Search

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

Background The Norwegian colorectal cancer (CRC) screening programme started in May 2022. Inequities in uptake of CRC screening is a concern, and we expect that immigrants are at risk of non-uptake. Immigrants from Poland are the most populous immigrant group in Norway. The purpose of this study was to identify and explore factors that may facilitate Polish immigrants’ access to the Norwegian CRC screening programme. Material and methods This study was based on qualitative interviews with ten Polish immigrants in Norway. The participants represented a convenience sample that varied in terms of gender, education, employment, time in Norway, place of residence, Norwegian language skills and ties to the Norwegian-Polish community. We performed thematic content analysis to understand CRC screening from the perspective of Polish immigrants, using transnationalism and Levesque’s conceptualization of accessibility as theoretical frameworks. Results We grouped our findings into three themes; “understanding of CRC development and the need to access health care”, “binationalism” and “improving accessibility through information”. Within these themes, various factors influenced the participants’ accessibility to CRC screening, namely knowledge about the screening and about causes, development and prevention of the disease, language, choice of screening country, trust in health personnel’s competence, information needs, methods and sources, as well as participants’ perception of the faecal immunochemical test screening user manual. These factors were further influenced by communication between the Polish community in Norway and Poland, as well as travel between the countries. Conclusion We identified several factors that can be targeted with an aim to increase Polish immigrants’ access to the Norwegian CRC screening programme. Effective measures could include increasing cultural competence among health care providers and providing information in Polish through Polish-speaking health care professionals, general practitioners and internet portals used by the Polish-speaking community. Focusing on accessibility in a transnational setting, our findings may be of interest for policy makers and service providers planning preventive health measures for immigrants.

Background The use of dietary and herbal supplements (DIHES) is widespread among people with multiple sclerosis (PwMS). PwMS are a highly informed patient group, and they use several types of sources to seek information on subjects related to their disease. However, it is still unknown where PwMS seek information about DIHES. It is important that PwMS make decisions about DIHES based on accurate, useful and accessible information. Therefore, the aim of this study was to explore where PwMS seek information on DIHES and how they experience and engage with this information. Methods Semi-structured interviews were conducted with eighteen PwMS using DIHES. Participants were selected from a cross-sectional survey. Diversity sampling was used, based on relevant characteristics such as gender and number of DIHES used during the past 12 months. The interviews were conducted face-to-face or over the telephone and lasted between 30 min and 1 hour. The interviews were recorded, transcribed verbatim, and analyzed using thematic network analysis in NVivo 12 Pro software. Results Three main themes emerged in the analysis: i) engaging with healthcare professionals (HCPs) regarding DIHES, ii) social networks as a source of information regarding DIHES, and iii) reliance on bodily sensations. Most participants navigated all three types of sources. All participants had at some point discussed DIHES with an HCP. Information from HCPs was considered reliable and valuable, but HCPs were viewed as uncommitted to the dialogue about DIHES. Recommendations from others were often the driver of decisions regarding use of DIHES. However, the information from PwMS’ networks could be overwhelming and difficult to navigate. Finally, PwMS relied on their own experiences regarding DIHES and let their bodily sensations guide their use of DIHES. Conclusions Participants often rely on all three types of information sources to create a nuanced and comprehensive information base. However, PwMS may feel overwhelmed or confused with all the information they have gathered. These findings indicate the need for better guidance for PwMS concerning DIHES and an openness among HCPs to engage in dialogue.

This study reports on a health promotion intervention (HPI), where graphic facilitation (GF) was used as an innovative method to enable participation in a co-design process in a multi-ethnic and disadvantaged neighbourhood in Denmark. The aim was to enable middle-aged and older residents to participate in the research process of planning and evaluating the HPI, as well as in the activities it constituted. GF was used to document statements and inputs from residents through visual meeting minutes and resident experiences with coronavirus disease 2019 (COVID-19) lockdown were drawn by a graphic facilitator. We use the ladder of participation as a framework to unfold the participation enabled by GF. During the HPI, data were produced through ethnographic field studies in and outside the neighbourhood and in design workshops with residents. The study finds that GF helped in reaching a target group difficult to engage in research and that the engagement of a graphic facilitator shifted the power-balance between the researchers and the residents, redistributing expertise. Carrying out GF in a HPI is a collaborative endeavour and in addition to research competences, it requires the artistic and relational skills of a graphic facilitator. The co-created process of the visual minutes and COVID-19 experiences created a sense of ownership and encouraged the residents to reflect on their interaction with the researchers. The redistribution of expertise was conditioned by the power dynamics present and GF helped unfold these dynamics. This is especially important in an HPI engaging socio-economically vulnerable populations.This study reports on graphic facilitation as an innovative method to enable participation in health promotion interventions. It investigates how engagement from the target group was achieved. The study is set in an ethnically diverse and disadvantaged neighbourhood. Residents 45 years+ were invited to participate in two phases of HPI activities. In Phase I, a resident committee planned and evaluated four social outings aiming to build and strengthen social relations among the residents. A graphic facilitator was part of the process, visually documenting the residents’ inputs and facilitating a transparent and visual engagement process. In Phase II, seven residents participated in interviews about their experiences during coronavirus disease 2019 lockdown. The graphic facilitator transformed the interviews into an illustrative book communicating their experiences, and posters communicating expedient health behaviour during the pandemic. The graphic facilitation method made it possible to engage a heterogeneous group of residents and helped overcome language barriers. We conclude that it is a relevant method to use when engaging people unfamiliar to research and in risk of suffering from various health problems. The method is suitable for redistributing power and actively including everyday experiences as testimonies of expertise, thereby creating a sense of ownership among the participants.

Background Findings about the relationship between individuals’ social relations and general practitioner (GP) contact are ambiguous as to whether weak social relations are associated with an increased or decreased consultation pattern. Furthermore, social relations may affect GP contact differently for men compared to women, between socioeconomic groups and according to perceived need. The overall aim of the study is to examine the association between functional aspects of social relations, perceived emotional and instrumental social support, the tendency to consult a GP and the frequency of GP contact. Methods The study comprised 6911 individuals aged 49–61 at baseline from the Copenhagen Aging and Midlife Biobank (CAMB). We conducted a two-part regression to explore the association between perceived emotional and instrumental social support and GP contact (tendency and frequency), controlling for age, sex, occupational social class, cohabitation status and number of morbidities. Results Results show no overall effect of the perceived social support aspects of social relations on GP contact independent of health-related needs. Conclusions Our results do not support that perceived social support, reflecting functional aspects of social relations, are associated with general practitioner contact among middle-aged people. Trial registration The study has been registered and approved by the Danish Data Protection Agency and the local ethical committee (approval No.H-A-2008-126 and No. 2013-41-1814).Keywords: social relations, perceived social support, healthcare utilisation, general practitioner, middle-aged

This article presents provider experiences with the Cultural Formulation Interview (CFI) in Danish mental healthcare for migrant patients. Semi-structured interviews with 17 providers and 20 recorded CFI sessions were analyzed with a constructivist grounded theory approach. Based on our empirical material, we endorse the CFI’s ability to facilitate working alliance and a profound and contextually situated understanding of the patient. Further, the CFI supported less-experienced providers in investigating cultural issues. Conversely, we found that CFI questions about cultural identity and background evoked notions of distance and ‘othering’ in the encounter. Nine providers had felt discomfort and professional insecurity when the CFI compelled them to introduce explanatory frameworks of culture in the mental health assessment. Eleven providers had experienced that the abstract nature of the questions inhibited patient responses or led to short and stereotypical descriptions, which had limited analytical value. We describe the contradictory CFI experiences of alliance versus distance at three levels: 1) at the CFI instrument level; 2) at the organizational level; and 3) at the contextual and structural level. We demonstrate benefits and pitfalls of using the CFI with migrants in Denmark, which is an example of a European healthcare context where cultural consultation is not an integrated concept in health education programs and where the notion of culture is contentious due to negative political rhetoric on multiculturalism. We suggest that the CFI should be introduced with thorough training; focus on fidelity; and supervision in the clinical application and understanding of the concept of culture.

Background Return to work is a key rehabilitation goal for people with cardiovascular disease (CVD) because employment matters to individuals and societies. However, people recovering from CVD often struggle with returning to work and maintaining employment. To identify people in need of vocational counselling, we examined the probability of feeling under pressure to return to work following CVD. Methods We conducted a combined survey- and register-based study in a randomly selected, population-based cohort of 10,000 people diagnosed with atrial fibrillation, heart failure, heart valve disease, or ischaemic heart disease in 2018. The questionnaire covered return-to-work items, and we reported the probabilities of feeling under pressure to return to work with 95% confidence intervals (CIs) in categories defined by sex, age, and CVD diagnosis. Results The survey response rate was 51.1%. In this study, we included 842 respondents (79.7% men) aged 32–85 years, who had returned to work following a sick leave. Overall, 249 (29.7%) had felt pressure to return to work. The probability of feeling under pressure to return to work ranged from 18.3% (95% CI: 13.1–24.6) among men aged > 55 years with atrial fibrillation to 51.7% (95% CI: 32.5–70.6) among women aged ≤ 55 years with atrial fibrillation. In addition, 66.0% of all respondents had not been offered vocational rehabilitation, and 48.6% of those who reported a need for vocational counselling had unmet needs. Survey responses also indicated that many respondents had returned to work before feeling mentally and physically ready. Conclusion A substantial proportion of people with cardiovascular disease feel under pressure to return to work, and this pressure is associated with age, sex, and diagnosis. The results show that vocational rehabilitation must be improved and emphasize the importance of ensuring that cardiac rehabilitation programmes include all core rehabilitation components.

IntroductionPerson-centred care based on systematic and comprehensive patient-engagement is gaining momentum across healthcare systems. Providing care that is responsive to the needs, values and priorities of each patient is important for patients, relatives and providers alike, not least for the growing population of older patients living with multi-morbidity and associated complex care trajectories.ObjectivesThe aim of this systematic review is to investigate the effects of patient engagement interventions for older patients with multimorbidity.MethodsSystematic review conducted in August 2021. Two reviewers independently screened the international databases Embase and PubMed. Reviewers carried out duplicate and independent data extraction and assessment of study quality. Grading of Recommendations Assessment, Development and Evaluation was used to assess the quality of the evidence for each study.ResultsWe included twelve studies from primary care setting and hospitals. The included studies were heterogeneous in terms of characteristics of populations, types of interventions to enhance patient-engagement, outcome measures and length of follow-up. Nine of the 12 included studies found significant improvements in health and patient-reported outcomes such as higher quality-adjusted life-years, fewer hospital visits and disease specific symptoms. Quality of the included studies was of low to moderate.ConclusionThis review identifies potential beneficial effects of interventions to enhance patient-engagement in older adults with multimorbidity. Nevertheless, the limited and very diverse evidence-based calls for more robust studies into efficient approaches to engaging older adults with multimorbidity in care trajectories.

Aim: To document the challenges of developing and executing an interviewer-driven survey questionnaire in an ethnically diverse and deprived social housing area undergoing reconstruction in Denmark. Methods: The survey was initially planned to be conducted in three waves (before, during and after reconstruction of the housing area), based on a questionnaire covering health, wellbeing and social relations. The first two waves took place in 2018 and 2019 (invited n=~600 per wave) and the third wave will be conducted once the reconstruction is finalised. The approach to the third wave is under revision by the research team. The questionnaire was translated from Danish into the seven most common languages in the housing area. A bilingual interview team went door to door interviewing residents. Field notes were collected systematically during each wave to document the process. Results: The response rates were 35% ( n=209) and 22% ( n=132) for waves 1 and 2, respectively. There was an overall decrease in response rates between waves 1 and 2 for all language groups, but particularly for Arabic and Turkish-speaking men. The most frequently stated reasons for non-participation included illness and language barriers. The key lessons learnt were that overcoming linguistic and cultural barriers to conducting research among residents in this social housing area requires time and resources. Conclusions: Several challenges are associated with conducting a survey in ethnically diverse and deprived social housing areas. Documenting the challenges and learning from experience are both important, in order to include this hard-to-reach population in health research.

The provision of person-centered care (PCC) for older adults in emergency settings is important. This short communication explores the complexity of providing comprehensive PCC for older adults in emergency settings, based on a synthesis of existing literature and empirical data from a small-scale case study on the potential of improving patient engagement in a Danish emergency department (ED). Our findings highlight overall positive attitudes towards PCC, as patient engagement is perceived as important and feasible during the waiting hours that older patients experience. However, the key challenges include barriers in organizational structures and cross-sectoral care coordination. We conclude that staff education, optimized care coordination across sectors, and increased involvement of geriatric nurses may enhance the provision of PCC for older, complex adults in EDs. We further conclude that future research into the feasibility and effects of structured approaches for providing PCC in EDs is needed, including exploration of organizational models for PCC.

Background Shared decision-making (SDM) is a cornerstone in patient-centred care and there has been an increase in programmes aiming to improve clinicians’ abilities to engage in it. However, the evidence for such programmes’ effectiveness on clinicians’ use of SDM in clinical practice is sparse. The SDM Ambassador course, developed and facilitated by the Danish Association of Junior Doctors in Denmark (Junior Doctors Denmark) is a Danish SDM training programme for junior medical doctors (JMDs). This study aims to evaluate the SDM Ambassador course, with a focus on satisfaction, usefulness, and dissemination of learning outcomes in clinical practice. Methods This is a mixed methods study, consisting of an online survey followed by semi-structured interviews. The participants were JMDs who had trained to be SDM ambassadors between May 2016 and September 2020 (n=185). The ambassadors were invited to participate in the survey and 112 ambassadors completed it, corresponding to a response rate of 61%. Descriptive statistics and χ2-tests were conducted. Subsequently, purposive sampling was used to identify 10 ambassadors for interviews. The interviews were transcribed, encoded, and subsequently analysed thematically. Finally, the quantitative and qualitative results were integrated. Results Overall, the ambassadors were satisfied with their learning outcomes and experienced a greater capacity to unfold the perspectives of their patients. A majority (79%) reported that they had used SDM in their clinical practice with patients, and 59% had disseminated SDM to their colleagues. The usefulness and dissemination of learning outcomes in the clinic were shaped by the ambassadors’ perceptions of their moderate professional experience as junior doctors, and constrained by structural and cultural conditions in the context of their clinical practice. Conclusions Despite overall satisfaction with their learning outcomes, several ambassadors experienced conditions constraining the translation of their learning outcomes into clinical practice. To improve the efficacy of the training programme, continuous refresher courses should be added, while enhanced support at organisational and political levels is necessary for SDM to become an integral feature of the clinical encounter. Trial registration Not applicable.

(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 Polypharmacy, defined as the concurrent use of ≥5 medications, increases the risk of drug-drug and drug-disease interactions as well as non-adherence to drug therapy. This may have negative health consequences particularly among older adults due to age-related pharmacokinetic and pharmacodynamic changes. This study aims to uncover the occurrence of polypharmacy among older adults in Denmark and investigate how polypharmacy relates to mortality. Method This nationwide register-based study included 1,338,058 adults aged 65+ years between January 2013 and December 2017 in Denmark. Polypharmacy prevalence was measured at time of inclusion while incidence and the association between polypharmacy and mortality were measured over the five-year follow-up using Cox regression. In an attempt to adjust for confounding by indication, propensity scores with overlap weighting were introduced to the regression model. Results At time of inclusion, polypharmacy prevalence was 29% and over the five years follow-up, 47% of the remaining adults transitioned into polypharmacy. Identified risk factors included multimorbidity (2+ morbidities: HR = 3.51; 95% CI = 3.48–3.53), age (95+ years: HR = 2.85; 95% CI = 2.74–2.96), socioeconomic factors (Highest income quartile: HR = 0.81; 95% CI = 0.80–0.81), region of birth region (Non-western migrants: HR = 0.77; 95% CI = 0.75–0.79), marital status (Divorced: HR = 1.10; 95% CI = 1.10–1.12) and year of inclusion (2017: HR = 1.19; 95% CI = 1.19–1.22). Further analyses showed that polypharmacy involves many different drug cocktails with medication for the cardiovascular system (95%), blood and blood-forming organs (69%), alimentary tract and metabolism (61%) and nervous system (54%) contributing the most. After adjustment for propensity scores with OW, both polypharmacy (HR = 3.48, CI95% = 3.41–3.54) and excessive polypharmacy (HR = 3.48, CI95% = 3.43–3.53) increased the risk of death substantially. Conclusion A considerable proportion of older adults in Denmark were exposed to polypharmacy dependent on health status, socio-economic status, and societal factors. The associated three- to four-fold mortality risk indicate a need for further exploration of the appropriateness of polypharmacy among older adults.

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.

(1) Background: The effect of social relations on health and wellbeing is well documented. However, knowledge about social interventions specifically in nursing homes and their potential for health and wellbeing is inadequate. In this qualitative study, we explore the implementation of a social intervention entitled Tell Stories for Life implemented in Danish nursing homes. (2) Methods: Through a qualitative multi-perspective longitudinal approach, nursing home residents and employees were interviewed from May–December 2016 (N = 14). The authors made participatory observations and took field notes. (3) Results: The intervention did not appear to establish or strengthen social relations between nursing home residents. However, nursing home residents enjoyed participating, narrating and having someone listen to their stories. The identity of nursing home residents and their relationships to nursing home employees facilitating the intervention appeared to be strengthened. Barriers were related to lack of support from management, nursing home employees’ educational backgrounds and experiences, and nursing home residents’ cognitive ability. (4) Conclusions: This study found that the Tell Stories for Life intervention did not appear to strengthen and establish social relations among nursing home residents. However, we found that there might be potential for strengthening residents’ sense of identity and the relation between residents and nursing home employees.

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.

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.

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.

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.

Aims: The aim of this study was to explore patterns of complementary and alternative medicine use among Arab immigrants in Denmark, in order to increase insight into the hidden practices of this ethnic group. Methods: In this study, 21 Arab immigrants in Denmark were interviewed in Arabic. A purposive strategic sample was recruited from mosques, a healthcare center and by snowballing. Semi-structured interviews were conducted, then audiotaped and transcribed. The analysis was conducted according to Malterud’s principles for systematic text condensation and guidelines for qualitative research. Results: Different types of complementary and alternative medicine, referred to as Arabic and Islamic medicine, were used including dietary practices; spiritual healing and cupping therapy, which were mainly used for acute diseases, painful conditions and what so-called jinn-related diseases. Conclusions: Arabic and Islamic medicine is a special form of complementary and alternative medicine, used by some Arab immigrants, which appears to be deeply embedded in their health beliefs within cultural and religious contexts. Healthcare providers should be familiar with diverse health practices and beliefs in order to provide culturally sensitive care and improve the quality of care delivered to ethnic minority patients with different religious backgrounds.

Interest in patient-reported outcomes has been growing in multiple sclerosis research and clinical care in recent years. This situation reflects the need for developing, testing, and integrating measures that adequately capture patients' perspectives on symptoms, functional capacity, health status, and health-related quality of life. However, the patient perspective on the relevance, content, and use of patient-reported outcomes is yet to be investigated. Hence, this study aims to investigate the perspectives of people with multiple sclerosis on the value of patient-reported outcomes in clinical encounters, the most important aspects of living with multiple sclerosis that should be reflected in these reports, and possible opportunities and barriers for integrating this data into clinical care.A qualitative study was conducted to capture patient perspectives in a Danish population of people with multiple sclerosis. Initially, two focus group interviews were conducted with a total of 11 participants to explore their perspectives on patient-reported outcomes and related prospects and barriers. Subsequently, nine individual interviews were conducted to further investigate the identified aspects, opportunities, and barriers to use patient-reported outcomes in clinical care and treatment.In general, the informants were motivated to report patient-reported outcomes, and they believed these reports to be relevant in clinical encounters as well as to have potential to promote patient involvement by focusing on current challenges for others with this disease. However, differences in the perceived need for reporting patient-reported outcomes were detected regarding the stage in the multiple sclerosis care trajectory and in relation to the disease phenotypes. In terms of domains to be incorporated into patient-reported outcomes, a total of 28 were identified by the informants, including neurological symptoms, cognitive impairments, mental health and well-being, self-care activities, and social challenges. Several factors for integrating patient-reported outcomes into clinical care emerged as important, in particular related to timing and frequency of reporting patient reported outcomes, considerations of cognitive impairments, the need for individualized approaches to patient-reported outcomes, and the need for active use of these reports for adjustment of treatment approaches in clinical encounters.From the perspective of people with multiple sclerosis, patient-reported outcomes hold important potential for enhanced patient involvement leading to a more multifaceted agenda in clinical consultations. However, patient-reported outcomes need to be comprehensive and encompass a broad range of measures regarding neurological symptoms, cognitive impairments, mental health and well-being, self-care activities, and social challenges to adequately capture and support the needs of people with multiple sclerosis in clinical encounters. It is important to address barriers for integration of patient-reported outcomes into clinical care, with the aim of preventing misuse. Future studies should focus on the synergy between perspectives from both patients and clinicians to understand how integration of patient-reported outcomes in clinical care can succeed.

Objective To validate the Norwegian version of MAPPIN'SDM observer scales with regard to reliability, accuracy and the extent to which the scales include the essentials of the shared decision-making concept. Methods Three MAPPIN'SDM scales, focusing on the skills of doctor, patient and dyad, were applied to audiovisual records of 35 decision sequences. Inter-rater reliabilities were determined based on kappa coefficients. Sensitivities and specificities were calculated with regard to an expert reference standard. Convergent validities were calculated with the OPTION 5 scale. MAPPIN'SDM was qualitatively compared to OPTION5 using Makoul & Clayman's Integrative Model structure. Results Inter-rater reliabilities were high on average over 11 items in each of three observer scales (MAPPIN doctor =0.77, MAPPIN patient =0.82, MAPPIN dyad =0.77). Patient involvement was detected accurately (MAPPIN dyad : mean sensitivity/specificity 93/91%). Comparison with OPTION 5 showed weak to moderate correlation (Spearman's ρ/p-value: MAPPIN doctor :=0.44/0.009, MAPPIN patient : 0.38/0.024, MAPPIN dyad 0.40/0.016) and little content overlap. Conclusion MAPPIN'SDM norge is capable of assessing SDM highly reliably and accurately. Divergence from OPTION 5 reflects explicit disagreement regarding the concept's assumptions. Practice implications MAPPIN'SDM norge is ready for use in Norway. In-depth debate on the SDM concept's essentials is urgently needed.

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.

The Danish Heart Foundation and the non-governmental organization Neighborhood Mothers have co-developed a culturally adapted intervention seeking to promote healthy dietary behaviour among ethnic minority women. This feasibility study explores the potential of the intervention to reach ethnic minority women using health promotion initiatives. Participants attended instructor courses or cooking events, where culturally adapted, healthy recipes were introduced and meals prepared. Feasibility was explored using a mixed-method approach. Surveys were completed by 59 volunteers and 150 participants at five instructor courses and 21 cooking events. Individual interviews and focus group discussions were conducted with volunteers and participants after completion of the intervention. After the intervention, 61% of the 150 participants had high levels of knowledge about dietary recommendations, 96% intended to cook healthy dishes in the future and 84% intended to incorporate measuring equipment into their daily cooking routine. Participants with a high level of knowledge reported intention to change dietary behaviour more often than participants with lower levels of knowledge. Interviews confirmed that the participants cooked healthy dishes after participating, and incorporated knowledge about healthy food practices into their daily cooking. Few participants used measuring equipment. The intervention proved to be feasible as a health promotion initiative targeting a hard-to-reach population.

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: This paper examines the importance of recruitment site in relation to the recruitment of ethnic minorities into health research. It presents a synthesis of experiences drawn from six interlinked Danish studies which applied different methods and used healthcare facilities and educational settings as sites for recruitment. Methods: Inspired by interpretive reviewing, data on recruitment methods from the different studies were synthesized with a focus on the various levels of recruitment success achieved. This involved an iterative process of comparison, analysis and discussion of experiences among the researchers involved. Results: Success in recruitment seemed to depend partly on recruitment site. Using healthcare facilities as the recruitment site and healthcare professionals as gatekeepers was less efficient than using schools and employees from educational institutions. Successful study designs also depended on the possibility of singling out specific locations with a high proportion of the relevant ethnic minority target population. Conclusions:The findings, though based on a small number of cases, indicate that health professionals and healthcare institutions, despite their interest in high-quality health research into all population groups, fail to facilitate research access to some of the most disadvantaged groups, who need to be included in order to understand the mechanisms behind health disparities. This happens despite the genuine wish of many healthcare professionals to help facilitate such research. In this way, the findings indirectly emphasize the specific challenge of accessing more vulnerable and sick groups in research studies.

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.

BACKGROUND: The burden of breast cancer is a key challenge for women's health globally. Rehabilitation needs and strategies for living with long-term consequences of breast cancer and its treatment cannot be isolated from the social contexts of patients, including relationships with relatives and healthcare professionals.AIM: This study explores how healthcare professionals' categorisations engage with breast cancer patients' social identities in encounters about rehabilitation before hospital discharge.METHOD: We conducted a multiperspective case-based qualitative study at a Danish department of breast surgery, including participant observations and interviews with twelve patients and eight nurses. Data were analysed thematically using theories of categorisation and clinical encounters. Ethical considerations: The Danish Data Protection Agency approved the study (journal number 2012-41-0701).RESULTS: Interactions in clinical encounters are shaped by categorisations of patients' social identities in terms of social resources and ethnicity, and by the resource-constrained organisational context, with impact on the assessments of the patient's rehabilitation needs.CONCLUSIONS: There is a need for a greater focus on improving encounters between breast cancer patients and healthcare professionals to ensure that rehabilitation needs are accommodated for among diverse patient groups. BACKGROUND: The burden of breast cancer is a key challenge for women's health globally. Rehabilitation needs and strategies for living with long-term consequences of breast cancer and its treatment cannot be isolated from the social contexts of patients, including relationships with relatives and healthcare professionals.AIM: This study explores how healthcare professionals' categorisations engage with breast cancer patients' social identities in encounters about rehabilitation before hospital discharge.METHOD: We conducted a multiperspective case-based qualitative study at a Danish department of breast surgery, including participant observations and interviews with twelve patients and eight nurses. Data were analysed thematically using theories of categorisation and clinical encounters. Ethical considerations: The Danish Data Protection Agency approved the study (journal number 2012-41-0701).RESULTS: Interactions in clinical encounters are shaped by categorisations of patients' social identities in terms of social resources and ethnicity, and by the resource-constrained organisational context, with impact on the assessments of the patient's rehabilitation needs.CONCLUSIONS: There is a need for a greater focus on improving encounters between breast cancer patients and healthcare professionals to ensure that rehabilitation needs are accommodated for among diverse patient groups.

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.

In this article, we explore how Islam, minority status and refugee experiences intersect in shaping meaning-making processes following bereavement. We do this through a phenomenological analysis of a biographical account of personal loss told by Aisha, a Muslim Palestinian refugee living in Denmark, who narrates her experience of losing her husband to lung cancer. By drawing on a religious framework, Aisha creates meaning from her loss, which enables her to incorporate this loss into her life history and sustain agency. Her narrative invites wider audiences to witness her tale of overcoming loss, thus highlighting the complex way in which religious beliefs, minority status and migration history come together in shaping meaning-making processes, and the importance of reciprocity in narrative studies. 2015, Springer Science+Business Media New York. Scopus

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.

While the association between overall poor health and loneliness among older adults continues to be examined closely, less attention has been given to middle-aged adults. This paper examines the relationship between loneliness and health as measured by self-rated health, physical ability and multi-morbidity in a large sample of Danish adults between the ages of 52-92 years. Furthermore, it identifies vulnerable groups with regard to the year of birth and gender.We apply the survey-study method, using data collected by The Danish National Centre for Social Research in 2012. We analysed the association between loneliness and health in 9154 Danish adults through multi-variate regression analyses adjusting for the year of birth, gender, marital status, cohabitation status, employment status and home ownership.We found that loneliness was associated with increased risks of poor self-rated health (OR, 2.58; 95% Cl, 1.20-3.35), limited physical abilities (OR, 1.91; 95% Cl, 1.58-2.32) and multiple diagnoses (OR, 1.77; 95% Cl, 1.48-2.12). Lonely middle-aged adults (52-62 years of age) had an increased risk of having limited physical abilities.Among middle-aged and older Danish adults, loneliness was strongly associated with poor self-rated health, limited physical ability and multi-morbidity.

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 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.