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Ageing is a global concern with major social, health, and economic implications. While individual countries seek to develop responses to immediate, pressing needs, international attention and collaboration is required to most effectively address the multifaceted challenges and opportunities an ageing global population presents in the longer term. The Ageing, Longevity and Health stream of the International Alliance of Research Universities (IARU-ALH) was built on a solid foundation of first-class interdisciplinary research and on innovative outreach and communication centres. This interdisciplinary network conducts projects that span biology, medicine, social sciences, epidemiology, public health, policy, and demography, and actively engages with the public and other societal stakeholders. Here we posit that such international interdisciplinary networks are needed and uniquely placed to address major challenges related to health and ageing and ultimately will produce new understanding and knowledge to promote the awareness of healthy ageing and encourage societal change via novel, science-informed interventions. Global interdisciplinary research presents great potential and opportunities to accelerate our understanding of human ageing and to produce new, more effective solutions to a pressing, complex problem. However, more focused, strategic efforts and investments are required in order to deliver on these potentials and reap maximum benefits for individuals and societies. IARU-ALH members are determined to contribute, in collaboration with others, to delivering on this vision.

This qualitative study presents migrant patient perspectives on using the Cultural Formulation Interview (CFI) in mental health assessments in Denmark. Empirical data consisted of 20 recorded CFI sessions and 16 patient interviews, coded with a constructivist grounded theory approach. Empirical findings prompted us to draw on the theoretical framework of intersubjective recognition in the analytical process. Our analysis showed how patients had multiple previous experiences of misrecognition in life and healthcare. This seemed to restrain their self-esteem and available positions for expressing preferences and reservations during the CFI and led to negotiations of worthiness of care. Despite occasional lack of flow and information in the recorded CFI sessions, patients subsequently recounted how they felt the CFI recognised the complexity and context of their cultural identities and illness narratives. Patients described how the CFI-guided provider approach of curiosity and empowerment carried significant meaning and left them feeling dignified, hopeful and engaged in future care. Intersubjective recognition is fundamental in all human interaction, but we argue that the recognising CFI approach is particularly important in vulnerable and asymmetrical mental health assessment encounters where access to care is determined and when working with migrants or other marginalised groups.

(1) Background: Informal patient payments continue to persist in the Serbian health care system, exposing vulnerable groups to private spending on health care. Migrants may in particular be subject to such payments, as they often experience barriers in access to health care. Little is known about migrants paying informally to access health care in Serbia. The study aims to explore pathways of accessing health care, including the role of informal patient payments, from the perspectives of civil servants and non-western migrants in Serbia. (2) Methods: Respondents (n = 8 civil servants and n = 6 migrants) were recruited in Belgrade in 2018, where semi-structured interviews were conducted. The interviews were analysed applying the grounded theory methodological steps. (3) Results: Data reveal different pathways to navigate the Serbian health care system, and ultimately whether paying informally occurs. Migrants appear less prone to paying informally and receive the same or better-quality health care. Locals experience the need to pay informal patient payments, quasi-formal payments and to bring medicine, materials or equipment when in health facilities. (4) Conclusions: Paying informally or using private care in Serbia appear to have become common. Despite a comprehensive health insurance coverage, high levels of out-of-pocket payments show barriers in accessing health care. It is highly important to not confuse the cultural beliefs with forced spending on health care and such private spending should be reduced to not push people into poverty.

Background Compounds in clinical development for nonalcoholic steatohepatitis (NASH) improve liver histopathology in diet-induced obese mouse models of biopsy-confirmed NASH. Since the biopsy section used for histopathological evaluation represents only Methods Male leptin-deficient Lepob/Lepob mice were fed the Amylin liver NASH (AMLN) diet for 16 weeks before stratification into treatment groups using a biopsy-based evaluation of type I collagen αI (col1a1) levels. Mice were treated for 8 weeks with either vehicle (PO, QD), liraglutide (0.4 mg/kg, SC, QD), elafibranor (30 mg/kg, PO, QD) or INT-767 (10 mg/kg, PO, QD). Terminal quantitative histological assessment of liver lipid (hematoxylin-eosin staining), inflammation (galectin-3 immunohistochemistry (IHC); gal-3), and fibrosis (col1a1 IHC) was performed on terminal liver biopsies and compared with stereologically sampled serial sections spanning the medial, left and right lateral lobe of the liver. Results The distribution of liver lipid and fibrosis was markedly consistent across lobes, whereas inflammation showed some variability. While INT-767 and liraglutide significantly reduced total liver weight by 20 and 48%, respectively, elafibranor tended to exacerbate hepatomegaly in Lepob/Lepob-NASH mice. All three compounds markedly reduced biopsy-based relative liver lipid content. Elafibranor and INT-767 significantly reduced biopsy-based relative gal-3 levels (P Conclusions In conclusion, in-depth analyses of liver homogeneity demonstrated that drug-induced improvement in liver biopsy-assessed histopathology is representative for overall liver effects assessed using stereology. Importantly, these findings reveal how changes in whole-liver mass should be considered to provide a deeper understanding of apparent drug treatment efficacy in preclinical NASH studies.

ObjectivesSelf-rated health (SRH) is a strong predictor for healthcare utilisation among chronically ill patients. However, its association with acute hospitalisation is unclear. Individuals’ perception of urgency in acute illness expressed as degree-of-worry (DOW) is however associated with acute hospitalisation. This study examines DOW and SRH, respectively, and their association with acute hospitalisation within 48 hours after calling a medical helpline.DesignA prospective cohort study.SettingThe Medical Helpline 1813 (MH1813) in the Capital Region of Denmark, Copenhagen.ParticipantsAdult (≥18 years of age) patients and relatives/close friends calling the MH1813 between 24 January and 9 February 2017. A total of 6812 callers were included.Outcome measuresThe primary outcome measure was acute hospitalisation. Callers rated their DOW (1=minimum worry, 5=maximum worry) and SRH (1=excellent, 5=poor). Covariates included age, sex, Charlson Comorbidity Score and reason for calling. Logistic regression was conducted to measure the associations in three models: (1) crude; (2) age-and-sex-adjusted; (3) full fitted model (age, sex, comorbidity, reason for calling, DOW/SRH).ResultsOf 6812 callers, 492 (7.2%) were acutely hospitalised. Most callers rated their health as being excellent to good (65.3%) and 61% rated their worry to be low (DOW 1–3). Both the association between DOW and acute hospitalisation and SRH and acute hospitalisation indicated a dose–response relationship: DOW 1=ref, 3=1.8 (1.1;3.1), 5=3.5 (2.0;5.9) and SRH 1=ref, 3=0.8 (0.6;1.4), 5=1.6 (1.1;2.4). The association between DOW and acute hospitalisation decreased slightly, when further adjusting for SRH, whereas the estimates for SRH weakened markedly when including DOW.ConclusionsDOW and poor SRH were associated with acute hospitalisation. However, DOW had a stronger association with hospitalisation than SRH. This suggests that DOW may capture acutely ill patients’ perception of urgency better than SRH in relation to acute hospitalisation after calling a medical helpline.Trial registration numberNCT02979457.

Colorectal cancer (CRC) does not affect different sociodemographic groups uniformly. CRC screening programmes could seek to reduce this inequality; however, the screening programmes themselves might be subject to differential participation across sociodemographic groups. This study investigates the sociodemographic inequality at all steps in Denmark's nationwide CRC screening programme: screening participation, faecal immunochemical test (FIT) results, colonoscopy compliance, CRC diagnosis, and cancer stage.This cohort study includes all first-time invitees from the beginning of the Danish population-based CRC screening programme from 1 March 2014 to 31 December 2017.Sixty-four percent of the invitees participated in the screening programme, and of those 7% were FIT-positive. After being invited to further diagnostic procedures, 90% responded to the invitation, and among those 5% were CRC-positive. Among those diagnosed with CRC, 9% were stage IV. Through multivariable analyses, we identified sociodemographic inequalities in all steps of the screening programme from returning a stool sample to being diagnosed with CRC. Specifically, we identified inequalities across sex, age, migration status, relationship status, the screening status of one's partner, education, income, and use of health services. Women were more likely to participate compared to men (RR = 1.13; 95% CI: 1.12-1.13), but had a lower risk of a positive FIT result (RR = 0.67; 95% CI: 0.66-0.68) and of a CRC diagnosis (RR = 0.88; 95% CI: 0.82-0.93) compared to men. The likelihood of participating as well as the risk of positive FIT results and CRC diagnosis increased with age.All steps of the screening programme were subject to sociodemographic inequalities. Interventions are needed to target groups identified as having lower uptake as well as high-risk of being FIT- and/or CRC-positive. These groups include males, individuals aged 60+ years and individuals who do not visit their GP regularly.

Introduction Workplaces are important settings for implementation of smoke-free environments. In this study, we follow a medical production company with 677 employees that implemented one of the most stringent tobacco policies legally possible in Denmark – smoke-free work hours – which means that employees are not allowed to smoke during work time. This study explores tobacco use restrictions during work hours regarding readiness of implementation, focusing specifically on middle managers’ perceptions and considerations, as well as their perceived responsibility in enforcing these. Methods A case study is presented. Two focus groups of 10 middle managers were conducted, seven months before smoke-free work hours were implemented. The facilitators used open-ended questions, which consisted of a structured section with specific themes related to the implementation of smoke-free work hours. Focus groups were recorded, transcribed, and analyzed thematically. Results We identified five main themes: 1) Benefits of the new policy due to better health, lower sickness-related absences, increased productivity, and improved branding value; 2) Social interactions across smoking status; 3) Smoking is a private matter with ethical dimensions; 4) The role of middle managers and concerns about enforcement; and 5) Limited experience with resistance from the smoking employees. Conclusions The findings suggest that workplaces in the preparation phase should ensure that: 1) The middle managers gain training on how to talk with employees about smoking cessation; 2) The middle managers are equipped to handle the new policy and have a joint vision and understanding of why and how they should enforce it; and 3) Room is made for discussions on resistance and enforcementrelated challenges as well as ethical issues.

Colorectal cancer (CRC) contributes extensively to the overall cancer burden, with substantial and increasing social inequality in both incidence and survival. In several countries, this social inequality in incidence and survival has been increasing over time, and the increase is expected to continue. To overcome this, it is advised to implement nationwide CRC screening programmes, as these are effective in detecting possible signs of CRC, hence identifying earlier-stage cancer and reducing mortality. However, little is known about the distribution of these effects across population groups. It is possible that the outcomes of CRC screening are not equally distributed among participants, but rather that the screening programme serves some population groups better than others. The aim of this short communication based on published data is to describe the status of selective uptake according to sociodemographic and economic factors in CRC screening in Scandinavia. Furthermore, we raise questions that need to be addressed in future research in order to grasp the full effects of the screening programme and ultimately to ensure high uptake as well as participation in subsequent diagnostic procedures across population groups.

Socio-economically disadvantaged groups are characterised by a higher burden of disease than the background population. Paradoxically, they are often underrepresented in health research. Failing to include socio-economically disadvantaged groups in research impairs the ability to address the social mechanisms creating health disparities. The study describes how we have tried to accommodate identified challenges from the literature in conducting a questionnaire survey in a socio-economically deprived and ethnically diverse social housing area, and which new challenges we identified. The survey is planned before, during and after the structural changes take place. Through innovative approaches, we sought to accommodate identified barriers to reaching participants. The questionnaire was translated from Danish to the seven most prevalent languages in the area, based on data from the national register. A survey corps of native speaking interviewers went door-to-door to perform face-to-face interviews. To encourage participation, we used a recruitment strategy inspired by ethnographic data collection traditions, such as local presence, participation in local activities, and graphic facilitation on invitation letters. Wave 1 and 2 had a response rate of 35% (N = 209) and 22% (N = 132), respectively. 79 respondents participated in both waves. Despite our efforts to accommodate identified challenges such as language, illiteracy, and mistrust, the response rates are low. We identified new challenges in recruiting participants including participation fatigue, frustration with the restructure process, and a feeling of limited individual gain from participation. Many challenges are associated with conducting research among socio-economically disadvantaged groups. Documenting processes and learning from experiences are important steps in including groups with lower socio-economic status in health research in order to address the underlying social mechanisms creating health disparities.

This study explored the implementation of multidimensional preventive home visits targeted to older adults living in a disadvantaged community in Denmark. The intervention was adapted to include the following key components: involvement of community members in recruitment processes; a combination of individual and group-based dissemination; adaptation of materials to overcome language barriers; and diversity-sensitivity training for professionals. The study took place over 12 months between August 2016 and August 2017 and used various data sources: registry-based data, participant observations, combined with individual and focus group interviews with the target population (n = 22) and relevant health care professionals (n = 8). Here, we report on findings pertaining to implementation barriers and facilitators as seen from the perspective of professionals. Socioeconomic vulnerability was prominent, and uptake of health care services was low, indicating under-utilisation. Implementation facilitators and barriers were identified including potentials in nurturing local partnerships and proximity during recruitment; overcoming language barriers; offering diversity-sensitivity training for professionals; and a need for a more multidisciplinary, comprehensive scope of preventive visits for diverse older adults in disadvantaged communities. Thus, more focus on participatory, comprehensive and community-based health promotion are needed to ensure healthy ageing in the context of social inequality and ethnic diversity.

National healthcare systems need to adjust services and operations to accommodate the needs of complex, aging populations living with multimorbidity and polypharmacy. This paper suggests the use of a human-centred design as a method to engage older adults and key professionals in innovation processes aiming to design person-centred healthcare services and improve quality of life in older adults. We outline three innovation phases and highlight how such processes can create engagement and new insights on how life experiences of older adult’s shape preferences, beliefs, and habits. It is important to incorporate these insights into the design of successful strategies for ensuring age-friendly healthcare services. Our viewpoint is contextualised through a small-scale case study focusing on polypharmacy in older adults. From this case study, we extracted three challenges to producing co-designed health research: recruitment, time and resources, and funding. We discuss how to address these challenges. We argue for the involvement of older adults and professional stakeholders at an early stage in the design process to align expectations and to increase the likelihood of successful implementation of healthcare innovations that improve the quality of life for older adults.

Background The number of older adults with different ethnic and socioeconomic background is steadily increasing. There is a need for community-based health promotion interventions for older adults that are responsive to ethnic and socioeconomic diversity among target populations. The aim of this study is to explore encounters between older adults living in disadvantaged areas and health care professionals in the context of community-based health promotion. Methods Qualitative methods were used involving interviews and focus groups with older adults (n = 22) and municipal health care professionals (n = 8), and multiple observations were conducted. Data were analyzed thematically. Results Findings show a gap between health promotion services and older adults due to a perception of services as being neither accessible nor acceptable in the context of complex health and psychosocial needs. Health care professionals reported trust, proximity and presence as fundamental factors for improving acceptability and accessibility of health promotion services. Conclusions There is a need to develop participatory approaches to engage older adults who live in disadvantaged areas in municipal health promotion services and to ensure that these services are relevant to these groups.

Emerging evidence points towards a lower quality of life, fragile social relations and suboptimal health behavior and status of residents living in social housing areas characterized by ethnic diversity and socioeconomic deprivation. Community-based health promotion interventions developed in collaboration with the target group and adjusted to the local context can affect the acceptance of and engagement in such interventions. However, few studies have investigated the potential of community-based interventions in deprived social housing areas. This study explores residents&rsquo, perspectives on engagement in a community-based health promotion intervention focusing on enhancing social relations. The study builds on qualitative methods including participant observations combined with pre- and post-intervention interviews with a selected group of residents (n = 9). Data were thematically analyzed with focuses on participation in an everyday life context, concepts of othering, and territorial stigmatization. Engagement in the intervention was motivated by the need to establish and enhance social relations, and to explore the world outside the housing area. However, barriers including cultural and language differences among residents, and competing contextual factors, challenged engagement. We conclude that participatory community-based interventions have a potential to enhance social relations in deprived social housing areas. However, adequate support and efforts to overcome the identified barriers are needed.

AIM To evaluate the pharmacodynamics of compounds in clinical development for nonalcoholic steatohepatitis (NASH) in obese mouse models of biopsy-confirmed NASH. METHODS Male wild-type C57BL/6J mice (DIO-NASH) and Lepob/ob (ob/ob-NASH) mice were fed a diet high in trans-fat (40%), fructose (20%) and cholesterol (2%) for 30 and 21 wk, respectively. Prior to treatment, all mice underwent liver biopsy for confirmation and stratification of liver steatosis and fibrosis, using the nonalcoholic fatty liver disease activity score (NAS) and fibrosis staging system. The mice were kept on the diet and received vehicle, liraglutide (0.2 mg/kg, SC, BID), obeticholic acid (OCA, 30 mg/kg PO, QD), or elafibranor (30 mg/kg PO, QD) for eight weeks. Within-subject comparisons were performed on changes in steatosis, inflammation, ballooning degeneration, and fibrosis scores. In addition, compound effects were evaluated by quantitative liver histology, including percent fractional area of liver fat, galectin-3, and collagen 1a1. RESULTS Liraglutide and elafibranor, but not OCA, reduced body weight in both models. Liraglutide improved steatosis scores in DIO-NASH mice only. Elafibranor and OCA reduced histopathological scores of hepatic steatosis and inflammation in both models, but only elafibranor reduced fibrosis severity. Liraglutide and OCA reduced total liver fat, collagen 1a1, and galectin-3 content, driven by significant reductions in liver weight. The individual drug effects on NASH histological endpoints were supported by global gene expression (RNA sequencing) and liver lipid biochemistry. CONCLUSION DIO-NASH and ob/ob-NASH mouse models show distinct treatment effects of liraglutide, OCA, and elafibranor, being in general agreement with corresponding findings in clinical trials for NASH. The present data therefore further supports the clinical translatability and utility of DIO-NASH and ob/ob-NASH mouse models of NASH for probing the therapeutic efficacy of compounds in preclinical drug development for NASH.

Background Global migration increases ethnic and cultural diversity and demands mental health services to adapt to provide all patients with equal access to good quality care. Patient satisfaction surveys can inform this service delivery, thus we explored patient satisfaction among non-Western migrants receiving treatment in a Danish specialized outpatient mental health clinic [Competence Centre for Transcultural Psychiatry (CTP)]. Methods We used multivariate logistic regression models to estimate associations between ‘Overall treatment satisfaction’ and treatment-related items plus potential confounders from a cross-sectional patient satisfaction survey (n = 686). The satisfaction questionnaire was a self-report measurement tool developed locally at CTP. Participants were non-Western migrants above 18 years with Post-Traumatic Stress Disorder (PTSD) or depression diagnoses according to ICD-10. Results Most participants (n = 497; 82.6%) reported overall satisfaction with their mental health treatment, but less than half (n = 311; 48.8%) reported an improvement in health and situation after end of treatment. Participants who experienced a subjective improvement in their health and situation had significantly higher odds of being satisfied with their mental health treatment [odds ratio (OR) = 8.5, 95% confidence interval (CI): 4.0–18.1]. Perceptions of influence on the treatment course (OR = 4.7, 95% CI: 2.4–9.2), and of understanding and respect for one’s cultural background (OR = 3.4, 95% CI: 1.5–7.6) were significantly associated with treatment satisfaction. Age and sex were insignificant in the final regression model. Conclusions Implications for practice based on our findings are to enhance person-centred care and shared decision-making with all patients regardless of cultural background and to prioritize pre- and postgraduate training in cultural competences and cultural humility for healthcare providers.

Aims: The cultural competence training of healthcare professionals is a key element in ensuring the quality of both the access and delivery of healthcare to increasingly ethnically diverse populations. The aim of this study is to investigate Danish medical teachers’ opinions about cultural competence, their willingness to receive training and preparedness to teach cultural competence topics. Methods: The survey was sent to medical teachers, clinical teachers and external lecturers who teach in the medical programme at the University of Copenhagen. A total of 1400 medical teachers received the survey, and 199 responded. The response rate is 14%. Data were analysed through descriptive calculations, and answers to open-ended questions were coded using content analysis. Results: Results showed that 82.4% of the informants agreed or strongly agreed that the medical education programme should include training on cultural issues, and 60.3% agreed or strongly agreed that students should be assessed on their cultural competence skills. Regarding preparedness to teach a diverse classroom, 88.4% felt somewhat or very prepared to engage and motivate all students. About 70% were interested in receiving training on cultural competence. Conclusions: Generally, there is interest in and acknowledgement of the importance of cultural competence in Danish medical education among teachers at the University of Copenhagen. This creates an opportunity to implement cultural competence in the medical curriculum, training of teachers and strengthening the diversity sensitivity of the organisation. However, support for this programme by management and the allocation of an appropriate level of resources is a prerequisite to the success of the programme.

Aims: To present and discuss implementation experiences regarding the involvement of community pharmacists with ethnic minority backgrounds in a medication review intervention for ethnic minority poly-pharmacy patients in Denmark. Methods: Data sources include 1) reflection notes from an introductory seminar with pharmacists and the cross-disciplinary research team and 2) five individual interviews and one focus group interview with pharmacists. Data were thematically coded and synthesised to identify underlying rationales and challenges encountered when involving professionals with ethnic minority backgrounds in interventions for ethnic minorities. Results: Informants perceived the need for interventions targeted at ethnic minority poly-pharmacy patients, and highlighted the potential of involving professionals with diverse ethnic backgrounds in such interventions. However, implementation created challenges, because the professional identity of the pharmacists reduced their options for serving as peers with the same ethnic background. Furthermore, issues related to organisational difficulties and overcoming language barriers in the intervention impacted on the potential of involving professionals with ethnic minority backgrounds. Conclusions: Involving healthcare professionals with ethnic minority backgrounds in encounters with ethnic minorities holds potential for the adaptation of services to ethnically diverse populations, thus improving access to and quality of care. However, it is important to ensure sufficient personal and organisational support and to acknowledge the delicate balance between simultaneously serving as a peer and as a professional.

Background The use of complementary and alternative medicine (CAM) are widespread among people with Multiple Sclerosis (PwMS) and are often used concomitant with conventional treatment. Natural medicine and dietary supplements (NADS) are the most frequently used CAM modality and among other patient groups use of NADS concomitant with conventional medicine has been reported as a potential risk to patients’ safety due to risk of drug interactions. The use of NADS concomitant with conventional medicine has, however, not been investigated among PwMS. This study's aim was to investigate the prevalence of NADS and conventional MS-related medicine use among PwMS, specific types of NADS and conventional MS-related medicine used, the prevalence of NADS used concomitant with conventional MS-related medicine, and to characterize PwMS who use NADS and PwMS who use NADS concomitant with conventional MS-related medicine in a Danish context. Methods The study was a cross-sectional study conducted as an interviewer-administered survey via phone in April 2019. The questionnaire includes questions about the use of NADS and conventional MS medicine as well as sociodemographic and health-related factors. In total 384 PwMS answered the questionnaire. Both descriptive and logistic analyses were used to analyze the data. Results The results show that the majority of PwMS use conventional MS-related medicine. In total, 85 % (n=322) had used at least one NADS within the last 12 months including vitamin D. When excluding vitamin D, the use of NADS within the last 12 months was 78.4% (n=298). Beside vitamin D the most reported types of NADS used were fatty acids (37%), Multivitamins (37%), and Calcium (35%). A total of 75.8% (n=288) reported using NADS concomitant with conventional MS medicine, and the products most often combined with conventional MS medicine were Vitamin D, Multivitamin, Calcium, Magnesium, and fatty acids. The results suggest that PwMS using NADS concomitant with conventional MS-related medicine are characterized by a high prevalence of young and newly diagnosed patients with a high education level. Conclusion The study contributes to a better understanding of NADS used among PwMS. The study shows that the majority of PwMS use NADS and that they use it concomitant with conventional MS-medicine. Furthermore, the detailed mapping of the specific types of NADS used gives a nuanced insight into the specific products of NADS used among PwMS, including different kinds of vitamins, minerals, and herbal remedies.

Social relations are part of the complex set of factors affecting health and well-being in old age. This systematic review seeks to uncover whether social interventions have an effect on social and health-related measures among nursing home residents. The authors screened PubMed, Scopus, and PsycINFO for relevant peer-reviewed literature. Interventions were included if (1) they focused primarily on social relations or related terms such as loneliness, social support, social isolation, social network, or being involuntarily alone either as the base theory of the intervention or as an outcome measure of the intervention; (2) they were implemented at nursing homes (or similar setting); (3) they had a narrative activity as its core (as opposed to dancing, gardening or other physical activity); (4) their participants met either physically or nonphysically, ie, via video-conference or the like; and if (5) they targeted residents at a nursing home. The authors systematically appraised the quality of the final selection of studies using the Mixed Methods Assessments Tool (MMAT) version 2011 and did a qualitative synthesis of the final study selection. A total of 10 studies were included. Reminiscence therapy was the most common intervention. Studies also included video-conference, cognitive, and support group interventions. All studies found the social interventions brought about positive trends on either/or the social and health-related measures included. Despite limited and very diverse evidence, our systematic review indicated a positive social and health-related potential of social interventions for older people living in nursing homes or similar institutions.

IntroductionResidential areas constitute an important arena for health, well-being and social relations. Structural interventions such as demolition and area renewal have been used to reduce inequality in health and well-being in disadvantaged areas. However, the effects of larger structural interventions are inconclusive. In a longitudinal perspective, this study aims to analyse how large-scale structural changes in an ethnic diverse social housing area are associated with the residents’ health, well-being and social relations.Methods and analysisIn this multimethods study, we examine this aim among middle-aged and older residents in a multiethnic social housing area in a Danish municipality by the inclusion of comprehensive survey (in 2018, 2019 and 2020), register (yearly 2015–2025) and qualitative (2018–2020) data. Municipal Health Profile survey data from 2017 and 2021 will be used for comparison. The area will undergo large structural changes in the built environment during 2018–2021. A ‘natural experiment’ (n=6000) compares differences in health and social outcomes across the study period between the study area and a similar neighbouring area not undergoing structural changes. Through user engagement in the design of the study, throughout the different phases of the study and in the two co-created interventions embedded in the study design, a focus on empowerment and recognition of the resources and perspectives of residents are encouraged.Ethics and disseminationThe study is registered in the University of Copenhagen’s record of biobanks and research projects containing personal data and will be conducted in accordance with the principles of the Helsinki Declaration. Residential and municipal representatives and local non-governmental organisations are engaged in the design and execution of the study to ensure the usefulness, reflexive interpretation of data, and relevance of interventions. Results will be published in international peer-reviewed scientific journals, presented at conferences and as short reports through the use of both written and visual outputs.

Asthma is a chronic respiratory disease that can be controlled with appropriate medicinal treatment. Adherence to pharmacological treatment is therefore critical. Self-efficacy plays a key role in adherence to medicine in chronic diseases, including asthma. Additionally, ethnic minorities have poor adherence to medicines. However, the impact of religion on self-efficacy and adherence is understudied. Therefore, the aim of this study was to explore the role of self-efficacy in adherence to asthma medicine treatment and the influence of religion on self-efficacy among young, Muslim minority women. A focus group and individual interviews with 10 Muslim minority women (14&ndash, 24 years of age) living in Denmark were conducted. Data analysis was deductive using Bandura&rsquo, s theory of self-efficacy and modes of agency. Overall, religion was shown to affect self-efficacy. The women reported changes in self-perceived self-efficacy during the holy month of Ramadan. In addition, praying was used as an alternative to medicine for controlling asthma symptoms. However, the women did not perceive religion and treating asthma with medicine as mutually exclusive, but rather as coexisting for the shared goal of controlling asthma symptoms. It is important for healthcare professionals (HCPs) to be aware of the link between self-efficacy, religion and adherence to asthma medicine treatment. This awareness can aid HCPs in giving advice regarding adherence to asthma treatment, and when monitoring treatment to improve the quality of asthma care for young Muslim minority women.

Elderly migrants constitute a considerable share of global return migration, nevertheless, literature on the health aspects of the return migration among these migrants is still scarce. This study explores the significance of return migration among elderly, chronically ill Bosnian refugees from Denmark and the role of health issues in their decision to return. It is based on semi-structured interviews with 33 elderly, chronically ill Bosnian refugees who have moved back to Bosnia and Herzegovina, and 10 elderly, chronically ill Bosnian refugees who have remained in Denmark. The interviews show that physical health, in the sense of the absence of illness and easy access to necessary health-care services and medicines, was not highly prioritized when the decision was made whether or not to return. However, if health is regarded more broadly as involving more than mere physical health and the absence of illness, health did matter. Viewed as physical, social and mental well-being in line with WHO’s definition of health, health was indeed one of the most important factors when the decision to return was made.

Patients' family relations play an important part in the provision of patient-centred cancer care, not least when healthcare professionals encounter seriously ill patients with dependent children. Little is known about how children are perceived and dealt with in clinical encounters. In this qualitative comparative study, we explore the influence of medical contexts in three Danish hospital wards, haematology, oncological gynaecology and neuro-intensive care, on communication with patients about their children. In exploring the degree to which the inclusion of children in clinical encounters is dependent on context, we took a comparative approach based on fieldwork in wards either exclusively focusing on cancer treatment or partially involved in critical phases of cancer treatment. We conducted 49 semi-structured, in-depth interviews with doctors and nurses, and 27 days of participant observation. The thematic analysis was based on Bateson's conceptualisation of communication. We found that healthcare professionals' approach to children in clinical encounters and the ways in which children were positioned on each ward were influenced by aspects specific to the ward, including the diagnosis and treatments that related specifically to the patient. Our findings suggest the need to explore further the influence of medical contexts on the inclusion of children in patient communication.

Background: 'Remigration bias' is often referred to when explaining low mortality outcomes among migrants compared with local-born. The hypothesis suggests that severely ill migrants tend to return to their country of origin, but it has hitherto not been tested in a large-scale epidemiological study. Consequently, we studied whether migrants with severe disease were more likely to emigrate compared with migrants without severe disease. Methods: A historic prospective cohort study was conducted based on all adult refugees and family reunification immigrants (n = 114,331) who obtained residence permission in Denmark between 1 January 1993 and 31 December 2010. Migrants with severe disease were identified through the Danish National Patient Register. Emigrations during follow-up (1 January 1993 to 31 December 2011) were identified using the Danish Civil Registration System. Hazard ratios were calculated for emigration among migrants with different levels of disease severity, adjusting for sex, age and income. Results: Results showed progressively fewer emigrations with increasing disease severity. Migrants with low (HR = 0.92; 95% CI: 0.80-1.06), moderate (HR = 0.84; 95% CI: 0.67-1.06) and high (HR = 0.70; 95% CI: 0.55-0.90) disease severity had fewer emigrations to 'country of origin' compared with migrants without disease. For emigration to 'any country', results likewise showed fewer emigrations among migrants with low (HR = 0.86; 95% CI: 0.78-0.95), moderate (HR = 0.73; 95% CI: 0.62-0.87) and high (HR = 0.64; 95% CI: 0.53-0.76) disease severity. This tendency was also observed by nationality and migrant status. On the disease-specific level, no uniform tendencies in emigration patterns were identified. Conclusion: The results do not generally support the hypothesis of 'remigration bias' but rather suggest the opposite. Accordingly, remigration bias does not appear to explain lower mortality of migrants.

Aims: Scandinavian cancer care policies emphasise community-level rehabilitation services, but little is known about changes in service provision over time. This follow-up study explores development in these services in Danish municipalities, focusing on availability, utilisation and organisation of services, including existing opportunities and challenges. Methods: A national survey among all 98 Danish municipalities was conducted in 2013 (baseline) and repeated in 2016 (follow-up). The electronic questionnaire comprised closed- and open-ended questions. Data were analysed using descriptive statistics and content analysis. Results: A total of 93 municipalities responded (95% response rate) and the services offered primarily comprised group physical activity, dietary advice, smoking cessation and individual counselling on physical activity. The number of patients enrolled was below the estimated number needing rehabilitation in Denmark. Inequality in utilisation by ethnicity, age and gender was reported. Key challenges for the delivery of services were: inadequate referral and recruitment procedures; lack of needs assessment tools; obstacles to ensuring collaboration and referral of patients between hospitals and municipalities; and inadequate evidence on the rehabilitation’s effect. Key recommendations include ensuring collaboration between municipalities; provision of diagnosis-specific group-based activities; services focusing on physical activity; and gender-specific activities directed particularly at men. Conclusions: This study, which highlights improvements in the provision of community-level cancer rehabilitation, recommends that more effort be made to ensure equality in utilisation across patient groups, improved integration of municipal-level services into cancer care trajectories, more uniform documentation of service delivery and the enforcement of patient outcomes to gradually build a more robust evidence base for community-level cancer rehabilitation.

Allergic diseases are common and frequently coexist. Allergen immunotherapy (AIT) is a disease-modifying treatment for IgE-mediated allergic disease with effects beyond cessation of AIT that may include important preventive effects. The European Academy of Allergy and Clinical Immunology (EAACI) has developed a clinical practice guideline to provide evidence-based recommendations for AIT for prevention of i) development of allergic comorbidities in those with established allergic diseases, ii) development of first allergic condition and iii) allergic sensitization. This guideline has been developed using the Appraisal of Guidelines for Research & Evaluation (AGREE II) framework, which involved a multi-disciplinary expert working group, a systematic review of the underpinning evidence and external peer-review of draft recommendations. Our key recommendation is that a three year course of subcutaneous or sublingual AIT can be recommended for children and adolescents with moderate to severe allergic rhinitis (AR) triggered by grass/birch pollen allergy to prevent asthma for up to two years post-AIT in addition to its sustained effect on AR symptoms and medication. Some trial data even suggest a preventive effect on asthma symptoms and medication more than two years post AIT. We need more evidence concerning AIT for prevention in individuals with AR triggered by house dust mites or other allergens and for the prevention of allergic sensitization, the first allergic disease or for prevention of allergic co-morbidities in those with other allergic conditions. Evidence for the preventive potential of AIT as disease modifying treatment exists but there is an urgent need for more high-quality clinical trials. This article is protected by copyright. All rights reserved.

PURPOSE: The European Academy of Allergy and Clinical Immunology (EAACI) has produced Guidelines on Allergen Immunotherapy (AIT). We sought to gauge the preparedness of primary care to participate in the delivery of AIT in Europe.METHODS: We undertook a mixed-methods, situational analysis. This involved a purposeful literature search, and two surveys: one to primary care clinicians and the other to a wider group of stakeholders across Europe.RESULTS: The 10 papers identified all pointed out gaps or deficiencies in allergy care provision in primary care. The surveys also highlighted similar concerns, particularly in relation to concerns about lack of knowledge, skills, infrastructural weaknesses, reimbursement policies and communication with specialists as barriers to evidence-based care. Almost all countries (92%) reported the availability of AIT. In spite of that, only 28% and 44% of the countries reported the availability of guidelines for primary care physicians and specialists, respectively. Agreed pathways between specialists and primary care physicians were reported as existing in 32-48% of countries. Reimbursement appeared to be an important barrier as AIT was only fully reimbursed in 32% of countries. Additionally, 44% of respondents considered accessibility to AIT and 36% stating patient costs were barriers.CONCLUSIONS: Successful working with primary care providers is essential to scaling-up AIT provision in Europe, but to achieve this the identified barriers must be overcome. Development of primary care interpretation of guidelines to aid patient selection, establishment of disease management pathways and collaboration with specialist groups are required as a matter of urgency. This article is protected by copyright. All rights reserved.

Early identification of patients with serious infections is a clinical challenge for both medical helplines and emergency departments (ED). Serious infections might be difficult to identify as some patients present unspecific symptoms and a normal body temperature. It is therefore important to describe characteristics and help-seeking behaviour (HSB) with the aim to identify infections earlier. The study population was part of a data collection carried out between 24.01-09.02 2017, at the Emergency Medical Services Copenhagen (Medical Helpline 1813). Among 11,340 patients in contact with the Medical Helpline, we identified adult patients seen in the EDs with a diagnosis of infection (ICD-10 classification). Quantitative and qualitative (recorded voicelogs) data were extracted and a mixed methods study (convergent design) was performed. Descriptive statistics and logistic regression was used for the quantitative data strand. Thematic analysis was used for the qualitative data strand. Both data strands were integrated to describe the characteristics of the HSB of patients with infections. In total 3,614 adult patients were triaged to an ED, and 753 (20.8%) were diagnosed with infection of which 83 (11%) were hospitalized. ED patients with infection were younger (Median: 42 vs 47 years, p=

Migrants are less likely to participate in mammography screening programmes compared with local-born populations in Europe. We explored perceptions of breast cancer risk and the influence on participation in mammography screening programmes among migrant women born in countries with low incidence rates of breast cancer. We conducted eight individual interviews and six group interviews including a total of 29 women aged 50-69 years living in Copenhagen, Denmark. Women were migrants born in Somalia, Turkey, Pakistan or Arab countries. Phenomenological analysis was used. Breast cancer was perceived to be caused by multiple factors, including genetics, health behaviour, stress, fertility and breastfeeding. Some women perceived breast cancer to be more prevalent in Denmark as compared with their country of birth, and perceived their risk of developing breast cancer to increase with length of stay in Denmark. Although most women agreed on the relevance of mammography screening, other cancers, chronic and infectious diseases and mental health problems were mentioned as equally or more important to target in public health programmes. A life course perspective comprising previous and current circumstances in country of birth as well as immigration country is important for understanding and influencing the screening behaviour of migrants.

Male infant circumcision is a controversial and debated topic in both scientific and public discourses in parts of Western Europe. Debates are heated and it is not always entirely clear what is in the best interest of the male infant. In this article, we discuss the importance of returning to core principles of evidence-based, patient-centred care that may help move the discussion away from the current, increasingly polarised positions. According to principles of evidence-based medicine, systematic retrieval and critical appraisal of the best evidence available should be a core consideration in all decisions regarding healthcare policy and practice. Applying this principle to male infant circumcision, we need a careful, dispassionate critique of the evidence in relation to the benefits and risks associated with the procedure and an assessment of the potential health gains and adverse effects of any interventions (such as legislation) that may be introduced. Currently, the more robust evidence-base has tended to focus on biomedical aspects of male infant circumcision and this shows consistent evidence of important benefits of this practice, but also some risks. However, health is multi-dimensional and when considering male infant circumcision, there is therefore a need to broaden the perspective to also include psycho-social considerations. It is also imperative that those striving to deliver patient-centred care keep the best interests of the patient/family at the heart of their decision-making, promote autonomy and do not inadvertently exceed the fine line between beneficence and medical paternalism.In summary, we argue that a more comprehensive and robust evidence-base is needed to enable evidence-based policy-making and that these uncertainties are communicated to patients/families so they can in the light of this evidence make an informed choice.

BACKGROUND: There is a need to establish the effectiveness, cost-effectiveness and safety of allergen immunotherapy (AIT) for the prevention of allergic disease.METHODS: Two reviewers independently screened nine international biomedical databases. Studies were quantitatively synthesized using random-effects meta-analyses.RESULTS: 32 studies satisfied the inclusion criteria. Overall, meta-analysis found no conclusive evidence that AIT reduced the risk of developing a first allergic disease over the short-term (RR=0.30; 95%CI 0.04 to 2.09) and no randomized controlled evidence was found in relation to its longer-term effects for this outcome. There was however a reduction in the short-term risk of those with allergic rhinitis developing asthma (RR=0.40; 95%CI 0.29 to 0.54), with this finding being robust to a pre-specified sensitivity analysis. We found inconclusive evidence that this benefit was maintained over the longer-term: RR=0.62; 95%CI 0.31 to 1.23. There was evidence that the risk of new sensitization was reduced over the short-term, but this was not confirmed in the sensitivity analysis: RR=0.72; 95%CI 0.24 to 2.18. There was no clear evidence of any longer-term reduction in the risk of sensitization: RR=0.47; 95%CI 0.08 to 2.77. AIT appeared to have an acceptable side-effect profile.CONCLUSIONS: AIT did not result in a statistically significant reduction in the risk of developing a first allergic disease. There was however evidence of a reduced short-term risk of developing asthma in those with allergic rhinitis, but it is unclear whether this benefit was maintained over the longer-term. We are unable to comment on the cost-effectiveness of AIT. This article is protected by copyright. All rights reserved.

Background: While previous research establishes an association between social relations, health and use of healthcare services among older people, how to implement this knowledge in real-life settings has received much less attention. This study will explore the relationship between social relations, health and use of healthcare services in a Danish mid-life population sample. In addition, the study will explore individual and contextual factors affecting the implementation of a group-based life story intervention aimed at establishing and strengthening social relations among older people at nursing homes in Denmark.Methods/design: A combined quantitative register-based approach and a qualitative implementation approach will be applied in this study. First, we will quantitatively analyse the relationship between social relations, health status and use of healthcare services among middle-aged people in Denmark by linking survey data on social relations, loneliness, self-perceived health and disease status from the Copenhagen Aging and Midlife Biobank (CAMB) (n = 7191) with national registries through the Public Health Database on use of healthcare services and demographic and socioeconomic factors. Second, we will qualitatively analyse individual and contextual factors affecting the implementation process of the group-based life story intervention based on semi-structured interviews (n = 16), observations and field notes with and among intervention stakeholders, i.e., participants and group leaders facilitating the intervention.Discussion: The results of this study are expected to improve knowledge about mechanisms through which social relations are associated with health status and use of healthcare services and to inform the implementation of future interventions targeting social relations among older people at nursing homes.Trial registration: The study has been registered and approved by the Danish Data Protection Agency. Seperate approvals have been attained for the qualitative data (Approval No. SUND-2016-08), and for the quantitative data in the CAMB database which has also received approval from the local ethical committee (approval No.H-A-2008-126 and No. 2013–41-1814, respectively).

Background The burden of cognitive impairment has increased substantially as a consequence of population ageing. Ageing processes and morbidity patterns may vary according to country of origin, however little is known regarding cognitive impairment among the increasing numbers of ageing migrants in Europe. This study was undertaken to compare the burden of dementia among migrants and Danish-born. Methods A register-based, historical prospective cohort study. Refugees and family …

Background: The impact of migration on the risk of anaphylaxis remains unknown. We hypothesized that non-Western immigrants have a lower incidence of anaphylaxis compared to Danish-born. We investigated variations in hospital attendance for anaphylaxis between immigrants and Danish-born including time- and age- trends. Methods: A register-based, historical prospective cohort design. Refugees or family reunified immigrants (n = 127 250) who, between January 1, 1994 and December 31, 2010, obtained residency permits in Denmark were included and matched in a 1 : 6 ratio on age and sex with Danish-born individuals (n = 740 600). Personal identification numbers were cross-linked to the Danish National Patient Registry identifying all first-time hospital attendances for anaphylaxis from January 1, 1994 and December 31, 2010. Incidence rate ratios were estimated, stratified for sex and region of birth, adjusting for age using a Cox regression model including the influence of duration of residence and age when residence was obtained. Results: In total 1053 hospital attendances for anaphylaxis were identified: 89 among non-Western immigrants, 9 among Western immigrants and 955 among Danish-born patients. Both male (RR = 0.65; 95%CI: 0.46;0.90) and female (RR = 0.64; 95%CI: 0.48;0.85) non-Western immigrants had a significantly lower risk ratio of hospital attendance for anaphylaxis compared to Danish-born. Compared to Danish-born, non-Western immigrants living in Denmark during the entire follow-up period also showed a decreased risk (RR = 0.65; 95%CI: 0.34;1.25). Compared to Danish-born, non-Western immigrants who obtained residence permission as children had a decreased risk of hospital attendance for anaphylaxis (RR = 0.48; 95%CI: 0.25;0.91). Conclusion: This Danish register-based study using nationwide data revealed fewer hospital attendances for anaphylaxis among non-Western immigrants compared to Danish-born; however this protection was lost over time.

Refugee children and their families may experience impaired access to healthcare; therefore, we aimed to uncover human papillomavirus (HPV) immunization patterns among a large group of refugee girls compared with Danish-born girls. We also examined possible predictors of uptake among refugee girls. We used a register-based cohort design where refugee girls (n=3264) who, between 1 January 1994 and 31 December 2010, obtained residency permits in Denmark, were included and matched on age and sex with Danish-born girls (n=19 584). Personal identification numbers were cross-linked to the National Danish Health Service Register, identifying all contacts for HPV-immunization in both the ordinary HPV-immunization program and in a catch-up program. We applied logistic regression to estimate the odds ratios (OR) of uptake. We found that refugee girls had significantly lower HPV immunization uptake compared with Danish-born girls in the ordinary immunization program (OR=0.44; 95% confidence interval: 0.37-0.51) and the catch-up program (OR=0.61; 95% confidence interval: 0.54-0.69). The difference in odds decreased after adjusting by family income, but remained significant for the ordinary immunization program. We also identified that region of origin, duration of residence, and income were predictors of uptake among refugee girls. The lower uptake of HPV immunization among refugee girls raises questions about the coverage of this immunization program across increasingly ethnic diverse societies. More efforts to secure equal uptake are needed.

BackgroundIn Denmark, immigrants have been found to have a higher use of healthcare services abroad. Since this use may have an impact on both the individual patient and the healthcare system in the country of residence, research into underlying reasons is of increasing relevance. This study therefore investigates what motives patients with an immigrant background have for seeking healthcare services in their region of origin.MethodsThe study was based on 10 semi-structured interviews with 10 patients who had an immigrant background, primarily originating from Turkey and the Middle East, recruited at a clinic of immigrant medicine in Denmark. The interviews were analysed thematically to elucidate motives for seeking healthcare services abroad, with focus on identifying push and pull factors.ResultsFour motives for seeking healthcare in the region of origin were salient in the material: the perception of availability, in terms of quantity and access; familiarity, conceptualised as feeling comfortable within the healthcare system; perception of quality of services; and finally, the perceived need for a second opinion. All motives emerged simultaneously as push factors, motivating immigrants to explore healthcare services abroad, and pull factors, attracting them to their country of origin. Affordability did not emerge as an independent motive but influenced the other factors.ConclusionThe use of healthcare services abroad by patients with an immigrant background constitutes active health-seeking behaviours shaped by a range of factors perceived to be limiting access to high-quality services in Denmark. Further research, including quantitative studies, should be initiated to investigate the importance of these motives among larger, more diverse immigrant groups, consequences for treatment regimes, and the healthcare professionals’ perspective on the use of healthcare in the region of origin among immigrant patients. Background: In Denmark, immigrants have been found to have a higher use of healthcare services abroad. Since this use may have an impact on both the individual patient and the healthcare system in the country of residence, research into underlying reasons is of increasing relevance. This study therefore investigates what motives patients with an immigrant background have for seeking healthcare services in their region of origin.Methods: The study was based on 10 semi-structured interviews with 10 patients who had an immigrant background, primarily originating from Turkey and the Middle East, recruited at a clinic of immigrant medicine in Denmark. The interviews were analysed thematically to elucidate motives for seeking healthcare services abroad, with focus on identifying push and pull factors.Results: Four motives for seeking healthcare in the region of origin were salient in the material: the perception of availability, in terms of quantity and access; familiarity, conceptualised as feeling comfortable within the healthcare system; perception of quality of services; and finally, the perceived need for a second opinion. All motives emerged simultaneously as push factors, motivating immigrants to explore healthcare services abroad, and pull factors, attracting them to their country of origin. Affordability did not emerge as an independent motive but influenced the other factors.Conclusion: The use of healthcare services abroad by patients with an immigrant background constitutes active health-seeking behaviours shaped by a range of factors perceived to be limiting access to high-quality services in Denmark. Further research, including quantitative studies, should be initiated to investigate the importance of these motives among larger, more diverse immigrant groups, consequences for treatment regimes, and the healthcare professionals’ perspective on the use of healthcare in the region of origin among immigrant patients.

Ethnic and religious pluralism are now key features of most Western societies, with Muslims representing the largest religious minority group. Although Muslims are ethnically, culturally and linguistically heterogeneous, they share common core beliefs these centring on the unity of Allah (God) and the message sent to mankind in The Holy Qur'an. A key theme running through The Qur'an is the contrast between the transitory nature of this world and the permanent abode of the Akhirah (Hereafter). Bereavement represents a significant life event, often resulting in major social, psychological and spiritual transitions.1 In this paper, we consider core Muslim beliefs in relation to death and bereavement, and draw on these beliefs and teachings, the limited available empirical data on the subject and our personal experiences to reflect on possible implications for care, particularly in relation to patients being managed in Western secular care contexts (see Box 1 for further details). Box 1 Methodology Sources of information We searched Medline in September 2012 for relevant articles regardless of language and date of publication using a combination of the following search terms: bereavement, death, dying, grief, Muslim and Islam. Bibliographies of identified articles and personal libraries were screened. We drew on our research data-sets, particularly the study ‘Developing services to meet the end-of-life care needs of South Asian Sikh and Muslim patients and their families in Scotland’ and an ongoing Danish study on ethnicity, migration and cancer care.2 Our own experiences of witnessing and caring for bereaved individuals were an additional source of information. These experiences are based on research among, as well as personal relations to, bereaved Muslims and the healthcare professionals caring for them.

Inequality in use of mammography screening across population groups is a concern since migrants are more likely to become non-users compared to the general population. The aim of this study was to a) identify determinants of participation among migrant groups and Danish-born women with emphasis on the effect of household size, socioeconomic position and use of healthcare services, and b) test whether effects of determinants were consistent across migrant and non-migrant groups.We used data from the first eight invitation rounds of the mammography screening programme in Copenhagen, Denmark (1991-2008) in combination with register-based data.The crude odds ratio (OR) for not participating in mammography screening was 1.38 (95% CI, 1.30-1.46) for women born in other-Western and 1.80 (95% CI, 1.71-1.90) for women born in non-Western countries compared to Danish-born women. The adjusted OR was 1.14 (95% CI, 1.06-1.21) for other-Western and 1.19 (95% CI, 1.11-1.27) for women born in non-Western countries. Lack of contact with a general practitioner or dental services, and not being employed had a significant negative effect on use of mammography screening. Higher-educated women were significantly less likely to use mammography screening in all groups whilst hospitalisation had a significant effect among Danish-born women. Living alone was consistently associated with non-use of mammography screening. The probability of becoming a non-user was significantly less among women living within households of two to four persons compared to women living alone. Except in the case of age and hospitalisation, trends were similar across country of birth, but the relative importance of specific determinants in explaining use of mammography screening differed.Household size, socioeconomic position and use of healthcare services were determinants of participation in mammography screening. This study emphasises the need for conducting refined analyses distinguishing among subgroups within diverse populations when explaining differences in screening behaviour.

Background Systematic assessments of cancer patients' rehabilitation needs are a prerequisite for devising appropriate survivorship programs. Little is known about the fit between needs assessment outlined in national rehabilitation policies and clinical practice. This study aimed to explore clinical practices related to identification and documentation of rehabilitation needs among patients with colorectal cancer at Danish hospitals. Material and methods A retrospective clinical audit was conducted utilizing data from patient files randomly selected at surgical and oncology hospital departments treating colorectal cancer patients. Forty patients were included, 10 from each department. Semi-structured interviews were carried out among clinical nurse specialists. Audit data was analyzed using descriptive statistics, qualitative data using thematic analysis. Results Documentation of physical, psychological and social rehabilitation needs initially and at end of treatment was evident in 10% (n = 2) of surgical patient trajectories and 35% (n = 7) of oncology trajectories. Physical rehabilitation needs were documented among 90% (n = 36) of all patients. Referral to municipal rehabilitation services was documented among 5% (n = 2) of all patients. Assessments at surgical departments were shaped by the inherent continuous assessment of rehabilitation needs within standardized fast-track colorectal cancer surgery. In contrast, the implementation of locally developed assessment tools inspired by the distress thermometer (DT) in oncology departments was challenged by a lack of competencies and funding, impeding integration of data into patient files. Conclusion Consensus must be reached on how to ensure more systematic, comprehensive assessments of rehabilitation needs throughout clinical cancer care. Fast-track surgery ensures systematic documentation of physical needs, but the lack of inclusion of data collected by the DT in oncological departments questions the efficacy of assessment tools and points to a need for distinguishing between surgical and oncological settings in national rehabilitation policies.

Objective To examine quality of life and coping strategies among immigrant women living with chronic pain. Design Qualitative content analysis based on in-depth semistructured interviews. Setting A clinic specifically targeting immigrants at a larger university hospital in Copenhagen, Denmark. Participants Non-western female immigrant patients suffering from chronic pain (n=13). Main outcome measures Experiences of the impact of chronic pain on quality of life. Results Chronic pain was perceived to have an extensive, adverse effect on all aspects of quality of life, including physical health, mental well-being and social relations. This included the ability to maintain activities of daily living and the ability to work. Chronic pain was further experienced as a cause of emotional distress, depression and altered personalities, which all had great consequences on women9s social interactions, causing change and loss of social relations. A variety of coping strategies were used to cope with the pain, manage its consequences, and restore a level of health that would enable women to function and fulfil social roles. Many participants coped with the pain by altering everyday life, keeping daily activities to a minimum and taking pain-killing drugs, offering temporary relief. Seeking healthcare was another coping strategy used as an active means to assert agency and as a temporary distraction from pain. However, accessing healthcare also involved a risk of disagreement and disappointments. Conclusions Chronic pain had a severe negative impact on quality of life and necessitated alterations in everyday life and active health-seeking strategies. Implications for practice imply a need for a more holistic approach to immigrant women with chronic pain, including a family-centred approach. Further research is needed to explore similarities or differences in and between populations with diverse ethnic, socioeconomic and psychosocial backgrounds, and to assess how ethnicity and culture might influence the experiences of chronic pain.

Background: The increasing number of elderly migrants in Europe poses challenges for the organisation of healthcare and social services if these migrants do not remigrate to their countries of birth at old age. More insight into perceptions of aging among migrant women is needed to inform service delivery for culturally and linguistic diverse populations, yet few studies have explored this field. The aim of this study is to explore perceptions of aging among middle-aged migrant women, with emphasis on identifying factors shaping their decisions on whether to remigrate or stay in Denmark during old age. Methods: The study is based on 14 semi-structured interviews including a total of 29 migrant women residing in Copenhagen, Denmark. The women were born in Somalia, Turkey, India, Iran, Pakistan, or Middle Eastern countries. The majority of participants were middle-aged and had one or more chronic illnesses. The analysis was inspired by phenomenological methods and guided by theory on access to services, social relations, and belonging. Results: The results showed that the existence of chronic conditions requiring frequent use of medical care and the availability of high-quality healthcare in Denmark were important factors for the decision to spend one’s old age in Denmark rather than to remigrate to one’s country of origin. Similarly, availability of social services providing financial and tangible support for the elderly was perceived to be important during old age. For these middle-aged women, social ties to children and grandchildren in Denmark and feelings of belonging further nourished a wish to stay in Denmark rather than remigrating. Conclusions: Since the study suggests that elderly migrants will be utilising healthcare and social services in Denmark rather than returning to their countries of birth, these services should prepare for increased cultural and linguistic diversity among users. This could entail provision of translators, specific outreach programmes, and culturally adapted services to meet elderly from diverse linguistic, religious, and cultural backgrounds.

Studies show a high level of mental health problems among refugee children. This study examined whether a subset of refugee children living in Denmark accessed psychiatric healthcare services more than those born in the country. This study compared 24,427 refugee children from Asia, The Middle East, Sub-Saharan Africa and former Yugoslavia, who obtained residency in Denmark between 1 January 1993 and 31 December 2010 with 146,562 Danish-born children, matched 1:6 on age and sex. The study looked at contacts with psychiatric hospitals as well as psychologists and psychiatrists in private practice. Between 1 January 1996 and 30 June 2012, 3.5 % of the refugee children accessed psychiatric healthcare services compared to 7.7 % of the Danish-born children. The rate ratio of having any first-time psychiatric contact was 0.42 (95 % CI 0.40–0.45) among refugee boys and 0.35 (95 % CI 0.33–0.37) among refugee girls, compared to Danish-born children. Figures were similar for those accessing private psychologists or psychiatrists, emergency room, inpatient and outpatient services. Refugee children used fewer psychiatric healthcare services than Danish-born children. This may indicate that refugee children experience barriers in accessing psychiatric healthcare systems and do not receive adequate assessment of their mental health and subsequent referral to specialist services.

Objective: To explore experiences of social support needs among South Asian Muslim patients with lifelimiting illness, living in Scotland, who are parents of young children. Design: Secondary analysis of data from a multiperspective, longitudinal Scottish study involving indepth semistructured interviews with patients, their nominated carers and healthcare professionals. Data were analysed using interpretive phenomenological analysis. Setting: Edinburgh, Scotland. Participants: South-Asian Muslim patients with life-limiting illness with children under the age of 18 (n=8), their carer (n=6) and their healthcare professional. Main outcome measures: Access and provision of social support in palliative care. Results: Open-ended qualitative interviews identified four main themes: (1) parental sadness over being unable to provide tangible support; (2) parental desire to continue to provide emotional support; (3) limited availability of informal social support networks; and (4) differing perspectives between healthcare professionals and patients on patient access to social support sources, with a subtheme being the capacity of male carers to provide social support. South-Asian parents at the end of life had limited access to extended-network support. Gender roles appeared as challenging for healthcare providers who at times overestimated the amount of support a female carer could provide and underestimated the amount of support male carers provided. Implications for practice include the need for greater awareness by healthcare providers of the social support needs of ethnic minority and migrant parents with life-limiting illnesses and especially an awareness of the importance of the role of male and female carers. Further research is needed to explore how the timing of migration impacts the need for and availability of tangible and emotional informal social support among ethnic minority parents with life-limiting illness. Chief Scientist Office, Scottish Government Health Department (grant number CZH/4/242). Publication fees were provided by Danish Research Centre for Migration Ethnicity and Health. Scopus