Educational outcomes and the role of comorbidity among adolescents with type 1-diabetes in Denmark.

AIMS: To examine educational outcomes among adolescents with type 1 diabetes and determine the role of comorbidity. METHODS: We conducted a nationwide register-based cohort study including 3370 individuals born between 1991 and 2003 and diagnosed with type 1 diabetes before the age of 16. They were all matched with up to four individuals without type 1 diabetes on age, gender, parents' educational level and immigration status. Information on comorbidity was based on hospital diagnoses. The individuals were followed in registers to determine whether they finished compulsory school (9th grade, usually at the age of 15-16 years), and were enrolled in secondary education by age 18 years. RESULTS: Individuals with type 1 diabetes were more likely not to complete compulsory school (OR 1.44, 95% CI 1.26-1.64), and not being enrolled in an upper secondary education by age 18 (OR 1.50, 95% CI 1.31-1.73) compared to their peers. A total of 1869 (56%) individuals with type 1 diabetes were registered with at least one somatic (n = 1709) or psychiatric comorbidity (n = 389). Those with type 1 diabetes and psychiatric comorbidity were more likely not to complete compulsory school (OR 2.47, 95% CI 1.54-3.96), and not being enrolled in an upper secondary education by age 18 (OR 3.66, 95% CI 2.27-5.91) compared to those with type 1 diabetes only. Further, there was a tendency towards an association between having somatic comorbidity and adverse educational outcomes (OR 1.25, 95% CI 0.97-1.63; OR 1.26, 95% CI 0.95-1.66) among adolescents with type 1 diabetes. The associations differed markedly between diagnostic comorbidity groups. CONCLUSION: Type 1 diabetes affects educational attainment and participation among adolescents. Psychiatric comorbidity contributes to adverse educational outcomes in this group, and there is a tendency that somatic comorbidity also plays a role.

Diabetic complications and risk of depression and anxiety among adults with type 2 diabetes.

AIMS: To investigate if diabetic complications increase the risk of depression and/or anxiety among adults with type 2 diabetes. METHODS: This register-based, prospective study included 265,799 adult individuals diagnosed with type 2 diabetes between 1997 and 2017 without a recent history of depression or anxiety. Diabetic complications included cardiovascular disease, amputation of lower extremities, neuropathy, nephropathy and retinopathy. Both diabetic complications and depression and anxiety were defined by hospital contacts and prescription-based medication. All individuals were followed from the date of type 2 diabetes diagnosis until the date of incident depression or anxiety, emigration, death or 31 December 2018, whichever occurred first. RESULTS: The total risk time was 1,915,390 person-years. The incidence rate of depression and/or anxiety was 3368 per 100,000 person-years among individuals with diabetic complications and 1929 per 100,000 person-years among those without. Having or developing any diabetic complication was associated with an increased risk of depression and/or anxiety (HR 1.77, 95% CI 1.73-1.80). The risk for depression and/or anxiety was increased for all types of diabetic complications. The strongest association was found for amputation of lower extremities (HR 2.16, 95% CI 2.01-2.31) and the weakest for retinopathy (HR 1.13, 95% CI 1.09-1.17). CONCLUSION: Individuals with type 2 diabetes and diabetic complications are at increased risk of depression and anxiety. This points towards the importance of an increased clinical focus on mental well-being among individuals with type 2 diabetes and complications.

Using instrumental variables to correct for bias in real-world cohort studies of the effects of disease-modifying treatment in MS.

BACKGROUND: Estimating the effect of disease-modifying treatment of MS in observational studies is impaired by bias from unmeasured confounders, in particular indication bias. OBJECTIVE: To show how instrumental variables (IVs) reduce bias. METHODS: All patients with relapsing onset of MS 1996-2010, identified by the nationwide Danish Multiple Sclerosis Registry, were followed from onset. Exposure was treatment index throughout the first 12 years from onset, defined as a cumulative function of months without and with medium- or high-efficacy treatment, and outcomes were hazard ratios (HRs) per unit treatment index for sustained Expanded Disability Scale Score (EDSS) 4 and 6 adjusted for age at onset and sex, without and with an IV. We used the onset cohort (1996-2000; 2001-2005; 2006-2010) as an IV because treatment index increased across the cohorts. RESULTS: We included 6014 patients. With conventional Cox regression, HRs for EDSS 4 and 6 were 1.15 [95% CI: 1.13-1.18] and 1.17 [1.13-1.20] per unit treatment index. Only with IVs, we confirmed a beneficial effect of treatment with HRs of 0.86 [0.81-0.91] and 0.82 [0.74-0.90]. CONCLUSION: The use of IVs eliminates indication bias and confirms that treatment is effective in delaying disability. IVs could, under some circumstances, be an alternative to marginal structural models.

Risk of cardiovascular disease in patients with multiple sclerosis treated with fingolimod compared to natalizumab: A nationwide cohort study of 2095 patients in Denmark.

BACKGROUND: Fingolimod may be associated with risk of developing cardiovascular disease (CVD). Studies including reference groups and long follow-up are scarce. OBJECTIVES: We hypothesized that patients treated with fingolimod would be at higher risk of developing CVD compared to patients treated with natalizumab. METHODS: A nationwide 12-year cohort study linking individual-level data from the Danish Multiple Sclerosis Registry with health registries on 2095 adult patients with multiple sclerosis (MS) without any health records of CVD at follow-up start. Exposure to fingolimod and natalizumab was defined by the first treatment of at least 3 months. Cohort entry was from 2011 to 2018. We defined CVD as a composite measure, including hypertension, ischemic heart disease, atrial fibrillation, heart failure, and stroke. We used multivariable adjusted Cox regression. RESULTS: There were 28.8 and 17.4 CVD events per 1000 person-years in fingolimod and natalizumab groups, respectively. Compared to natalizumab-treated patients, fingolimod-treated patients had a higher risk of CVD (hazard ratio (HR) = 1.57; 95% confidence interval (CI) = 1.18-2.08). Hypertension comprised 200 of 244 CVD events. CONCLUSION: We found an increased risk of CVD in patients with MS treated with fingolimod. This increased risk was mainly due to hypertension.

Sleep disorders and sleep disturbances in persons with multiple sclerosis: A population-based matched case-control study in Denmark.

Introduction Adverse sleep is common in multiple sclerosis (MS). Population-based studies including adequate control groups are lacking. We hypothesized that the prevalence of sleep disorders and other sleep disturbances would be higher in persons with MS than in controls. Methods We conducted a population-based study linking individual-level data from the Danish MS Registry (n=21,943 persons with MS) and the Danish Population Registry (n=109,715 matched controls) with information on sleep disorders from the Danish National Patient Registry and other sleep disturbances assessed by dispensed prescription drugs from the Danish National Prescription Registry. Results Prevalence of diagnosed sleep disorders in terms of central hypersomnia (0.15% vs. 0.06%), sleep disturbances (1.05% vs. 0.70%), and sleep movements (0.22% vs. 0.13%) and other sleep disturbances identified by dispensed central acting (10.73% vs. 1.10%) and hypnotic use (30.65% vs. 20.13%) medication was statistically significantly higher among persons with MS when compared to controls. We found no statistically significant difference in the prevalence of sleep apnea and parasomnia between groups. Stratified by sex and age at MS diagnosis, results for differences between persons with MS and controls were similar. Conclusion In this registry-based study, we found that the prevalence of several diagnosed sleep disorders was higher persons with MS than in controls, that is those reflecting insomnia and daytime symptoms including hypersomnia. Other sleep disturbances identified by dispensed prescription medication was markedly higher in persons with MS than controls.

Characteristics associated with non-initiation and non-completion of human papillomavirus vaccination among Danish girls: a nationwide register-based cohort study.

AIM: The aim was to identify maternal and paternal socioeconomic and demographic characteristics for non-initiation and non-completion of the human papillomavirus (HPV) vaccination among Danish girls including time-trends. METHODS: This nationwide register-based cohort study included all girls residing in Denmark who were offered free-of-charge HPV vaccination as a part of the childhood vaccination program between 2009 and 2018 (birth cohorts 1996-2005). The study samples included 296,461 daughter-mother dyads and 291,025 daughter-father dyads. Data from the Danish Vaccination Register were linked with socioeconomic and demographic data from Statistics Denmark. HPV vaccination status was classified as 'non-initiation' for girls who received no HPV vaccine and as 'non-completion' for girls who initiated the HPV vaccination program but did not receive all the scheduled HPV vaccines. Data were analyzed using logistic regression models. RESULTS: Non-initiation of HPV vaccination was 13.7%, and non-completion was 24.2% among girls who initiated the HPV vaccination program. Girls of parents who were descendants of immigrants (adjusted odds ratio: 1.50; 95% confidence interval: 1.35-1.68), were at least 35-years old at time of birth, had basic or no education, had a low income, were not in the labor market, and were unmarried had the highest non-initiation and non-completion odds. The associations between socioeconomic and demographic characteristics and HPV vaccination uptake were similar for mothers and fathers. CONCLUSIONS: Despite free-of-charge availability to HPV vaccination in Denmark, we found disparities in non-initiation and non-completion of HPV vaccination among Danish girls by both mothers' and fathers' socioeconomic and demographic characteristics.

Changes in weight status during the COVID-19 pandemic: impact of educational level and mental health.

BACKGROUND: The COVID-19 pandemic has resulted in a disruption of daily routines and changes in health behaviors leading to widespread concerns about unfavorable changes in weight status and a potential increase in the prevalence of obesity. This study examined the long-term impact of the COVID-19 pandemic on changes in weight status and its possible dependency on educational level and mental health. METHODS: The study utilizes the Danish Health and Well-being Survey with repeated self-reported information on weight status collected before the COVID-19 pandemic (autumn of 2019) and twice during the pandemic (autumns of 2020 and 2021). Information on educational level was derived from registers, whereas mental health was measured using validated scales. Generalized estimating equations were performed to investigate changes in mean weight and body mass index (BMI) category (BMI < 30 to BMI ≥ 30) between 2019 and 2021 and to investigate potential differences in changes in weight status by pre-pandemic educational level and mental health. RESULTS: Mean weight significantly increased by 0.34 kg [95% confidence interval (CI): 0.16-0.51] in 2020 and by 0.46 kg (95% CI: 0.26-0.66) in 2021 compared with pre-pandemic weight status. The increase was greater among individuals with lower educational levels and poorer mental health. There were no significant changes in BMI category during the pandemic. CONCLUSION: The results showed a significant increase in mean weight among the Danish population, particularly among individuals with lower educational levels and poorer mental health, but without detectable differences in obesity, supporting a long-term but minor impact of the COVID-19 pandemic on weight status.

Potentially avoidable mortality among adults with intellectual disability.

Persons with intellectual disabilities (ID) face pronounced health disparities. The aim of this study was to describe premature mortality by causes of death and avoidable mortality among persons with ID compared to the general Danish population. This study is based on a Danish nationwide cohort of adults (aged 18-74 years) with ID (n = 57 663) and an age- and sex-matched reference cohort (n = 607 097) which was established by linkage between several registers. The cohorts were followed in the Register of Causes of Death between 2000 and 2020. Causes of death were categorized into preventable, treatable, or unavoidable deaths using the OECD/Eurostat classification and furthermore categorized into specific interventions. We compared the observed and expected number of deaths by calculating standardized mortality ratio (SMR). Among persons with ID the number of deaths was 9400 whereof 5437 (58%) were avoidable. SMR for preventable deaths, e.g. by reducing smoking and alcohol intake or by vaccination, was 2.62 (95% CI, 2.51-2.73), and SMR for treatable deaths, e.g. by earlier diagnosis and treatment, was 6.00 (5.72-6.29). Unavoidable mortality was also six-fold increased (SMR = 6.03; 5.84-6.22). Preventable deaths were higher for persons with mild ID compared to severe ID, while treatable and unavoidable mortality were highest for persons with severe ID. The study confirmed that persons with ID have an amplified risk of mortality across all categories. There is a need for competence development of social care and healthcare personnel and reasonable adjustment of health promotion programs and healthcare services for people with ID.

The Impact of Implementation Fidelity of a School-Based Multi-Component Smoking Prevention Intervention on Vocational Students' Smoking Behavior: A Cluster-Randomized Controlled Trial.

Preventing young people's cigarette smoking is a major public health priority, and smoking is especially prevalent in vocational schools. Well-enforced comprehensive school tobacco policies accompanied by preventive efforts show potential to reduce smoking, but the implementation process is crucial to achieve the intended effect. We investigate whether and how implementation fidelity of a multi-component smoking prevention intervention impacted student smoking outcomes after 4-5 months among students in Danish vocational education and training (national age range 15-65 years, mean 25.6) and preparatory basic education (national age range 15-25 years, mean 17.6) institutions using questionnaire data from a cluster-RCT. The intervention included a smoke-free school hours policy, educational curriculum, and class competition. We calculated an overall implementation fidelity measure combining staff-reported school-level delivery (fidelity) and student-reported receipt (participation, responsiveness), and used multilevel regression models to analyze associations with smoking outcomes (smoking daily, regularly, and during school hours). We supplemented the analysis with restricted cubic spline regression. Additionally, we stratified the analyses by school types and analyzed associations between implementation fidelity of the separate intervention components and smoking outcomes. High implementation was associated with lower odds of regular smoking (OR: 0.37, 95% CI: 0.18-0.78) and smoking during school hours, but not daily smoking, and these associations varied between the school settings. When analyzed separately, implementation fidelity of the components did not affect the outcomes significantly. Our findings underline the need to support the implementation process of school tobacco policy interventions to ensure the intended effects of reducing students' smoking.

Social inequalities in trajectories of contacts with the healthcare system in adolescence and young adulthood.

BACKGROUND: Understanding of healthcare utilization of different populations is useful for prevention and prioritization of healthcare resources. This study aims to identify populations following different trajectories of contacts with the healthcare system and to describe social inequalities between the groups. METHODS: Individuals born 1980-2000 in Denmark were linked to national registers. Contacts with somatic hospitals, psychiatric hospitals, general practitioners, and redeemed prescriptions were counted for each year between 16 and 37 years of age. Trajectories of contacts with the four dimensions of healthcare use were identified using group-based multi-trajectory modeling. RESULTS: Five trajectory groups were identified. One group had low healthcare utilization over time (12% in women; 27% in men). The largest group had low healthcare utilization but more contacts with especially GP (39% in women; 43% in men). A third group had more contacts with most dimensions of the healthcare system (33% in women; 21% in men). The fourth group had many contacts with especially somatic hospitals and GP (7% in women; 4% in men). The fifth group had many contacts especially to psychiatric hospitals (8% in women; 5% in men). Shorter parental education, parental unemployment, family income below the poverty line, and cohabitation with one or no parent was more frequent in the two high utilization groups compared to the lower utilization groups. CONCLUSION: The observed trajectories of health service use and the social inequalities between trajectory groups highlight that prevention and treatment targeting the entire population will benefit from a complementary focus on social inequalities in health.

The association between education and fear of recurrence among breast cancer patients in follow-up - and the mediating effect of self-efficacy.

BACKGROUND: Major restructuring of surveillance after breast cancer treatment with less follow-up consultations may result in insecurity and fear of recurrence (FCR) among the less resourceful breast cancer patients. We investigate the association between breast cancer patients' education and FCR and if self-efficacy mediates the associations between education and FCR. MATERIAL AND METHODS: A questionnaire survey was conducted from 2017 to 2019, among 1773 breast cancer patients shortly after having their follow-up switched from regular outpatient visits with an oncologist to either nurse-led or patient-initiated follow-up, with a subsequent questionnaire after 12 months. Data on disease and treatment characteristics were extracted from medical records and the Danish Breast Cancer Group Database. Logistic regression analyses were used to examine the association between education and FCR. Separate analyses were conducted for patients ≤ and >5 years since diagnosis and all models were adjusted for age and cohabitation status. To explore potential mediation by self-efficacy, we conducted regression analyses on education and FCR further adjusting for self-efficacy. RESULTS: The participation rate was 57%, and after the exclusion of patients due to missing data, 917 were included in analyses. Patients with long education had significantly less FCR compared to patients with short education (OR (95% CI) 0.71 (0.51;0,99)). When separated by time since diagnosis, there was no association among patients >5 years since diagnosis while the OR was 0.51 (95% CI, 0.30;0.85) for patients ≤5 years since diagnosis. Further adjusting for self-efficacy among patients <5 years since diagnosis resulted in an OR of 0.56 (95% CI, 0.33;0.95) among patients with long compared to short education. CONCLUSION: Up to 5 years after diagnosis, breast cancer patients with long education are less likely to experience FCR than patients with short education. Self-efficacy mediated only a very small part of this association, indicating that other factors play a role in socioeconomic differences in FCR among breast cancer patients.

The Impact of the Danish National Smoking Ban From 2007 on the Incidence of Eight Smoking-related Diseases: A Nationwide Register-based Interrupted Time Series Analysis.

BACKGROUND: Previous research has documented the effect of comprehensive smoking bans on preventing various adverse health outcomes in the years post-ban. In 2007, Denmark implemented a national smoking ban that prohibited indoor smoking in workplaces and public settings, although only partial restrictions applied in specific premises such as small bars, one-person offices, and in psychiatric units. We tested the hypothesis that the implementation of the national smoking ban was associated with a decrease in incidence of smoking-related morbidity in the Danish population compared to the pre-ban period. METHODS: Interrupted time series analyses including the entire Danish population (≥30 years) was conducted. Information of hospitalizations and cause-specific mortality due to acute myocardial infarction, heart failure, hemorrhagic stroke, ischemic stroke, chronic obstructive pulmonary disease, cancer in bronchus and lung, cancer in lip, mouth, oral cavity, and pharynx, and bladder cancer were obtained from population-based registers. Poisson regression models accounting for seasonal variations and secular trends quantified immediate changes in incidence rates occurring at the time of the smoking ban as well as changes in the post-ban trend compared to pre-ban levels. RESULTS: Overall, we observed no consistent declines in incidence of cardiovascular diseases, chronic obstructive pulmonary disease, or the specific types of cancer in the post-ban period compared with the pre-ban period. CONCLUSION: No consistent reduction in incidence of smoking-related diseases was observed after the smoking ban was introduced in Denmark. This probably reflects that the Danish smoking ban included several exemptions, resulting in a less comprehensive ban compared to those introduced in other countries. IMPLICATIONS: In this study, we found that the Danish national smoking ban from 2007 did not consistently reduced the incidence of eight smoking-related outcomes in the post-ban period compared to pre-ban levels. We argue that due to the exemptions in the smoking ban, which for example allowed smoking in specific premises of the care and nursing sector, in one-person offices, and small bars, the ban was not sufficiently comprehensive to influence smoking behavior and thereof the incidence of smoking-related morbidity. Our findings highlight the importance of introducing comprehensive legislative measures to yield largest health benefits at a population level.

Prediction of disease recurrence or residual disease after primary endoscopic resection of pT1 colorectal cancer-results from a large nationwide Danish study.

PURPOSE: Risk assessment of disease recurrence in pT1 colorectal cancer is crucial in order to select the appropriate treatment strategy. The study aimed to develop a prediction model, based on histopathological data, for the probability of disease recurrence and residual disease in patients with pT1 colorectal cancer. METHODS: The model dataset consisted of 558 patients with pT1 CRC who had undergone endoscopic resection only (n = 339) or endoscopic resection followed by subsequent bowel resection (n = 219). Tissue blocks and slides were retrieved from Pathology Departments from all regions in Denmark. All original slides were evaluated by one experienced gastrointestinal pathologist (TPK). New sections were cut and stained for haematoxylin and eosin (HE) and immunohistochemical markers. Missing values were multiple imputed. A logistic regression model with backward elimination was used to construct the prediction model. RESULTS: The final prediction model for disease recurrence demonstrated good performance with AUC of 0.75 [95% CI 0.72-0.78], HL chi-squared test of 0.59 and scaled Brier score of 10%. The final prediction model for residual disease demonstrated medium performance with an AUC of 0.68 [0.63-0.72]. CONCLUSION: We developed a prediction model for the probability of disease recurrence in pT1 CRC with good performance and calibration based on histopathological data. Together with lymphatic and venous invasion, an involved resection margin (0 mm) as opposed to a margin of ≤ 1 mm was an independent risk factor for both disease recurrence and residual disease.

Higher overall admittance of immigrants to specialised palliative care in Denmark: a nationwide register-based study of 99,624 patients with cancer.

BACKGROUND: The population of immigrants in Europe is ageing. Accordingly, the number of immigrants with life-threatening diseases and need for specialised palliative care will increase. In Europe, immigrants' admittance to specialised palliative care is not well explored. AIM: To investigate whether country of origin was associated with admittance to (I) palliative care team/unit, (II) hospice, and/or (III) specialised palliative care, overall (i.e. palliative care team/unit and/or hospice). DESIGN: Data sources for the population cohort study were the Danish Palliative Care Database and several nationwide registers. We investigated the associations between country of origin and admittance to specialised palliative care, overall, and to type of palliative care using logistic regression analyses. SETTING/PARTICIPANTS: In 2010-2016, 104,775 cancer patients died in Denmark: 96% were born in Denmark, 2% in other Western countries, and 2% in non-Western countries. RESULTS: Overall admittance to specialised palliative care was higher for immigrants from other Western (OR = 1.13; 95%CI: 1.03-1.24) and non-Western countries (OR = 1.22; 95%CI: 1.08-1.37) than for the majority population. Similar results were found for admittance to palliative care teams. No difference in admittance to hospice was found for immigrants from other Western countries (OR = 1.04; 95%CI: 0.93-1.16) compared to the majority population, while lower admittance was found for non-Western immigrants (OR = 0.70; 95%CI: 0.60-0.81). CONCLUSION: Admittance to specialised palliative care was higher for immigrants than for the majority population as higher admittance to palliative care teams for non-Western immigrants more than compensated for the lower hospice admittance. This may reflect a combination of larger needs and that hospital-based and home-based services are perceived as preferable by immigrants.

Long-term exposure to transportation noise and risk of type 2 diabetes: A cohort study.

BACKGROUND: Some studies have found transportation noise to be associated with higher diabetes risk. This includes studies based on millions of participants, relying entirely on register-based confounder adjustment, which raises concern about residual lifestyle confounding. We aimed to investigate associations between noise and type 2 diabetes (T2D), including investigation of effects of increasing confounder adjustment for register-data and lifestyle. METHODS: In a cohort of 286,151 participants randomly selected across Denmark in 2010-2013 and followed up until 2017, we identified 7574 incident T2D cases. Based on residential address-history for all participants linked with exposure assessment of high spatial resolution, we calculated 10-year time-weighted mean road and railway noise at the most (LdenMax) and least (LdenMin) exposed façades and air pollution (PM2.5). We used Cox models to calculate hazard ratios (HR) with increasing adjustment for individual- and area-level register-based sociodemographic covariates, self-reported lifestyle and air pollution. RESULTS: We found that a 10 dB increase in 10-year mean road LdenMin was associated with HRs (95% CI) of 1.06 (1.02-1.10) after adjustment for age, sex and year, 1.08 (1.04-1.13) after further adjustment for register-based sociodemographic covariates, 1.07 (1.03-1.12) after further lifestyle adjustment (e.g. smoking, diet and alcohol) and 1.06 (1.02-1.11) after further PM2.5 adjustment. For road LdenMax, the corresponding HRs were 1.07 (1.04-1.10), 1.05 (1.02-1.08), 1.04 (1.01-1.07) and 1.03 (1.00-1.06). Railway noise was associated with HRs of 1.04 (0.98-1.11) for LdenMax and 1.02 (0.92-1.12) for LdenMin after adjustment for sociodemographic and lifestyle covariates and PM2.5. CONCLUSIONS: Long-term exposure to road traffic noise was associated with T2D, which together with previous literature indicates that T2D should be considered when calculating health impacts of noise. After sociodemographic adjustment, further lifestyle adjustment only changed HRs slightly, suggesting that large register-based studies with adjustment for key sociodemographic covariates can produce reliable results.

Factors related to COVID-19 vaccine hesitancy in Denmark: A national study in the autumn of 2021.

AIMS: The novelty of the COVID-19 pandemic and fast-developed vaccines may increase concerns about the safety and effectiveness of the COVID-19 vaccine and thereby influence vaccine hesitancy. The aims of this study were to examine (a) the main reasons for COVID-19 vaccine hesitancy and (b) factors associated with COVID-19 vaccine hesitancy. METHODS: A nationwide survey was conducted in the autumn of 2021 when most Danes had received at least one dose of a COVID-19 vaccine. The sample (N=13,570) was based on a random selection of individuals (⩾15 years), and data were collected via self-administered mailed questionnaires (digital and physical). The participants were asked whether they had been vaccinated against COVID-19, and if they had not, they were asked about their reasons for vaccine hesitancy. Logistic regression models were used to determine factors associated with vaccine hesitancy. RESULTS: In all, 5,384 (39.7%) individuals completed the questionnaire. The main reasons for vaccine hesitancy were worries about adverse effects (57.6%) and the belief that natural immunity is better than vaccination (43.8%). Factors associated with vaccine hesitancy included female sex, younger age, being divorced, a country of origin other than Denmark, lower educational level, being unemployed, previously infected with COVID-19 and being worried to a greater extent about oneself and others getting infected. Mental health indicators were not associated with vaccine hesitancy. CONCLUSIONS: COVID-19 vaccine hesitancy is likely to pose a challenge for population immunity. To reduce vaccine hesitancy and increase vaccination uptake, future vaccination programmes should focus on specific socio-demographic subgroups identified in this study.

Trends in smoking-related diseases by socioeconomic position following a national smoking ban in 2007: a nationwide study in the Danish population.

BACKGROUND: National comprehensive smoke-free legislation has been found to decrease the incidence of several smoking-related diseases. In 2007, Denmark introduced a national smoking ban, which banned smoking indoor in workplaces and public places, although only partial restrictions were applied in certain settings. We examined the impact of the smoking ban on smoking-related diseases and whether this differed across socioeconomic groups. METHODS: Interrupted time series analyses of nationwide register data were performed using Poisson regression models to examine the differential impact of the smoking ban on monthly incidence rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers from 2002 to 2015. Immediate changes in incidence rates after the smoking ban and long-term changes in disease trends were estimated by comparing data from the pre- and post-ban period. Models were stratified by socioeconomic position. RESULTS: Overall, we found neither immediate changes in rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers following the smoking ban nor long-term post-ban changes in disease trends as compared to before the ban. Results did not differ across socioeconomic groups. A pronounced socioeconomic gradient in incidence rates was observed for all outcomes both before and after the smoking ban. CONCLUSION: The national smoking ban was not associated with a lower incidence of smoking-related diseases in the post-ban period compared to pre-ban levels and no differences between socioeconomic groups were observed. Future tobacco control in Denmark should consider which measures most effectively target the low socioeconomic groups to decrease the current strong socioeconomic inequality in health.

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.

Labor force participation during COVID-19 and risk of depression: a Danish register study.

BACKGROUND: COVID-19 caused economic insecurity for businesses and their employees. Understanding effects of changes in labor force participation on depression risk during economic recession is fundamental for early diagnosis. The study evaluates if changes in labor force participation are associated with depression risk during COVID-19 in Denmark. METHODS: A register-based longitudinal study of Danes aged 25-67 years without depression 2 years prior to baseline defined as February 2020. An eight-level categorical variable on stable or changing labor force participation was defined from monthly employment percentage gradients in the Danish Register-based Evaluation and Marginalization Database from February 2020. The cohort was followed until 31 December 2020 for depressions overall and mild-, moderate- and severe depression. Sex-stratified cox regression models with hazard ratios (HR) and 95% confidence intervals (95% CI) were performed accounting for important confounders. RESULTS: In total, 1 619 240 (50.3%) men of mean age 45.6 years and 1 598 587 (49.7%) women of mean age 45.9 years were included. Becoming unemployed implied an increased HR of depression in men (HR 2.02; 95% CI 1.94-2.10) and women (2.19; 2.12-2.26) compared to a steady-state full-time employment. Being outside the labor force or employed part-time implied an elevated HR in men (3.02; 2.82-3.23 and 2.41; 2.35-2.48) and women (3.13; 2.30-3.31 and 2.30; 2.26-2.35), respectively, compared to a steady-state full-time employment. CONCLUSIONS: Changes in labor force participation were associated with higher risk of depression relative to a steady-state full-time employment particularly among individuals with low labor force participation during COVID-19.

Educational differences in healthcare use among survivors after breast, prostate, lung, and colon cancer - a SEQUEL cohort study.

BACKGROUND: Many cancer survivors experience late effects after cancer. Comorbidity, health literacy, late effects, and help-seeking behavior may affect healthcare use and may differ among socioeconomic groups. We examined healthcare use among cancer survivors, compared with cancer-free individuals, and investigated educational differences in healthcare use among cancer survivors. METHODS: A Danish cohort of 127,472 breast, prostate, lung, and colon cancer survivors from the national cancer databases, and 637,258 age- and sex-matched cancer-free individuals was established. Date of entry was 12 months after diagnosis/index date (for cancer-free individuals). Follow-up ended at death, emigration, new primary cancer, December 31st, 2018, or up to 10 years. Information about education and healthcare use, defined as the number of consultations with general practitioner (GP), private practicing specialists (PPS), hospital, and acute healthcare contacts 1-9 years after diagnosis/index date, was extracted from national registers. We used Poisson regression models to compare healthcare use between cancer survivors and cancer-free individuals, and to investigate the association between education and healthcare use among cancer survivors. RESULTS: Cancer survivors had more GP, hospital, and acute healthcare contacts than cancer-free individuals, while the use of PPS were alike. One-to-four-year survivors with short compared to long education had more GP consultations (breast, rate ratios (RR) = 1.28, 95% CI = 1.25-1.30; prostate, RR = 1.14, 95% CI = 1.10-1.18; lung, RR = 1.18, 95% CI = 1.13-1.23; and colon cancer, RR = 1.17, 95% CI = 1.13-1.22) and acute contacts (breast, RR = 1.35, 95% CI = 1.26-1.45; prostate, RR = 1.26, 95% CI = 1.15-1.38; lung, RR = 1.24, 95% CI = 1.16-1.33; and colon cancer, RR = 1.35, 95% CI = 1.14-1.60), even after adjusting for comorbidity. One-to-four-year survivors with short compared to long education had less consultations with PPS, while no association was observed for hospital contacts. CONCLUSION: Cancer survivors used more healthcare than cancer-free individuals. Cancer survivors with short education had more GP and acute healthcare contacts than survivors with long education. To optimize healthcare use after cancer, we need to better understand survivors' healthcare-seeking behaviors and their specific needs, especially among survivors with short education.