Developing Interpersonal Trust Between Service Users and Professionals in Integrated Services: Compensating for Latent Distrust, Vulnerabilities and Uncertainty Shaped by Organisational Context.

INTRODUCTION: Studies show a need for trust between stakeholders in integrated services. However, few studies have investigated how trust develops between stakeholders on a micro-level. In a Danish intersectoral intervention for persons on sick leave due to common mental disorders, we explored why trust is needed and how trust is developed between micro-level stakeholders. METHODOLOGY: The qualitative study was based on 12 observations of inter-organisational meetings, 16 interviews with service users, 24 interviews with health care professionals and employment consultants, and 8 interviews with supervisors. The analysis was guided by the theoretical concepts (dis-) trust, vulnerability and uncertainty. RESULTS: Latent distrust between involved organisations, and vulnerabilities and uncertainties related to employment consultants' statutory power over service users caused a perceived need for interpersonal trust. Time to establish knowledge-based relationships, healthcare professionals' caring approach, and creating a feeling of sharing interests were compensating trust-building strategies that were often regarded as positive. DISCUSSION AND CONCLUSION: Trust in personal relationships between stakeholders appeared to compensate for contextually shaped distrust, vulnerability and uncertainty. Identifying latent distrust, vulnerabilities, uncertainties, and power structures might be key to improving trust-building strategies in a specific context. The time-consuming process of trust-building between micro-level stakeholders should be supported structurally.

Shared Decision Making in an Integrated Mental Health and Vocational Rehabilitation Intervention: Stakeholder Practices and Experiences.

INTRODUCTION: A Danish integrated mental health care and vocational intervention was developed to support the return-to-work process for people with common mental disorders. Shared decision making was a core element of the intervention to ensure a person-centred approach. The study aim is to describe how shared decision making was practiced and experienced and to discuss its potential in this integrated care context. THEORY AND METHODS: Shared decision making practice and experience was studied in participant observation (n = 20), interviews (n = 12), focus groups interviews (n = 2), and shared plan documents (n = 12). Research methods and analyses were guided by theoretically defined ideals of shared decision making. RESULTS: Shared decision making constituted a general value rather than a structured method in practice. Clients experienced a more person-centred collaboration with professionals, compared to the regular vocational system. Contextual factors regarding vocational legislation and the intervention design influenced the decision latitude. CONCLUSION: Shared decision making has the potential to support a person-centred approach in integrated services. However, we recommend clarifying decisions applicable for shared decision making, to ensure thorough training, develop and test decision aids, and ensure supportive organisational conditions for shared decision making in interprofessional collaboration.

Developing Normative Integration among Professionals in an Intersectoral Collaboration: A Multi-Method Investigation of an Integrated Intervention for People on Sick Leave Due to Common Mental Disorders.

INTRODUCTION: Intersectoral integration is recommended in vocational rehabilitation, though difficult to implement. We describe barriers to and strategies for the development of normative integration in an intersectoral, team-based vocational rehabilitation intervention. METHOD: Attitudes and behaviours regarding the development of shared culture, norms, and goals in the collaboration between health care professionals and employment consultants were investigated through 30 semi-structured interviews, participant observation of 12 intersectoral meetings, and document analysis of 12 joint plans. RESULTS: Organisational factors and unsettled power balance between professionals constituted barriers to the development of a shared culture. These issues were resolved by establishing smaller work teams, and through health care professionals' gradual acceptance of employment consultants' control in their capacity as administrators of legislation. Some barriers to shared norms were resolved explicitly, whereas implicit diverging norms were continuously negotiated. The development of shared goals was supported by clarifying the fit between individual, professional, and organisational goals, though the alignment of goals required a paradigmatic change of mindset among the health care professionals. CONCLUSION: This study shows how normative integration among health care professionals and employment consultants is feasible in co-located intersectoral teams, with positive implications for the delivery of coherent support.

Finasteride treatment and male breast cancer: a register-based cohort study in four Nordic countries.

A potential link has been suggested between dispensed finasteride and increased risk of male breast cancer (MBC). Due to the rare occurrence of MBC, it remains to be established if such a relationship exists. The purpose of this study was to combine nationwide registers in four countries to assess the potential association between dispensed finasteride and MBC. A cohort of all males with dispensed finasteride in Denmark, Finland, Norway, and Sweden (1,365,088 person years) was followed up for up to 15 years for breast cancer, and compared to a cohort of males unexposed to finasteride. Individual-level register data included country, dates of dispensed finasteride, MBC diagnosis, and death. Incidence rate ratios (IRRs) were estimated using a generalized linear model with a Poisson distribution. An increased risk of MBC was found among finasteride users (IRR = 1.44, 95% confidence interval [95% CI] = 1.11-1.88) compared to nonusers. The IRR increased to 1.60 (95% CI = 1.20-2.13) when users in Norway and Sweden with short follow-up time were excluded. The highest IRR was seen among men with medium duration of dispensed finasteride, medium accumulated consumption of finasteride, and among men with first dispensed finasteride prescription 1-3 years prior to diagnosis. The analyses suggested possible ascertainment bias and did not support a clear relationship between dispensed finasteride and MBC. In conclusion, a significant association between dispensed finasteride and MBC was identified. However, due to limited data for adjustment of potential confounding and surveillance bias in the present study, further research is needed to confirm these results.

A socioeconomic deprivation index for small areas in Denmark.

AIMS: To describe the development of a deprivation index for Danish parishes and to investigate its association with all-cause mortality compared with the Townsend index and individual-level factors. METHODS: Nine socioeconomic factors were aggregated to the parish level from individual-level register data comprising the entire Danish population in 2005. A principal component analysis was conducted to reduce the number of factors and to apply weights. An ecological analysis investigated the association between the Danish Deprivation Index (DANDEX) and standardised mortality ratios in Danish parishes. Results were compared with the Townsend index and a possible modifying effect of population density was investigated. Sensitivity of the index was investigated with multilevel survival analyses evaluating the association between all-cause mortality and DANDEX, the Townsend Index, individual-level socioeconomic factors, and population density. RESULTS: DANDEX consists of two components measuring socioeconomic properties of all 2119 Danish parishes. The first component measures deprivation related to housing (house and car ownership) while the second component is related to classical measures of socioeconomic status (education, income, occupation). A clear gradient in standardised mortality ratios was seen across quintiles of both index components. Modifying effects were seen when stratifying the index components by population density. In a frailty model, DANDEX accounted for 76% of the between-parish variation in all-cause mortality, while the Townsend index and individual socioeconomic factors accounted for 71 and 76%, respectively. CONCLUSIONS: The index can be used to identify Danish parishes by their levels of deprivation and it provides municipalities with a tool to allocate resources to the geographic areas where they are most needed.

Neighbourhoods matter too: the association between neighbourhood socioeconomic position, population density and breast, prostate and lung cancer incidence in Denmark between 2004 and 2008.

BACKGROUND: Previous studies have shown that cancer incidence is related to a number of individual factors, including socioeconomic status. The aim of this study was to refine the current knowledge about indicators associated with cancer incidence by evaluating the influence of neighbourhood characteristics on breast, prostate and lung cancer incidence in Denmark. METHODS: All women aged 30-83 years were followed for breast cancer between 2004 and 2008, men between 50 and 83 years were followed for prostate cancer and both sexes between ages 50 and 83 were followed for lung cancer. Registry data obtained from Statistics Denmark included age, sex, availability of breast cancer screening, marital status, education, disposable income and occupational socioeconomic status on the individual level and population density and neighbourhood socioeconomic status (the proportion of unemployed) on the parish level. Frailty modelling with individuals on the first level and parishes on the second level was conducted. RESULTS: A significantly lower HR of breast cancer was found in areas with low population density (HR=0.93; CI 0.88 to 0.99), while neighbourhood unemployment had no effect. Inhabitants of lower unemployment areas had a higher risk of prostate cancer (HR=1.14; CI 1.08 to 1.21) compared with those in higher unemployment areas, whereas population density had no effect. Risk of lung cancer was lower in areas with lowest population density (HR=0.80; CI 0.74 to 0.85) and lowest in areas with lowest unemployment (HR=0.88; CI 0.84 to 0.92). CONCLUSIONS: In addition to individual-level factors, characteristics on the neighbourhood level also have an influence on breast, prostate and lung cancer incidence.

Do neighborhoods affect individual mortality? A systematic review and meta-analysis of multilevel studies.

There has been increasing interest in investigating whether inhabitants in socially or physically deprived neighborhoods have higher mortality when individual socioeconomic status is adjusted for. Results so far appear ambiguous and the objective of this study was to conduct a systematic literature review of previous studies and to quantify the association between area-level socioeconomic status (ALSES) and all-cause mortality in a meta-analysis. Current guidelines for systematic reviews and meta-analyses were followed. Articles were retrieved from Medline, Embase, Social Sciences Citation Index and PsycInfo and individually evaluated by two researchers. Only peer-reviewed multilevel studies from high-income countries, which analyzed the influence of at least one area-level indicator and which controlled for individual SES, were included. The ALSES estimates in each study were first combined into a single estimate using weighted linear regression. In the meta-analysis we calculated combined estimates with random effects to account for heterogeneity between studies. Out of the 40 studies found eligible for the systematic review 18 studies were included in the meta-analysis. The systematic review suggests that there is an association between social cohesion and mortality but found no evidence for a clear association for area-level income inequality or for social capital. Studies including more than one area level suggest that characteristics on different area levels contribute to individual mortality. In the meta-analysis we found significantly higher mortality among inhabitants living in areas with low ALSES. Associations were stronger for men and younger age groups and in studies analyzing geographical units with fewer inhabitants.

Population density, socioeconomic environment and all-cause mortality: a multilevel survival analysis of 2.7 million individuals in Denmark.

This study examines the relative effects of population density and area-level SES on all-cause mortality in Denmark. A shared frailty model was fitted with 2.7 million persons aged 30-81 years in 2,121 parishes. Residence in areas with high population density increased all-cause mortality for all age groups. For older age groups, residence in areas with higher proportions of unemployed persons had an additional effect. Area-level factors explained considerably more variation in mortality among the elderly than among younger generations. Overall this study suggests that structural prevention efforts in neighborhoods could help reduce mortality when mediating processes between area-level socioeconomic status, population density and mortality are found.

Are characteristics of the school district associated with active transportation to school in Danish adolescents?

BACKGROUND: This study sought to determine the influence of individual factors on active transportation to school among Danish seventh graders and whether school district factors are associated with such behaviour independently of individual factors. METHODS: Mixed effects logistic regression models determined the effects of individual (gender, family affluence, enjoyment of school and academic performance) and school district factors (educational level, household savings, land use and size) on active transportation to school (by foot, bicycle or other active means) among 10 380 pupils aged 13-15 years nested in 407 school districts. RESULTS: Of all students, 64.4% used active transportation to school daily. Boys, those with perceived higher school performance and those with lower family affluence were more likely to use active transportation to school. After adjustment for all individual factors listed above, high household savings at the school district level was associated with higher odds of active transportation to school. As factors of land use, low level of farming land use and high proportion of single houses were associated with active transportation to school. CONCLUSIONS: Policies aiming at reducing social inequalities at the school district level may enhance active transportation to school. School districts with farming land use face barriers for active transportation to school, requiring special policy attention.