasive treatment among CR-attendees as compared to CR-non-attendees. METHODS: From a cohort of 138 290 persons aged 30-69 years, we identified consecutive MI patients, between 1 April 2000 and 31 March 2002. There were 206 MI patients, who survived until admission, and among the 200 who survived 30 days, 145 (72.5%) attended a comprehensive CR programme. Data were obtained from patient charts and from Danish population registers, and as a result we had no non-participation for the study. RESULTS: The 2-year mortality proportions for patients surviving the first 30 days of admission were 2.8 and 21.8% among CR-attendees and CR-non-attendees, respectively (P < 0.0001). Among CR-non-attendees, there was a smaller fraction having an invasive treatment performed as compared with CR-attendees. By multiple logistic regression controlling for age and sex, CR-attendance was associated with chest pain, whereas CR-non-attendance was associated with low gross income, single living and inverted T-wave in the electrocardiogram. CONCLUSION: CR attendance rate was 72.5%. Non-attendees have a higher mortality risk, which in part may be attributed to selection of healthy patients. Non-attendees are older and more likely to have atypical symptoms at admission, a low socioeconomic status and to live alone. Special attention is needed to improve CR attendance among such patients.

Physical activity and low-back pain in schoolchildren.

Design of the experiment is to study the cross-sectional sample with retrospective information. The objective is to identify the types of physical activity associated with the decreased occurrence of low-back pain (LBP) in schoolchildren. Physical activity may be hypothesized to possess a potential for LBP prevention. The possible connection between LBP and specific sports activities is however sparsely documented. A total of 546, 15- to 16-year-old schoolchildren filled a questionnaire on current physical activities and LBP occurrence and severity. In multiple logistic regressions, the association of LBP with exposure variables was corrected for body height and weight (data from school health service files) and for anthropometric and school furniture parameters. More than half of the children reported pain or discomfort in the low-back region during the preceding 3 months, and 1/4 experienced a decreased functioning or need of care because of LBP. LBP correlated with physical inactivity, e.g. time spent on homework and hours watching TV or video, and with a series of sports activities, e.g. jogging, handball playing and gymnastics. Among sports activities, only swimming and the number of hours per week participating in soccer were associated with a decreased LBP prevalence. With the exception of swimming and soccer, the types of sport reported by this schoolchild population do not offer themselves for consideration as tools for LBP prevention. Based on the associations found with indicators of physical inactivity, attempts to motivate the children to increase their general physical activity level should be considered for trial.

Prevalence of pain in the head, back and feet in refugees previously exposed to torture: a ten-year follow-up study.

AIM: To estimate change over 10 years concerning the prevalence of pain in the head, back and feet, among previously tortured refugees settled in Denmark, and to compare associations between methods of torture and prevalent pain at baseline and at 10-year follow-up. METHODS: 139 refugees previously exposed to torture in their home country were interviewed at a Danish rehabilitation clinic on average 8 years after their final release from confinement and re-interviewed 10 years later. Interviews focused on history of exposure to physical and mental torture and on pain in the head, back and feet prevalent at study. RESULTS: The mean number of times imprisoned was 2.5 and the mean cumulative duration of imprisonment 19.4 months. The most frequent physical torture method reported was beating (95.0%) and the main mental torture method deprivation (88.5%). Pain reported at follow-up was strongly associated with pain reported at baseline, and the prevalence of pain increased considerably (pain in the head, 47.5% at baseline and 58.3% at follow-up; back, 48.2% and 75.5%; feet, 23.7% and 63.3%). Predictor patterns at baseline and at follow-up had common traits, so that pain in the head and pain in the feet both were associated with the number of torture methods as well as specific methods, both at baseline and at follow-up. Pain in the back at baseline was associated with torture. CONCLUSION: Two decades after the torture took place, increasing proportions of survivors seem to suffer from pain associated with the type and bodily focus of the torture. This presents a considerable challenge to future evidence-based development of effective treatment programs.

Validity of PTSD in a sample of refugee children: can a separate diagnostic entity be justified?

The objective of this study was to examine the construct validity of PTSD in a sample of refugee children from the Middle East-- more specifically, to assess whether associations between traumatic events and specific PTSD symptoms were more outspoken than (1) the associations of PTSD symptoms with non-traumatic exposures, and (2) the associations of violent exposures with symptoms other than PTSD-symptoms. Parents of 311 refugee children from the Middle East were interviewed concerning their children's traumatic experiences and mental health symptoms. The specific PTSD symptoms did not cluster in a factor analysis. The PTSD symptom complex was significantly predicted not only by violent exposures (mother tortured, OR 8.2, p < 0.005; father disappeared OR 3.2, p < 0.05) but also by indicators of family interaction and parents' occupational situation. The two identified violent exposures had significant independent associations with a series of symptoms including symptoms other than those of PTSD (r(s) ranging from 0.25 to 0.44, p < 0.001). Thus it does not seem sufficient to focus solely on PTSD symptomatology when assessing the mental health needs of refugee children.

Can the development of new dental caries in Danish schoolchildren be predicted from surveillance data in the School Dental Service?

BACKGROUND: Dental screening programmes for Danish children generally target all children, irrespective of their individual caries risk. The standard screening interval is approximately 12 months. A valid systematic screening tool based on routine information sources is however indispensable, if more selective screening strategies should be developed to target the children at highest risk. OBJECTIVE: To estimate the precision with which Danish schoolchildren at high risk for developing dental caries within 1 year can be identified based on information from routine registers. METHODS: Based on data from the Danish National Board of Health's Recording System for the Danish Child Dental Services and from the Central Office of Civil Registration, 3705 schoolchildren aged 7-12 years were followed through 1994-1996. Dental health information as of 1994 and changes 1994-1995 were applied in multiple logistic regressions together with social data as of 1995 to estimate the individual 1-year (1995-1996) risk of developing caries. RESULTS: In 1995, 37.4% of the children had a DMFS index above 0, and during the following year 21.8% of all children developed new caries. The individual child's 1-year caries risk could be estimated relatively accurately at baseline as indicated by the area (76%) under the receiver operating characteristic curve. About 40% of children with an estimated risk of 20% and above developed new caries, whereas 90% of the rest of the children did not do so. CONCLUSION: Based on information from Danish routine registers children at low caries risk may be identified relatively precisely. This may form the basis for the continuous development and targeting of high-risk strategies, in which the screening for caries among children of estimated low risk may be postponed at least 1 year.

Prevalent pain and pain level among torture survivors: a follow-up study.

AIM: To estimate change over nine months and over two years, as concerns the prevalence and level of pain in the head, back and feet, among previously tortured refugees settled in Denmark, and to compare associations between torture methods and the prevalence of pain at baseline and at follow-up. METHODS: Sixty-nine refugees previously exposed to torture in their home country were interviewed at a Danish rehabilitation clinic. Fifty-four accepted to be re-interviewed after nine months, and 47 were interviewed again 14 months later. Interviews focussed on the history of exposure to physical and mental torture and on pain in the head, back and feet at baseline and at follow-up. RESULTS: The mean cumulative duration of imprisonment was 1.7 years, and on the average more than 10 years elapsed between torture and examination. The most frequent physical torture method reported was beating (97%), whereas the main mental torture method was threats of death (97%). The prevalence of pain reported at the follow-up interviews did not differ significantly from that reported at baseline (pain in the head, 81% at baseline and 77% at 23-month follow-up; back, 78% and 81%; feet, 59% and 70%). The same pattern was found when examining the level of pain as indicated by Visual Analogue Scales. Pain in the feet at follow-up was associated with previous exposure to beating against the feet. Pain in the back at baseline and pain in the head at follow-up were associated with suffocation. CONCLUSION: More than ten years after the torture took place, survivors of torture continue to suffer from pain associated with the type of torture they had been subjected to. This presents a considerable challenge to future evidence-based development of effective treatment programmes.

Main competences and skills to perform Essential Public Health Operations, offered by Schools of Public Health in four European countries: a short pilot report.

OBJECTIVES: To consider the stage of implementation of main competences and EPHO skills in selected schools of public health in four European countries-France, Poland, Portugal, and the UK. METHODS: By use of visual analogue scales (VAS) ranging 1-5, the leads of three schools of public health (SPH) in each of the four countries, France, Poland, Portugal and the UK, reported the strength of intellectual and practical competences as well as skills to perform essential public health operations (EPHOs), offered by their education and training programmes. RESULTS: The self-reports indicated substantial coverage of the multidimensional public health discipline. Each country representation had its overall characteristic profile, and there was found noteworthy within-country as well as between-country variation. CONCLUSIONS: The schools should meet the challenge of establishing collaborative networks, which will be important for public health strategy making and implementation, for shaping a coherent public health profession, and thus ultimately for population health. This pilot report should be followed up by more systematically penetrating and comprehensive analyses to identify met and unmet needs in public health education and training.

Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study.

UNLABELLED: This study of 9605 community-dwelling residents supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in elderly in a northern European region known to be deficient in vitamin D, especially during winter periods. INTRODUCTION: We evaluated the effect of two programs for the prevention of osteoporotic fractures leading to acute hospital admission in a population of elderly community-dwelling residents. MATERIALS AND METHODS: This was a factorial, cluster-randomized, pragmatic, intervention study. We included 9605 community-dwelling residents aged 66+ years. We offered a prevention program of a daily supplement of 1000 mg of elemental calcium as calcium carbonate and 400 IU (10 microg) of vitamin D3 to a total of 4957 participants. Another program with evaluation and suggestions for the improvement of the domestic environment was offered to a total of 5063 participants. Both programs included revision of the resident's current pharmaceutical treatment. We achieved information on osteoporotic fractures in the study population from the Danish Hospital Registration Database. We defined osteoporotic fractures as low energy fractures of the proximal humerus, distal forearm, vertebral column, pelvis, cervical femur, and intertrochanteric femur. RESULTS: Active participation was 50.3% in the Calcium and Vitamin D Program and 46.4% in the Environmental and Health Program. We observed a 16% reduction in fracture incidence rate (relative risk [RR], 0.84; CI, 0.72-0.98; p < 0.025) among male and female residents offered the Calcium and Vitamin D Program (intention-to-prevent analysis). CONCLUSIONS: This study supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in community-dwelling elderly people in a northern European region known to be deficient in vitamin D, especially during winter periods.

The effects on length of stay of introducing a fast track patient pathway for myocardial infarction: a before and after evaluation.

The aim was to assess whether the implementation of a fast-track patient pathway (FTPP) at an invasive treatment ward (ITW) could reduce the length of hospital stay (LOHS), among patients with non-ST Elevation Myocardial Infarction (NSTEMI). A before-and-after study was carried out, based on historical data from a total of 202 patients with NSTEMI admitted to a coronary ITW during two inclusion periods each lasting 100 days (Period I, 2004, no fast track, 95 consecutive patients; Period II, 2005, fast track implemented, 107 consecutive patients). Patients were followed during 180 days as concerns the total LOHS. A total of 33 patients passed through the FTPP. Their mean total LOHS was significantly shorter (3.3 days reduction; 95% CI 1.7, 5.5 days) as compared with all Period II patients. In total, Period II patients, however, spent significantly more days (mean, 1.7 days more; 95% CI 0.2, 3.3 days) in hospital than Period I patients. Thus, the implementation of FTPP reduced the mean LOHS for patients selected for the FTPP, but the mean LOHS for other patients rose and so the overall mean LOHS turned out to be significantly prolonged. The implementation of FTPP appears a complicated matter; changing one component has consequences for the wider health-care system.

Health services use associated with emergency department closure.

OBJECTIVE: To study changes in health services consumption following substantial reduction in the availability of local emergency services in a small municipality population. METHOD: A dynamic cohort (21,000 residents of Viborg County, Denmark, of which 2,300 from Morsø municipality) was followed, 1997-2003. Data were extracted from administrative registries including information on individual use of emergency services and other hospital care, contact with GPs and socioeconomic background. Health services' use by the Morsø population was measured before reduction in emergency room opening hours, during a period of reduced opening hours and after closure, compared with the rest of Viborg County. RESULTS: Emergency service use did not change among Morsø municipality residents compared to other Viborg County residents. Compared to men in other parts of the county, Morsø men did not change their use of substitute health services. By contrast, Morsø women compared to the rest of Viborg county reduced their use of GP services in terms of face-to-face visits (ß = -0.08, P = 0.020), telephone consultations (ß = -0.11, P = 0.007), home visits (ß = -0.48, P = 0.009), and their inpatient hospital utilization (ß = -0.12, P = 0.022) during the period when emergeny services were only available in the daytime. CONCLUSIONS: Emergency services at neighbouring hospitals (40 kilometres distance) were able to compensate, in part, for the decreased local emergency service provision. Concurrent changes in health care utilization patterns were observed among local residents that varied by gender.