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Objective: This study examines the experiences of clinical encounters with young unaccompanied refugees in Norway and Denmark among both general practitioners (GPs) and physicians in migrant health clinics (MHC physicians), and it identifies important aspects that should be taken into consideration for improving the quality of healthcare for these patients., Methodology: Ten individual in-depth interviews with physicians in Norway and Denmark were conducted and analysed using interpretative phenomenology. Axel Honneth's theory of recognition was our theoretical lens., Results: The physicians described these patients as vulnerable individuals. They adopted a variety of approaches in their encounters with young unaccompanied refugees spanning from a 'holistic' to an 'instrumental' approach. Those who described an instrumental approach focused on understanding and categorising symptoms from a biomedical perspective, while those describing a holistic approach considered 'the whole person' within their everyday context. Those with a more holistic approach also expressed the importance of interdisciplinary collaboration and defined work-divide. Relationships of trust between physicians and the young unaccompanied refugees were shown to be an important facilitator for adequate healthcare, but this required availability, continuity, and dialogue., Conclusion: Our results highlight how physicians' encounters with vulnerable young refugees actualize previously documented contrasts between holistic and instrumental approaches in clinical work. We argue that recognition in healthcare is conditional on physicians taking a holistic approach. This approach can help build relationships of trust and can support interdisciplinary collaboration. Moreover, such an approach can facilitate the essential components of Honneth's theory of recognition, namely social esteem and emotional support. Barriers to greater interdisciplinary collaboration in healthcare services need to be addressed at the system level.

We use language to achieve understanding, and language barriers can have major health consequences for patients with serious illness. While ethnic minorities are more likely to experience social inequalities in health and health care, communicative processes in language-discordant cancer care remain unexplored. This study aimed to investigate communication between patients with cancer and limited Danish proficiency and oncology clinicians, with special emphasis on how linguistic barriers influenced patient involvement and decision-making. 18 participant observations of clinical encounters were conducted. Field notes and transcriptions of audio recordings were analyzed, and three themes were identified: Miscommunication and uncertainty as a basic linguistic condition ; Impact of time on patient involvement ; Unequally divided roles and (mis)communication responsibilities . The results showed that professional interpreting could not eradicate miscommunication but was crucial for achieving understanding. Organizational factors related to time and professional interpreting limited patient involvement. Without professional interpreting, patients' relatives were assigned massive communication responsibilities. When no Danish-speaking relatives partook, clinicians' ethical dilemmas further increased as did patient safety risks. Language barriers have consequences for everyone who engages in health communication, and the generated knowledge about how linguistic inequality manifests itself in clinical practice can be used to reduce social inequalities in health and health care.

Background: Approximately one-third of patient appointments in Danish health care result in failures, leading to patient risk and sizable resource waste. Existing interventions to alleviate no-shows often target the patients. The underlying reason behind these interventions is a view that attendance or nonattendance is solely the patient's problem. However, these interventions often prove to be ineffective and can perpetuate social biases and health inequalities, leaving behind patients who are more vulnerable or disadvantaged (in terms of social, economical, and linguistic factors, etc). A more holistic understanding of no-shows is needed to optimize processes, reduce waste, and support patients who are vulnerable., Objective: This study aims to gain a deep and more comprehensive understanding of the causes, mechanisms, and recurring patterns and elements contributing to nonattendance at Danish hospitals in the Region of Southern Denmark. It emphasizes the patient perspective and analyzes the relational and organizational processes surrounding no-shows in health care. In addition, the study aims to identify effective communicative strategies and organizational processes that can support the development and implementation of successful interventions., Methods: The study uses mixed quantitative-qualitative methods, encompassing 4 analytical projects focusing on nonattendance patterns, patient knowledge and behavior, the management of hospital appointments, and in situ communication. To address the complexity of no-shows in health care, the study incorporates various data sources. The quantitative data sources include the electronic patient records, Danish central registries, Danish National Patient Registry, and Register of Medicinal Product Statistics. Baseline characteristics of patients at different levels are compared using chi-square tests and Kruskal-Wallis tests. The qualitative studies involve observational data, individual semistructured interviews with patients and practitioners, and video recordings of patient consultations., Results: This paper presents the protocol of the study, which was funded by the Novo Nordisk Foundation in July 2022. Recruitment started in February 2023. It is anticipated that the quantitative data analysis will be completed by the end of September 2023, with the qualitative investigation starting in October 2023. The first study findings are anticipated to be available by the end of 2024., Conclusions: The existing studies of nonattendance in Danish health care are inadequate in addressing relational and organizational factors leading to hospital no-shows. Interventions have had limited effect, highlighting the Danish health care system's failure to accommodate patients who are vulnerable. Effective interventions require a qualitative approach and robust ethnographic data to supplement the description and categorization of no-shows at hospitals. Obtaining comprehensive knowledge about the causes of missed patient appointments will yield practical benefits, enhancing the safety, coherence, and quality of treatment in health care., International Registered Report Identifier (irrid): PRR1-10.2196/46227., (©Daria Schwalbe, Morten Sodemann, Maria Iachina, Bente Mertz Nørgård, Nina Høy Chodkiewicz, Jette Ammentorp. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 03.11.2023.)

Little is known about the combined effect of several risk factors occurring simultaneously, and the perspectives of patients with language barriers or dementia are lacking because these patients are often excluded as research participants. This study aimed at investigating medication safety among older migrants with cognitive disorders who use five or more medications daily from the perspective of older patients and their relatives. Eight semi-structured interviews with patients and relatives were conducted in their homes. The study adopted an inductive hermeneutic phenomenological approach and used both "Analyzing the present" and "Systematic text condensation" as inspiration for the analysis. Three main themes were identified: (i) potential medication safety and threats, (ii) communication and missing medication information and (iii) everyday life with medication. Threats to medication safety included medication perceptions, health perceptions, and cognitive impairment of the patient as well as miscommunication among departments, wrong diagnosis and medication, and unlocked medication cabinets. However, most families expressed having no problems concerning medication, which could be a result of limited engagement of the patient and relatives in the medical treatment and limited medication information provided to the families by healthcare professionals., (© 2023 The Authors. Basic & Clinical Pharmacology & Toxicology published by John Wiley & Sons Ltd on behalf of Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).)

Background: Concepts such as patient-centred care, patient empowerment and patient participation have challenged our understanding of what it means to be a patient and what role patients play in care pathways. Consequently, patientology as the medical sociological and anthropological study of patients is currently being reconceptualized through perspectives of health as individualized and privatized capital., Aims: This article explores the potential of such a patientological perspective to enhance our understanding of and tailor care pathways. Particularly, we aim to investigate how such a perspective can contribute to tailoring care pathways to the capacities of individual patients and their relatives., Materials & Methods: We elaborate on an emerging health capital-theoretic model for patientology and study its potential for optimizing care pathways through two distinct cases of care contexts: communicative challenges in the context of integrative primary care for vulnerable chronically ill multi-morbid patients and the potential of parent involvement in the acute hospitalization of children suspected to be affected by multisystem inflammatory syndrome in children., Results: Our results shed light on the importance of cultural and social capital of patients and their relatives in the design of effective tailored care pathways. We find that a lack of cultural and social capital presents a significant barrier to effective communication between patients and the healthcare professionals involved in their care pathways. We also find that understanding the cultural and social capital of relatives provides an entry point to their effective involvement in the care pathways of their children., Discussion & Conclusion: The implications of these findings extend beyond the concrete care contexts studied. This article contributes to our understanding of care pathways through a perspective of health inequalities being based on differences in health capital and demonstrates how the health capital-theoretic patientology model facilitates the systematic development of guidelines for healthcare professionals to assess patients' resources and tailor their care pathways accordingly., (© 2022 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Aim: The aim is to identify important factors for immigrants' health and well-being and for their use (or non-use) of primary health care (PHC) and other non-specialised services, and for possible ways that PHC can support healthy ageing of immigrants., Background: Older persons are an increasing share of the immigrant population in the global north, frequently in contact with various forms of health services, (PHC services most of all. Consequently, PHC services are in a particularly unique position to support healthy ageing of immigrants., Methods: The position paper builds on five international, multi-professional and cross-disciplinary small group discussions as well as an international workshop early summer. During the discussions and the workshop, topics were arrived at as to factors related to the health situation of older immigrants, their needs, and health-seeking behaviour, and to how PHC professionals could support healthy ageing in immigrants. Those main topics in turn guided search for relevant research literature and informed the selection of the main research questions of this paper., Findings: Several factors, in addition to culture and cultural differences, are important to for PHC professionals and decision-makers to take into consideration in encounters with older immigrants. The socio-economic position of the older immigrant and close relatives, inter-generational relationships within the immigrant communities, country-specific factors in the host country like health care expenditure, and communication skills in health professionals are all examples of factors playing an important role regarding the health and health-seeking behaviour of older immigrants.

The 'thrifty phenotype' hypothesis proposed that fetal undernutrition increases risk of diabetes in later life. Undernourished low birthweight Indian babies are paradoxically more adipose compared to well-nourished European babies, and are at higher risk of diabetes in later life. Twin pregnancies are an example of in utero growth restrictive environment due to shared maternal nutrition. There are few studies of body composition in twins. We performed secondary analysis of anthropometric body composition of twins and singletons in Guinea-Bissau, an economically deprived African country.Anthropometric data were available on 7-34 year-old twins ( n = 209, 97 males) and singletons ( n = 182, 86 males) in the Guinea-Bissau Twin Registry at the Bandim Health Project. Twins had lower birthweight (2420 vs 3100 g, p < 0.001); and at follow-up, lower height (HAZ mean Z-score difference, -0.21, p = 0.055), weight (WAZ -0.73, p = 0.024) and BMI (BAZ -0.22, p = 0.079) compared to singletons but higher adiposity (skinfolds: +0.33 SD, p = 0.001). Twins also had higher fasting (+0.38 SD, p < 0.001) and 2-hour OGTT glucose concentrations (+0.29 SD, p < 0.05). Linear mixed-effect model accounting for intrapair correlations and interactions confirmed that twins were thinner but fatter across the age range. Data on maternal morbidity and prematurity were not available in this cohort.African populations are known to have a muscular (less adipose) body composition. Demonstration of a thin-fat phenotype in twins in a low socio-economic African country supports the thesis that it could be a manifestation of early life undernutrition and not exclusive to Indians. This phenotype could increase risk of diabetes and related conditions.

Background: Body mass index (BMI) shows strong continuity over childhood and adolescence and high childhood BMI is the strongest predictor of adult obesity. Genetic factors strongly contribute to this continuity, but it is still poorly known how their contribution changes over childhood and adolescence. Thus, we used the genetic twin design to estimate the genetic correlations of BMI from infancy to adulthood and compared them to the genetic correlations of height., Methods: We pooled individual level data from 25 longitudinal twin cohorts including 38,530 complete twin pairs and having 283,766 longitudinal height and weight measures. The data were analyzed using Cholesky decomposition offering genetic and environmental correlations of BMI and height between all age combinations from 1 to 19 years of age., Results: The genetic correlations of BMI and height were stronger than the trait correlations. For BMI, we found that genetic correlations decreased as the age between the assessments increased, a trend that was especially visible from early to middle childhood. In contrast, for height, the genetic correlations were strong between all ages. Age-to-age correlations between environmental factors shared by co-twins were found for BMI in early childhood but disappeared altogether by middle childhood. For height, shared environmental correlations persisted from infancy to adulthood., Conclusions: Our results suggest that the genes affecting BMI change over childhood and adolescence leading to decreasing age-to-age genetic correlations. This change is especially visible from early to middle childhood indicating that new genetic factors start to affect BMI in middle childhood. Identifying mediating pathways of these genetic factors can open possibilities for interventions, especially for those children with high genetic predisposition to adult obesity., (© 2022. The Author(s).)

Objective: Interest in the coproduction concept in healthcare is increasing. According to coproduction, services are, unlike goods, always coproduced by a user and a service provider. This study explored how immigrants and refugees perceive the coproduction of their healthcare service in clinical encounters., Methods: We conducted semi-structured interviews with thirteen patients with varied backgrounds and health problems. Participants were purposefully recruited in an interdisciplinary clinic for immigrants and refugees at a Danish University Hospital. Interviews were transcribed, anonymized, and analyzed using meaning condensation., Results: Patients emphasized the importance of a safe space where they could be themselves and feel supported. This encouraged them to be open and assume an active role in the coproduction of their health. A stable therapeutic alliance based on kindness and kinship helped them find strength and take responsibility for their own health., Conclusions: This study improves our understanding of how immigrants and refugees experience the coproduction of healthcare services. Further studies, evaluating long-term outcomes of coproduction efforts, are required., Practice Implications: Providing a safe space in which health professionals have time to listen and empathically validate immigrant and refugee patients' lived realities, can enable patients to open up and become agents of their own health., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The concept of coproduction shows great promise for meaningful partnerships between patients and health professionals. This is particularly relevant for immigrant patients who are less inclined to take an active role in consultations. The present study described health professionals' practices and experiences of coproducing healthcare service with immigrant and refugee patients in clinical encounters., Methods: We conducted a three-phase qualitative study with immigrant and refugee patients and health professionals at an interdisciplinary outpatient clinic for immigrants and refugees with complex long-standing health problems at a Danish university hospital. First, we conducted 25 observations of consultations between seven professionals (three doctors, three nurses, one social worker) and 24 patients with varied backgrounds and health problems. Findings were discussed in a focus group and individual interviews with the migrant clinic's staff. Finally, the themes were discussed with co-researchers and revised in a member check with experienced clinicians. Data were analyzed through meaning condensation, supported by the NVivo software., Results: We identified four themes characterizing the work of health professionals in creating coproduced healthcare service: a team effort of sense-making, disentangling the chaos first, when everything fails - listen to the patient, and continuity - becoming part of the patient's story., Conclusion: Interdisciplinary work fostering values of doing what makes sense to form a positive partnership with the patient allows health professionals to act autonomously, flexibly, and creatively. Using communication tools designed around patient needs, create optimal conditions for coproduction as health professionals empathically validate and integrate patient experiences. Professionals need advanced listening and relational skills and tolerance of ambiguity and insecurity. Relational continuity facilitates long-term coproduction but also bears risks of emotional dependency., Competing Interests: The following statement is also included in the manuscript in Section 4.2 and the attached declaration of interest: One co-author (DSN) participated in the focus group discussion and the member check. Another co-author (MSO) participated in the member check. As both also work in the clinic, they were able to add valuable critical observations and further exemplifications due to their extensive experience on working with immigrant patients. Researching in their own organization, they were aware of their dual roles of researcher and study participant and needed to align their own subjectivity with their attention and understanding of the data, the situation, their judgments, and their responsible actions, (© 2022 The Authors. Published by Elsevier Ltd.)

Background: Older migrants with cognitive impairment exposed to polypharmacy constitute a vulnerable group of patients. To our knowledge, evidence on medication safety among this patient group with multiple risk factors is lacking., Objectives: To explore the perspectives of health care professionals on medication safety among older migrants with cognitive impairment taking five or more medications daily., Methods: A total of 34 health care professionals (general practitioners and hospital-, community pharmacy-, and home care staff) participated in the study, comprising nine focus groups and one semi-structured interview, and shared their perspectives on medication safety among older migrants with cognitive impairment exposed to polypharmacy. The analysis was inspired by Revsbæk and Tanggaard's "Analyzing in the Present" and was followed by systematic text condensation., Results: Three main themes emerged: (i) the importance of relationships in medication safety, (ii) culture and finances as risk factors, and (iii) the health care system as a risk factor. Subthemes and codes were related within and across main themes and revealed a high level of complexity within the barriers to medication safety. Some of these barriers were closely related to characteristics of this specific patient group, while others were more general barriers that also affected other patient groups. Participants found that these more general problems were complicated further by language barriers and cognitive impairment when working with this patient group., Conclusion: Health care professionals across various sectors and professions experienced several barriers that threatened medication safety among older migrants with cognitive impairment exposed to polypharmacy. Closer collaboration between health care professionals, patients, and relatives is required to improve medication safety., Competing Interests: None., (© 2022 The Authors.)

INTRODUCTION Medical doctors in Denmark are clinically challenged by ethnic minority patients, resulting in delayed or incorrect treatments. Apart from language barriers, little is known about the nature of the challenges presented by ethnic minority patients. The present study investigated the level of agreement between the patients' main problems, doctors' referral notes and patient-reported problems documented at a hospital-based migrant health outpatient clinic. METHODS A retrospective cross-sectional study was conducted on 150 patients referred to the Migrant Health Clinic (MHC), Odense University Hospital, Denmark. The study was based on a full "Problem list" that was co-produced with the patient. Cohen's kappa (κ) and Chamberlain's proportionate positive agreement (pppa) were calculated for the medical and socioeconomic problems described in the referrals and MHC notes, respectively. RESULTS Significant agreement between patient and referring doctor was found for only two health complaints: musculoskeletal pain (κ = 0.43 and pppa = 0.69) and Type 2 diabetes mellitus (κ = 0.71 and pppa = 0.59). CONCLUSIONS Doctors and patients rarely agree on the patients' health problems. Patient engagement such as co-production of care may potentially produce the time and resources needed to help doctors identify the patients' priorities and describe them in referrals. FUNDING The Novo Nordisk Foundation granted a pregraduate scholarship to cover the salary of the corresponding author. TRIAL REGISTRATION not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Aim: We aimed to explore how interpreters experienced being part of a special designed health introduction course and to obtain their perspectives on the learning process. The overall aim was to improve health care to patients with language barriers., Design: With a hermeneutic phenomenological approach, we used participant observations as a method for collecting data., Method: The teaching methods used were case-based learning, role-play and active involvement including dialogs, discussions and critical reflections. The interpreters were divided into teams of 10-15 interpreters. Over the duration of 6 weeks, teaching sessions were conducted, with 3 hr/week planned., Results: The findings emphasize the importance of providing the interpreters with education, supervision and a work environment where they can confidentially share and get competent feedback on their experiences and linguistic skills, in order to ensure patients get the correct information in their native language., (© 2020 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Background: Refugees have increased health risks due to factors related to their country of origin, the migration itself and the receiving country. Based on systematic general health assessments of newly arrived refugees, we aimed to study the characteristics with regard to background, migration and health needs., Methods: All refugees (children/adolescents and adults) arriving in Aarhus, Denmark from 1 January 2014 to 1 November 2018 were offered a general health assessment by a doctor including: medical history, a physical examination and blood samples., Results: A cohort of 1431 (of 1618 invited, (88.4%) participants accepted the health assessment. The most commonly found health conditions in children were vitamin D deficiency (28.3%), elevated serum-IgE (34%) and lack of immunity against vaccine-preventable diseases (measles 20.1%, polio 3.9%). In adults, vitamin D deficiency (34.6%), IgE elevation (30%), latent tuberculosis (20.3%) and symptoms of PTSD (15.9%) were most prevalent. We found participants from Southern Asia (Iran, Afghanistan and Pakistan) to be overrepresented with regard to vitamin D deficiency, vitamin B12 deficiency and symptoms of PTSD. Furthermore, we found that origin in Africa was associated with latent tuberculosis. In total, 63.8% of examined refugees had one or more health problems requiring further testing, treatment or follow-up., Conclusions: A comprehensive health assessment among recently arrived refugees showed multiple health issues to address, and demonstrates the need of systematic health assessments for resettling refugees., Competing Interests: The authors report no conflicts of interest., (© 2021 Published by Elsevier Ltd.)

Background: The burden of diabetes mellitus in Sub-Saharan Africa is growing rapidly, and yet the prevalence and patient characteristics are still largely unknown., Objectives: We analyzed clinical and demographic characteristics of Type 2 diabetes (T2DM) patients attending a diabetes clinic in Guinea-Bissau from February 2008 to April 2014, and estimated the prevalence and risk factors of unknown-impaired fasting plasma glucose (FPG) and diabetes, as well as excess mortality associated with T2DM., Methods: We characterized T2DM patients attending the national diabetes clinic in Bissau. Diabetes was diagnosed based on FPG. We matched T2DM patients 1:1 with non-diabetes community controls on age and sex to determine relevant risk factors for T2DM using logistic regression. Furthermore, we matched patients 1:6 with community controls to assess long-term survival (until February 2019) in a Cox regression using calendar time as the underlying timescale. Verbal autopsies determined the cause of death among T2DM patients and controls., Results: The mean age among T2DM was 50.6 (SD 11.1), and the mean FPG at first consultation was high (13.2 mmol/L (SD 5.1)). Ethnicity, family history of diabetes, hypertension, and anthropometrics differed among T2DM patients, community controls with impaired FPG, and healthy controls. Family history of diabetes (OR = 5.65, 95% CI: 3.10-10.3) and elevated waist circumference (2.33, 1.26-4.29) were significant risk factors for T2DM. 20.4% (59/289) of community controls had abnormal FPG. T2DM patients had an excess mortality hazard ratio of 3.53 (95%CI: 1.92-6.52). Deaths caused by bacterial infections, including foot ulcers, were more common among T2DM patients, compared with community controls (54% (7/13) vs. 19% (5/27) (P = 0.02))., Conclusion: Several risk factors including were associated with T2DM in Guinea-Bissau. We found a high prevalence of elevated FPG among randomly selected community controls. In combination with higher mortality among T2DM patients, an urgent need for better treatment options and increased awareness.

Background: As an alternative to a professional interpreter, children or relatives often act as so-called 'language brokers' in the healthcare sector. Litterature have demonstrated that the cultural context is significant for the potential outcome for child language brokers. For individuals from a collectivistic family pattern, it becomes natural and is often regarded as respectful, to assist older relatives day and night., Aim: Very little is known about young people providing informal translation services in a Scandinavian context. We therefore aimed to capture the lived experiences of bilingual health professionals, students and postgraduates who have experienced interpreting for family members in a healthcare setting. By interviewing bilingual health professionals, we aimed to obtain two perspectives, the translators and the professionals, in one interview., Results: Analysing the conditions, meanings and reasoning, it became possible for us to understand the young translators' situations and how their life conditions affected their reasons for action in certain ways and in certain conditions. The analysis revealed four main themes: (i) the importance of social relations and cultural conditions; (ii) the hidden burden of consequences for participants' health conditions due to the focus on health-related consequences and emotionally difficult situations experienced by the participants; (iii) participants experienced limitations in language skills as a challenge; and (iv) being 'in between' in the encounter with the professional system., Conclusion: When family members interpret for the family, the family interpreter is at risk of being excluded by the family or being exposed to and involved in highly sensitive dilemmas that may forever impair normal family relations: health professionals should be aware of this and take professional responsibility., (© 2019 Nordic College of Caring Science.)

Purpose: Immigrant patients run a risk of receiving lower quality of care. Co-production, as the concept of how to collaboratively create valuable healthcare service for the patient, offers a new perspective that might help. The scoping review aimed at identifying and analysing factors facilitating co-production between immigrant patients and healthcare professionals., Methods: We searched seven scientific databases for peer-reviewed publications of all study designs. Two reviewers independently screened the publications for eligibility and performed data extraction. Data were analysed by applying an inductive, interpretive approach for data synthesis., Results: Fifteen publications were included for analysis. We identified six factors hat facilitate co-production: 1) prioritizing co-production in the organization, 2) providing a safe environment that promotes trust and patience, 3) using a language the patient understands, 4) respecting the patient's knowledge and priorities, 5) improvising with knowledge and courage, and 6) engaging in self-reflection., Conclusions: The scoping review illustrated that co-production with immigrant patients can be successful if the system and professionals are interested and prepared. Immigrant patients could be a valuable source of information and powerful co-producers of their own health. The study contributed to a growing body of research on patient-professional co-production in healthcare and might also prove relevant for other disadvantaged patient groups.

The human immunodeficiency virus (HIV) remains a leading cause of maternal morbidity and mortality in Sub-Saharan Africa. Prevention of mother-to-child transmission (PMTCT) has proven an effective strategy to end paediatric infections and ensure HIV-infected mothers access treatment. Based on cross-sectional data collected from June 2008 to May 2013, we assessed changes in HIV prevalence, risk factors for HIV, provision of PMTCT antiretroviral treatment (ART), and the association between HIV infection, birth outcomes and maternal characteristics at the Simão Mendes National Hospital, Guinea-Bissau's largest maternity ward. Among 24,107 women, the HIV prevalence was 3.3% for HIV-1, 0.8% for HIV-2 and 0.9% for HIV-1/2. A significant decline in HIV-1, HIV-2, and HIV-1/2 prevalence was observed over time. HIV infection was associated with age and ethnicity. A total of 85% of HIV-infected women received ART as part of PMTCT, yet overall treatment coverage during labour and delivery declined significantly for both mothers and infants. Twenty-two percent of infants did not receive treatment, and 67% of HIV-2-infected mothers and 77% of their infants received ineffective non-nucleoside reverse transcriptase inhibitors for PMTCT. Maternal HIV was associated with low birth weight but not stillbirth. Inadequate continuity of care and ART coverage present challenges to optimal PMTCT in Guinea-Bissau.

Background: In 2018, Europe faced the highest number of Measles cases in a decade. In Denmark, the childhood vaccination programme has a coverage of approximately 90%. To eliminate the disease, vaccine coverage needs to be above the herd immunity threshold of 95%. This can be even more difficult to obtain, when vaccination programmes break down due to war, natural disasters etc. and concern has been raised, that unvaccinated refugees could facilitate spread of measles when migrating., Methods: In order to address this concern, we tested 513 newly arrived refugees and family reunified refugees aged between 0 and 70 years for measles IgG antibodies. The participants were tested as part of a general health assessment between May 2016 and October 2018. In the cohort, 50% were males and the majority came from Syria (55%)., Results: We found that 85% of the total group of refugees had immunity against measles. The 15% lacking antibodies were evenly distributed between the various countries of origin. Moreover, we found immunity to increase with age, leaving young children most vulnerable to infection, 79.9% (<19 years) vs 89.1% (≥19 years). Interview questions on previous vaccinations did not correlate to serology., Conclusion: Refugees have measles immunity slightly lower than the host population., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: Antenatal care (ANC) utilization remains a challenge in efforts to reduce maternal mortality and improve maternal health in Uganda. This study aimed to identify perceived barriers to utilization of ANC services in a rural post-conflict area in northern Uganda., Methods: A qualitative study using in-depth interviews and focus group discussions of seventeen participants (pregnant women, health workers and a traditional birth attendant). The study was informed through a phenomenological approach to capture perceived barriers to utilization of ANC. The study was carried out in post-conflict Awach sub-county, Gulu District, northern Uganda. Data was analyzed using inductive conventional content analysis., Results: The main perceived barriers to ANC utilization were identified as: poor quality of care, including poor attitude of health workers; socio-cultural practices not being successfully aligned to ANC; and lack of support from the husband, including difficulties in encouraging him to attend ANC. Additionally, institutional structures and procedures at the health centers in terms of compulsory HIV testing and material requirements and transportation were perceived to prevent some pregnant women from attending ANC., Conclusions: Identifying local barriers to ANC utilization are important and should be considered when planning ANC programs. We propose that future efforts should focus on how to ensure a good patient-provider relationship and perceived quality of care, and further how to improve inter-spousal communication and sensitization of husbands for increased involvement in ANC. We recommend more research on how socio-cultural context can meaningfully be aligned to ANC to improve maternal health and reduce maternal mortality., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

This article presents narrative medicine as a new field of medical humanities. Narrative medicine has become influential over the world as well as in Denmark in recent years. Narrative medicine aims to counter the often reductionist way patients are perceived and treated in biomedicine and argues for the importance of seeing and hearing patients in the clinical practice as whole, complex persons. Through close reading of literary narratives about illness the medical students are assumed to become less unemphatic, more attuned to self-care and more tolerant towards ambiguity in the clinic.

Sub-Saharan Africa has the highest natural twinning rate in the world. Unfortunately, due to lack of adequate care during pregnancy, labor and postnatally, twin mortality in Sub-Saharan Africa also remains very high. Thus, it has been estimated that one in five twins dies during the childhood years. In spite of this, surprisingly few twin studies have been conducted in the region, making additional epidemiological data much needed. In 2009, we established one of the first twin registries in Sub-Saharan Africa at the Bandim Health Project in Guinea-Bissau. The registry had two main objectives. First, we wanted to describe the twinning rate and mortality patterns among newborn twins, including mortality risk factors and hospitalization patterns. Such studies can help the local clinicians improve twin health by identifying the most vulnerable children. Second, and in light of the rapidly increasing diabetes rates in Africa, we wanted to use the registry to particularly focus on metabolic disorders. Twins are often born with low birth weight, which according to the 'thrifty phenotype hypothesis' could predispose them to metabolic disorders later in life. Yet, no such 'fetal programming' data have previously been available from African twins despite the fact that nutritional patterns and influences from other factors (e.g., infections) could be markedly different here compared to high-income settings. In this article, we summarize the findings and current status of the Guinea-Bissau twin registry.

The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural-geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.

Introduction: Studies have shown that health care professionals lack cultural knowledge and cultural competences in the care of patients with a minority background. The aim of this study was to explore whether a cultural teaching program, the so-called ethnic patient coordinator program, had an impact on health professionals' self-perceived clinical competences in the encounter with the minority patient., Methodology: The study was designed as a qualitative study using participant observation and semistructured interviews with a practice-led research approach. In total, 30 health professionals participated in the program., Results/discussion: The coordinators described that they had learned to focus systematically on reducing language barriers and to overcome prejudices. Their new competences not only had a direct influence on patient-related practical skills but also affected the practice culture and their colleagues' approach to vulnerable patients with a minority background. Conclusion/Implication: The presence of an ethnic patient coordinator team may give rise to a more migrant-friendly and culturally competent hospital.

Objective: To examine associations between household-level characteristics and underweight in a post-conflict population., Design: Nutritional status of residents in the Gulu Health and Demographic Surveillance Site was obtained during a community-based cross-sectional study, ~6 years after the civil war. Household-level factors included headship, polygamy, household size, child-to-adult ratio, child crowding, living with a stunted or overweight person, deprived area, distance to health centre and socio-economic status. Multilevel logistic regression models examined associations of household and community factors with underweight, calculating OR, corresponding 95 % CI and intraclass correlation coefficients. Effect modification by gender and age was examined by interaction terms and stratified analyses., Setting: Rural post-conflict area in northern Uganda., Subjects: In total, 2799 households and 11 312 individuals were included, representing all age groups., Results: Living in a female-headed v. male-headed household was associated (OR; 95 % CI) with higher odds for underweight among adult men (2·18; 1·11, 4·27) and girls <5 years (1·51; 0·97, 2·34), but lower odds among adolescent women aged 13-19 years (0·46; 0·22, 0·97). Higher odds was seen for residents living in deprived areas (1·37; 0·97, 1·94), with increasing distance to health services (P-trend <0·05) and among adult men living alone v. living in an average-sized household of seven members (3·23; 1·22, 8·59). Residents living in polygamous households had lower odds for underweight (0·79; 0·65, 0·97)., Conclusions: The gender- and age-specific associations between household-level factors and underweight are likely to reflect local social capital structures. Adapting to these is crucial before implementing health and nutrition interventions.

Background: The genetic architecture of birth size may differ geographically and over time. We examined differences in the genetic and environmental contributions to birthweight, length and ponderal index (PI) across geographical-cultural regions (Europe, North America and Australia, and East Asia) and across birth cohorts, and how gestational age modifies these effects., Methods: Data from 26 twin cohorts in 16 countries including 57 613 monozygotic and dizygotic twin pairs were pooled. Genetic and environmental variations of birth size were estimated using genetic structural equation modelling., Results: The variance of birthweight and length was predominantly explained by shared environmental factors, whereas the variance of PI was explained both by shared and unique environmental factors. Genetic variance contributing to birth size was small. Adjusting for gestational age decreased the proportions of shared environmental variance and increased the propositions of unique environmental variance. Genetic variance was similar in the geographical-cultural regions, but shared environmental variance was smaller in East Asia than in Europe and North America and Australia. The total variance and shared environmental variance of birth length and PI were greater from the birth cohort 1990-99 onwards compared with the birth cohorts from 1970-79 to 1980-89., Conclusions: The contribution of genetic factors to birth size is smaller than that of shared environmental factors, which is partly explained by gestational age. Shared environmental variances of birth length and PI were greater in the latest birth cohorts and differed also across geographical-cultural regions. Shared environmental factors are important when explaining differences in the variation of birth size globally and over time.

Background: The World Health Organization recommends HIV testing is included in routine screening tests for all pregnant women in order to prevent mother-to-child-transmission of HIV and reduce maternal morbidity and mortality., Objectives: To assess the proportion of women approached and tested for HIV at delivery and factors associated with non-testing at the maternity ward of the Simão Mendes National Hospital (HNSM) in Bissau, Guinea-Bissau., Methods: We conducted a retrospective cross-sectional study among women presenting for delivery from June 2008 until May 2013. During the study period, national policy included opt-out HIV-testing at delivery. Modified Poisson regression models were used to examine the association of maternal characteristics with HIV testing. Time trends were determined using Pearson's χ2 test., Results: Seventy-seven percent (24,217/31,443) of women presenting for delivery were counselled regarding PMTCT, of whom 99.6% (24,107/24,217) proceeded with HIV testing. The provision of opt-out HIV testing at labour increased from 38.1% (1,514/3973) in 2008 to 95.7% (2,021/2,113) in 2013, p<0.001. There were four distinct periods (two or more consecutive calendar months) when less than 50% of women delivering at HNSM were tested. Periods of political instability were significantly associated with not testing for HIV (adjusted prevalence ratio [APR] 1.79; 95% CI 1.73-1.84), as was a lower educational status (APR 1.05; 95% CI 1.00-1.10), admission during evenings/nights (APR 1.05; 95% CI 1.01-1.09) and on Sundays (APR 1.14; 95% CI 1.07-1.22) and Mondays (APR 1.12; 95% CI 1.05-1.19)., Conclusions: Rapid scale-up of PMTCT HIV testing services and high testing coverage was possible in this resource-limited setting but suffered from regular interruptions, most likely because of test stock-outs. Establishing proper stock management systems and back-up plans for periods of political instability is required to ensure the maintenance of health system core functions and increase health system resilience., Competing Interests: The authors have declared that no competing interests exist.

Background: There is evidence that birth size is positively associated with height in later life, but it remains unclear whether this is explained by genetic factors or the intrauterine environment., Aim: To analyze the associations of birth weight, length and ponderal index with height from infancy through adulthood within mono- and dizygotic twin pairs, which provides insights into the role of genetic and environmental individual-specific factors., Methods: This study is based on the data from 28 twin cohorts in 17 countries. The pooled data included 41,852 complete twin pairs (55% monozygotic and 45% same-sex dizygotic) with information on birth weight and a total of 112,409 paired height measurements at ages ranging from 1 to 69 years. Birth length was available for 19,881 complete twin pairs, with a total of 72,692 paired height measurements. The association between birth size and later height was analyzed at both the individual and within-pair level by linear regression analyses., Results: Within twin pairs, regression coefficients showed that a 1-kg increase in birth weight and a 1-cm increase in birth length were associated with 1.14-4.25 cm and 0.18-0.90 cm taller height, respectively. The magnitude of the associations was generally greater within dizygotic than within monozygotic twin pairs, and this difference between zygosities was more pronounced for birth length., Conclusion: Both genetic and individual-specific environmental factors play a role in the association between birth size and later height from infancy to adulthood, with a larger role for genetics in the association with birth length than with birth weight., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: Older non-Western migrants in Europe are a vulnerable population, due to old age and multiple disadvantages related to language barriers and different understandings of care, health, and disease. Our aim was to gain a better understanding and insight into the care needs of families with refugee background Method: The study was designed as a qualitative exploration using semistructured individual interviews and family group interviews., Results: The results illustrate how vulnerability can "transmit" from one family member to another. Discrepancies between the older person's expectations and needs and society's expectations trap family members in ethical and moral dilemmas. This divides and stresses the family and results in difficult decision making, increased stress, and vulnerability., Conclusion and Implication: Migration and displacement can lead to ambivalent feelings among younger relatives regarding their role in caring for older relatives. Health professionals need to address and acknowledge this to be able to provide culturally congruent health care.

It is well established that boys are born heavier and longer than girls, but it remains unclear whether birth size in twins is affected by the sex of their co-twin. We conducted an individual-based pooled analysis of 21 twin cohorts in 15 countries derived from the COllaborative project of Development of Anthropometrical measures in Twins (CODATwins), including 67,850 dizygotic twin individuals. Linear regression analyses showed that boys having a co-twin sister were, on average, 31 g (95% CI 18 to 45) heavier and 0.16 cm (95% CI 0.045 to 0.274) longer than those with a co-twin brother. In girls, birth size was not associated (5 g birth weight; 95% CI -8 to -18 and -0.089 cm birth length; 95% CI -0.202 to 0.025) with the sex of the co-twin. Gestational age was slightly shorter in boy-boy pairs than in boy-girl and girl-girl pairs. When birth size was standardized by gestational age, the magnitude of the associations was attenuated in boys, particularly for birth weight. In conclusion, boys with a co-twin sister are heavier and longer at birth than those with a co-twin brother. However, these differences are modest and partly explained by a longer gestation in the presence of a co-twin sister.

Aims: Immigrants, refugees, and their descendants comprise 12% of Denmark's population. Some of these people do not speak or understand Danish well enough to communicate with the staff in a healthcare setting and therefore need interpreter services. Interpretation through video conferencing equipment (video interpretation) is frequently used and creates a forum where the interpreter is not physically present in the medical consultation. The aim of this study was to investigate the attitudes to and experiences with video interpretation among charge nurses in a Danish university hospital., Methods: An electronic questionnaire was sent to 99 charge nurses. The questionnaire comprised both closed and open-ended questions. The answers were analysed using descriptive statistics and thematic text condensation., Results: Of the 99 charge nurses, 78 (79%) completed the questionnaire. Most charge nurses, 21 (91%) of the daily/monthly users, and 21 (72%) of the monthly/yearly users, said that video interpretation increased the quality of their conversations with patients. A total of 19 (24%) departments had not used video interpretation within the last 12 months., Conclusions: The more the charge nurses used video interpretation, the more satisfied they were. Most of the charge nurses using video interpretation expressed satisfaction with the technology and found it easy to use. Some charge nurses are still content to allow family or friends to interpret. To reach its full potential, video interpretation technology has to be reliable and easily accessible for any consultation, including at the bedside.

Introduction: Immigrant patients often meet barriers to patient-centred healthcare in their new host countries. Given the heterogeneity of patients from ethnic minorities, established strategies for patient centredness might not work in their case. The concept of coproduction provides a new perspective on how to collaboratively create the highest possible value for both the patient and the healthcare system. The concept acknowledges that all service is coproduced and directs attention to the relationship between patient and care provider. Coproduction is still a new concept in healthcare and its use with vulnerable groups of patients requires further study. This protocol outlines a scoping review to be conducted on the current knowledge on coproduction of service by immigrants and their service providers in the healthcare sector., Methods and Analysis: We will use Joanna Briggs methodology for scoping reviews. The data will stem from the following databases: PubMed, Scopus, Ovid EMBASE, EBSCO CINAHL, EBSCO PsycINFO, Cochrane Library and Web of Science. We will also screen the websites of national authorities and research organisations for publications and review the literature lists of the identified articles for relevant references. We will include all types of literature on coproduction of healthcare or social service by immigrants and service providers, including their relationship with one another, communication and collaboration. Two reviewers will independently screen eligible publications and extract data using a checklist developed for this scoping review., Ethics and Dissemination: The results of the study will provide an innovative perspective on the coproduction of value in healthcare service by immigrant patients and care providers. We will present the results at national and international conferences, seminars and other events with relevant stakeholders and immigrant patients, and publish them in a peer-reviewed journal., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The aim of this study was to explore the everyday life conditions experienced by older migrants and their reasons for specific age- and health-related behaviour during the conduct of everyday life. The study comprised 16 qualitative interviews with migrants aged 56-96 years from Palestine, Lebanon, Iraq and Somalia. The three themes that emerged from the conditions, meanings and reasons analysis illustrated that the older persons were trapped in various ways -without language, in fragmented families and in an unfamiliar structure. We identified these themes as The importance of the life history, Lost in language barriers and Having a national sense of belonging. The main findings emphasise the vulnerability of older migrants in a resettlement country. With an unclear national identity and without the local language, older migrants struggle to develop a clear vision of their role in a minority community in a foreign country. Besides language skills and the need for interpreters, health professionals need to consider issues such as life history, traumas and national belonging when their usual approaches to managing health-related topics have failed., (© 2017 Nordic College of Caring Science.)

Background: There is evidence that birthweight is positively associated with body mass index (BMI) in later life, but it remains unclear whether this is explained by genetic factors or the intrauterine environment. We analysed the association between birthweight and BMI from infancy to adulthood within twin pairs, which provides insights into the role of genetic and environmental individual-specific factors., Methods: This study is based on the data from 27 twin cohorts in 17 countries. The pooled data included 78 642 twin individuals (20 635 monozygotic and 18 686 same-sex dizygotic twin pairs) with information on birthweight and a total of 214 930 BMI measurements at ages ranging from 1 to 49 years. The association between birthweight and BMI was analysed at both the individual and within-pair levels using linear regression analyses., Results: At the individual level, a 1-kg increase in birthweight was linearly associated with up to 0.9 kg/m2 higher BMI (P < 0.001). Within twin pairs, regression coefficients were generally greater (up to 1.2 kg/m2 per kg birthweight, P < 0.001) than those from the individual-level analyses. Intra-pair associations between birthweight and later BMI were similar in both zygosity groups and sexes and were lower in adulthood., Conclusions: These findings indicate that environmental factors unique to each individual have an important role in the positive association between birthweight and later BMI, at least until young adulthood., (© The Author 2017. Published by Oxford University Press on behalf of the International Epidemiological Association)

Background: The human immunodeficiency virus (HIV) continues to be a major cause of maternal and infant mortality and morbidity in sub-Saharan Africa. Prevention of mother-to-child transmission of HIV (PMTCT) strategies have proven effective in decreasing the number of children infected in utero, intrapartum and during the breastfeeding period. This qualitative study explores knowledge and perceptions of HIV amongst pregnant women, healthcare workers' experiences of the national PMTCT services, and barriers to PMTCT, during a period of programme scale-up in urban Guinea-Bissau (2010-11)., Methods: In-depth interviews were undertaken amongst 27 women and 19 key informants at local antenatal clinics and the national maternity ward in Bissau, Guinea-Bissau., Results: Amongst women who had been tested for HIV, awareness and knowledge of HIV and PMTCT remained low. Testing without informed consent was reported in some cases, in particular when the test was performed around the time of delivery. Possible drivers of inadequate counselling included lack of confidentiality, suboptimal healthcare worker training, lack of time, and perceived occupational risk. Demand-side barriers to PMTCT included lack of HIV and PMTCT knowledge, customary and cultural beliefs associated with HIV and ill-health, HIV stigma and discrimination, and fear of partnership dissolution., Conclusions: Socio-cultural and operational challenges, including HIV testing without informed consent, present significant barriers to the scale-up of PMTCT services in Bissau. Strengthening local capacity for effective counselling and testing in the antenatal setting is paramount. Further research into local customary beliefs relating to HIV is warranted.

Objectives: Studies have shown that depression and other mental illnesses are under-diagnosed among HIV-infected individuals. The aim of this study was to evaluate the use of mental health history and questionnaire-based screening instruments to identify HIV-infected individuals at risk of depression., Methods: The Beck Depression Inventory II (BDI-II) was used to assess the prevalence and severity of depressive symptoms among HIV-infected individuals attending two out-patient clinics in Denmark. HIV-infected individuals with a BDI-II score ≥ 20 were offered a clinical evaluation by a consultant psychiatrist. The BDI-II score was compared to the outcome of mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool., Results: A total of 501 HIV-infected individuals were included in the study. Symptoms of moderate/major depression (BDI-II score ≥ 20) were observed in 111 patients (22%); 65 of these patients consulted a psychiatrist, of whom 71% were diagnosed with a co-existing disorder. The BDI-II score was compared to the outcome of a mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool. The two questions showed a sensitivity and specificity of 95% and 68%, respectively, for diagnosis of current depression or risk of depression. A previous psychiatric history and substance abuse were independently associated with an increased risk of depression., Conclusions: We suggest that the mental health of HIV-infected individuals should be reviewed and a "risk-flag" three-step approach should be used (1) to screen routinely with the two verbal questions suggested by the EACS, (2) to identify whether there is a risk of depression and then screen with the BDI-II, and (3) to identify whether there is still a risk and then perform a full evaluation and obtain an accurate psychiatric diagnosis by a psychiatrist., (© 2016 British HIV Association.)

From June 2016, medical examination is no longer a mandatory part of the integration process for refugees arriving in Denmark. Throughout Denmark there is a great variation in the way medical examinations of refugees are carried out. There are neither national guidelines nor strategies for how to manage this challenge systematically and equally throughout the country. We encourage the local municipalities together with the regions and general practitioners to find a solution for a uniform approach.

Background: Twins may be at increased risk of dysglycaemic disorders due to adverse fetal conditions. Data from Africa regarding this association is limited. We studied impaired glucose tolerance (IGT) and other types of dysglycemia among twins and singletons in Guinea-Bissau., Methods: The study was conducted from February 2011 until March 2012 at the Bandim Health Project, a health and demographic surveillance system site in the capital Bissau. Twins (n = 209) and singletons (n = 182) were recruited from a previously established cohort. Oral glucose tolerance tests (OGTT) were performed, along with anthropometrics and collection of clinical and dietary data., Results: Median age was 16.6 and 14.2 years between twins and singletons, respectively (P = 0.08). Mean birth weight was 2410 vs. 3090 g, respectively (P < 0.001). Twins had higher median fasting- and two hour capillary plasma glucose, 5.4(3.2-8.2) vs. 5.0(3.2-11.5) mmol/L (P < 0.001) and 6.8(3.4-11.3) vs. 6.2(3.2-12.1) mmol/L (P < 0.001), respectively, compared to singletons. The prevalence of IGT was 2.5 % (5/209) vs. 3.5 % (6/182) (RR = 0.73, 95 % CI: 0.20-2.64). 12 % (25/209) of twins had impaired fasting glucose (IFG), compared to 3.5 % (6/182) of singletons (3.63, 1.53-8.62). Dysglycemia (IGT and/or IFG or overt diabetes) was found in 17 % (35/209) vs. 9 % (16/182) (1.90, 1.08-3.37), respectively., Conclusions: Twins had higher glucose levels in both the fasting and postprandial state. This may indicate a detrimental effect of the twin fetal environment on glucose metabolism later in life, a result contrary to Scandinavian register studies. The IGT burden was low in this young age group and the risk was similar in twins and singletons.

Background: Both genetic and environmental factors are known to affect body mass index (BMI), but detailed understanding of how their effects differ during childhood and adolescence is lacking., Objectives: We analyzed the genetic and environmental contributions to BMI variation from infancy to early adulthood and the ways they differ by sex and geographic regions representing high (North America and Australia), moderate (Europe), and low levels (East Asia) of obesogenic environments., Design: Data were available for 87,782 complete twin pairs from 0.5 to 19.5 y of age from 45 cohorts. Analyses were based on 383,092 BMI measurements. Variation in BMI was decomposed into genetic and environmental components through genetic structural equation modeling., Results: The variance of BMI increased from 5 y of age along with increasing mean BMI. The proportion of BMI variation explained by additive genetic factors was lowest at 4 y of age in boys (a(2) = 0.42) and girls (a(2) = 0.41) and then generally increased to 0.75 in both sexes at 19 y of age. This was because of a stronger influence of environmental factors shared by co-twins in midchildhood. After 15 y of age, the effect of shared environment was not observed. The sex-specific expression of genetic factors was seen in infancy but was most prominent at 13 y of age and older. The variance of BMI was highest in North America and Australia and lowest in East Asia, but the relative proportion of genetic variation to total variation remained roughly similar across different regions., Conclusions: Environmental factors shared by co-twins affect BMI in childhood, but little evidence for their contribution was found in late adolescence. Our results suggest that genetic factors play a major role in the variation of BMI in adolescence among populations of different ethnicities exposed to different environmental factors related to obesity., (© 2016 American Society for Nutrition.)

Height variation is known to be determined by both genetic and environmental factors, but a systematic description of how their influences differ by sex, age and global regions is lacking. We conducted an individual-based pooled analysis of 45 twin cohorts from 20 countries, including 180,520 paired measurements at ages 1-19 years. The proportion of height variation explained by shared environmental factors was greatest in early childhood, but these effects remained present until early adulthood. Accordingly, the relative genetic contribution increased with age and was greatest in adolescence (up to 0.83 in boys and 0.76 in girls). Comparing geographic-cultural regions (Europe, North-America and Australia, and East-Asia), genetic variance was greatest in North-America and Australia and lowest in East-Asia, but the relative proportion of genetic variation was roughly similar across these regions. Our findings provide further insights into height variation during childhood and adolescence in populations representing different ethnicities and exposed to different environments.

Objective: To determine the prevalence of adult malnutrition and associated risk factors in a post-conflict area of northern Uganda., Methods: A cross-sectional community survey was performed from September 2011 to June 2013. All registered residents in Gulu Health and Demographic Surveillance System aged 15 years and older were considered eligible. Trained field assistants collected anthropometric measurements (weight and height) and administered questionnaires with information on sociodemographic characteristics, food security, smoking and alcohol. Nutritional status was classified by body mass index., Results: In total, 2062 men and 2924 women participated and were included in the analyses. The prevalence of underweight was 22.3% for men and 16.0% for women, whereas the prevalence of overweight was 1.5% for men and 7.6% for women. In men, underweight was associated with younger (15-19 years) and older age (>55 years) (P < 0.001), being divorced/separated [odds ratio (OR) = 1.91 (95% confidence interval (CI): 1.21-2.99] and smoking (OR = 2.13, 95% CI: 1.67-2.73). For women, underweight was associated with older age (P < 0.001) and hungry-gap rainy season (May-July) (OR = 1.33, 95% CI: 1.04-1.69). Widowed or divorced/separated women were not more likely to be underweight. No association was found between education, alcohol consumption or food security score and underweight., Conclusions: Our findings are not in line with the conventional target groups in nutritional programmes and highlight the importance of continuous health and nutritional assessments of all population groups that reflect local social determinants and family structures., (© 2016 John Wiley & Sons Ltd.)

We analyzed birth order differences in means and variances of height and body mass index (BMI) in monozygotic (MZ) and dizygotic (DZ) twins from infancy to old age. The data were derived from the international CODATwins database. The total number of height and BMI measures from 0.5 to 79.5 years of age was 397,466. As expected, first-born twins had greater birth weight than second-born twins. With respect to height, first-born twins were slightly taller than second-born twins in childhood. After adjusting the results for birth weight, the birth order differences decreased and were no longer statistically significant. First-born twins had greater BMI than the second-born twins over childhood and adolescence. After adjusting the results for birth weight, birth order was still associated with BMI until 12 years of age. No interaction effect between birth order and zygosity was found. Only limited evidence was found that birth order influenced variances of height or BMI. The results were similar among boys and girls and also in MZ and DZ twins. Overall, the differences in height and BMI between first- and second-born twins were modest even in early childhood, while adjustment for birth weight reduced the birth order differences but did not remove them for BMI.

Purpose: When serious illness occurs, effective communication is essential but challenged by language barriers. This study explores how patients with limited Danish proficiency and their families experience language barriers during cancer care in two Danish public hospitals., Method: Adopting a phenomenological-hermeneutic approach, the study stresses narratives in understanding participants' lived experiences. Accordingly, nine qualitative, semi-structured interviews were conducted with 17 informants, including nine patients and eight relatives. The interviews were audio-recorded and transcribed verbatim., Results: Based on analysis, three themes were identified: 1) A history of pain behind the language barrier; 2) Linguistic pain-a feeling of being trapped in mother tongue; and 3) Barriers and pathways to linguistic safety. The findings reveal that painful stories were not only brought into the hospital but continued there. Painful feelings associated with being unable to communicate directly with the healthcare professionals seemed inescapable, but continuity of empathetic care providers, including professional interpreters, increased the well-being of both patients and family members., Conclusion: Language barriers not only make patients more susceptible to misunderstandings and medical errors but amplify experiences of pain during cancer care. The generated knowledge from this study emphasizes language as a foundational element in advancing more equitable cancer care.

Introduction: Male circumcision (MC) reduces the risk of HIV, and this risk reduction may be modified by socio-cultural factors such as the timing and method (medical and traditional) of circumcision. Understanding regional variations in circumcision practices and their relationship to HIV is crucial and can increase insight into the HIV epidemic in Africa., Methods: We used data from two retrospective HIV surveys conducted in Guinea-Bissau from 1993 to 1996 (1996 cohort) and from 2004 to 2007 (2006 cohort). Multivariate logistical models were used to investigate the relationships between HIV risk and circumcision status, timing, method of circumcision, and socio-demographic factors., Results: MC was protective against HIV infection in both cohorts, with adjusted odds ratios (AORs) of 0.28 (95% CI 0.12-0.66) and 0.30 (95% CI 0.09-0.93), respectively. We observed that post-pubertal (≥ 13 years) circumcision provided the highest level of HIV risk reduction in both cohorts compared to non-circumcised. However, the difference between pre-pubertal (≤ 12 years) and post-pubertal (≥ 13 years) circumcision was not significant in the multivariate analysis. Seventy-six percent (678/888) of circumcised males in the 2006 cohort were circumcised traditionally, and 7.7% of those males were HIV-infected compared to 1.9% of males circumcised medically, with AOR of 2.7 (95% CI 0.91-8.12)., Conclusion: MC is highly prevalent in Guinea-Bissau, but ethnic variations in method and timing may affect its protection against HIV. Our findings suggest that sexual risk behaviour and traditional circumcision may increases HIV risk. The relationship between circumcision age, sexual behaviour and HIV status remains unclear and warrants further research.