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AIM: There is limited evidence regarding prodromal symptoms of out-of-hospital cardiac arrest (OHCA). We aimed to describe patient characteristics, prodromal symptoms, and prognosis of patients contacting emergency medical services (EMS) within 24 hours before OHCA.METHODS: We identified all OHCA treated by Copenhagen EMS from 2016 through 2018 using the Danish Cardiac Arrest Registry and linked them to emergency calls. We included all pre-arrest calls by patients or bystanders if they were performed 1) within 24 hours before the OHCA call or 2) during the OHCA event for EMS-witnessed OHCA. Calls were reviewed by healthcare professionals using a survey guide.RESULTS: Among 4,071 patients, 481 patients (12%) had 539 calls within 24 hours prior to OHCA (60% male, median age 74 years of age). The patient spoke on the phone in 25% of calls. The most common symptoms were breathing problems (59%), confusion (23%), unconsciousness (20%), chest pain (20%), and paleness (19%). Patients with breathing problems compared to chest pain were more likely to be ≤75 years of age (55% versus 35%), less likely to be male (52% versus 73%), have shockable rhythm (10% versus 38%), receive bystander defibrillation (6% versus 19%) or EMS defibrillation (15% versus 65%), achieve return of spontaneous circulation (37% versus 68%) and survive 30 days following OHCA (10% versus 50%).CONCLUSION: More than 10% of patients with OHCA had a call to EMS within 24 hours before OHCA. The most common symptom was breathing problems which compared to chest pain had lower 30-day survival.

Background The number of patients calling for an ambulance increases. A considerable number of patients receive a non-specific diagnosis at discharge from the hospital, and this could imply less serious acute conditions, but the mortality has only scarcely been studied. The aim of this study was to examine the most frequent sub-diagnoses among patients with hospital non-specific diagnoses after calling 112 and their subsequent mortality. Methods A historical cohort study of patients brought to the hospital by ambulance after calling 112 in 2007–2014 and diagnosed with a non-specific diagnosis, chapter R or Z, in the International Classification of Diseases, 10th edition (ICD-10). 1-day and 30-day mortality was analyzed by survival analyses and compared by the log-rank test. Results We included 74,847 ambulance runs in 53,937 unique individuals. The most frequent diagnoses were ‘unspecified disease’ (Z039), constituting 47.0% (n 35,279). In children 0–9 years old, ‘febrile convulsions’ was the most frequent non-specific diagnosis used in 54.3% (n 1602). Overall, 1- and 30-day mortality was 2.2% (n 1205) and 6.0% (n 3258). The highest mortality was in the diagnostic group ‘suspected cardiovascular disease’ (Z035) and ‘unspecified disease’ (Z039) with 1-day mortality 2.6% (n 43) and 2.4% (n 589), and 30 day mortality of 6.32% (n 104) and 8.1% (n 1975). Conclusion Among patients calling an ambulance and discharged with non-specific diagnoses the 1- and 30-day mortality, despite modest mortality percentages lead to a high number of deaths.

Little is known about the occurrence of hypokalemia due to combination therapy for hypertension. Using data from Danish administrative registries, we investigated the association between different combinations of antihypertensive therapy and risk of developing hypokalemia. Using incidence density matching, 2 patients without hypokalemia were matched to a patient with hypokalemia (K

Background Occupational accidents continue to be a significant public health challenge worldwide. Construction workers in particular are at high risk of occupational accidents, and thus it is of major importance to identify possible predictors of occupational accidents among construction workers. We aimed to investigate the association between self-reported work pace and physical work demands and occupational accidents among ageing male construction workers in Denmark. Methods Data on perceived work pace, physical work demands, and occupational accidents was acquired from questionnaires sent to ageing construction workers in Denmark in 2016 as part of the ALFA project (ALdring og Fysisk Arbejde; Ageing and Physical Work). A sample of 1270 Danish male construction workers above 50 years of age was included in the present study. Multiple logistic regression models were applied, with adjustments for age, smoking, body mass index, musculoskeletal disorders, occupation, work experience, and support at work. Results Of 1270 construction workers, 166 (13.1%) reported an occupational accident within the last 12 months. There was no significant association between perceived work pace and occupational accidents, but physical work demands were associated with higher odds for occupational accidents, with an odds ratio of 2.27 (95% confidence interval 1.26–4.10) for medium physical work demands and 2.62 (95% confidence interval 1.50–4.57) for high physical work demands. Conclusions Ageing male construction workers with high physical work demands had statistically significant higher odds of having an occupational accident. By contrast, perceived work pace was not associated with occupational accidents in this large cross-sectional study.

INTRODUCTION: Family socioeconomic status influences pupils' academic achievements, and studies have established positive associations between physical fitness and academic achievements. However, whether physical fitness mediates the relationship remains unknown.OBJECTIVE: We investigated if pupils' physical fitness mediates the pathway between family socioeconomic status and academic achievement using causal inference-based mediation analysis.METHODS: This study included 527 girls and 552 boys between 13 and 15 years of age from the Danish municipality of Aalborg. Physical fitness was measured through VO2max tests in 2010 and demographic data were obtained from nationwide registers. Family socioeconomic status was classified into four levels ranging from 1 to 4, where level 1 represents the lowest and level 4 the highest based on either family income or education.RESULTS: Controlling for sex, ethnicity, age, and parents' cohabitation status, all total effects display higher academic achievement with increased family socioeconomic status. Splitting the effects, the direct effects reveal the existence of other pathways not involving physical fitness. The indirect effects established physical fitness as a mediator showing that pupils from family socioeconomic status levels one, three, and four changes grade by - 0.13 [95% confidence interval (CI) - 0.26, - 0.01], 0.07 (95% CI 0.00, 0.14), and 0.24 (95% CI 0.14, 0.34), respectively, compared to socioeconomic status level two. The corresponding proportions mediated are 18% (95% CI 1, 57), 6% (95 CI 0, 13), and 12% (95% CI 7, 18) when family socioeconomic status is based on education. Classifying family socioeconomic status on income, pupils from family socioeconomic status levels one, three, and four show grade changes of - 0.07 (95% CI - 0.16, 0.02), 0.22 (95% CI 0.13, 0.32), and 0.26 (95% CI 0.15, 0.37), respectively, compared to socioeconomic status level two. The corresponding proportions mediated are 12% (95% CI - 6, 41), 30% (95% CI 16, 54), and 20% (95% CI 12, 32).CONCLUSION: In conclusion, pupils' physical fitness partially mediated the pathway between family socioeconomic status and academic achievement.

Background The frailty phenotype is predictive of mortality and has been identified in the working population. This cross-sectional study aimed to investigate the prevalence of frailty and individual frailty symptoms among active and retired Danish manual workers and to delineate the relationship between frailty and lifestyle factors. Methods Manual workers aged 50–70 years answered questions relating to the Fried criteria for frailty (weight loss, exhaustion, slowness, weakness and inactivity). Only men were included in the analyses and respondents were stratified according to work status: active workers (n = 1555), early retirees (n = 289) and workers retired at or after normal pension age (n = 291). Associations between pre-frailty/frailty, work status and various lifestyle factors were estimated using binomial logistic regression. Results Overall, the prevalence of pre-frailty (one or two symptoms) and frailty (three or more symptoms) was 33.3% and 1.5%, respectively. Those who had retired early were more likely to be pre-frail/frail compared with active workers (odds ratio 2.20, 95% CI 1.61–3.01). Exhaustion was the most prominent symptom reported by 22.2% of active workers, 34.6% of early retirees and 16.5% of workers retired at normal retirement age. Lifestyle factors including obesity, physical inactivity and smoking but not alcohol intake were associated with pre-frailty/frailty. Conclusion Symptoms of frailty are identifiable and present among both active and retired manual workers. Data suggest discrepancies among Danish manual workers, with some having unhealthy lifestyles and being more prone to develop pre-frailty and frailty already in their sixth decade of life.

Background Hypokalemia is common in patients treated with antihypertensive drugs, but the impact of correcting hypokalemia is insufficiently studied. We examined the consequences of hypokalemia and borderline hypokalemia correction in patients with hypertension. Methods We identified 8976 patients with hypertension and plasma potassium concentrations ≤3.7 mmol/L within 100 days from combination antihypertensive therapy initiation. The first measurement between 6 and 100 days after the episode with potassium ≤3.7 mmol/L was retained. We investigated all-cause and cardiovascular mortality within 60-days from the second potassium measurement using Cox regression. Mortality was examined for seven predefined potassium intervals derived from the second measurement: 1.5–2.9 mmol/L (n = 271), 3.0–3.4 mmol/L (n = 1341), 3.5–3.7 (n = 1982) mmol/L, 3.8–4.0 mmol/L (n = 2398, reference), 4.1–4.6 mmol/L (n = 2498), 4.7–5.0 mmol/L (n = 352) and 5.1–7.1 mmol/L (n = 134). Results Multivariable analysis showed that potassium concentrations 1.5–2.9 mmol/L, 3.0–3.4 mmol/L, 4.7–5.0 mmol/L and 5.1–7.1 mmol/L were associated with increased all-cause mortality (HR 2.39, 95% CI 1.66–3.43; HR 1.36, 95% CI 1.04–1.78; HR 2.36, 95% CI 1.68–3.30 and HR 2.62, 95% CI 1.73–3.98, respectively). Potassium levels 4.6 mmol/L were associated with increased cardiovascular mortality. The adjusted standardized 60-day mortality risks in the seven strata were: 11.7% (95% CI 8.3–15.0%), 7.1% (95% CI 5.8–8.5%), 6.4% (95% CI 5.3–7.5%), 5.4% (4.5–6.3%), 6.3% (5.4–7.2%), 11.6% (95% CI 8.7–14.6%) and 12.6% (95% CI 8.2–16.9%), respectively. Conclusions Persistent hypokalemia was frequent and associated with increased all-cause and cardiovascular mortality. Increase in potassium to levels > 4.6 mmol/L in patients with initial hypokalemia or low normal potassium was associated with increased all-cause and cardiovascular mortality.

Background Health literacy concerns the ability of citizens to meet the complex demands of health in modern society. Data on the distribution of health literacy in general populations and how health literacy impacts health behavior and general health remains scarce. The present study aims to investigate the prevalence of health literacy levels and associations of health literacy with socioeconomic position, health risk behavior, and health status at a population level. Methods A nationwide cross-sectional survey linked to administrative registry data was applied to a randomly selected sample of 15,728 Danish individuals aged ≥25 years. By the short form HLS-EU-Q16 health literacy was measured for the domains of healthcare, disease prevention, and health promotion. Adjusted multinomial logistic regression analyses were used to estimate associations of health literacy with demographic and socioeconomic characteristics, health risk behavior (physical activity, smoking, alcohol consumption, body weight), and health status (sickness benefits, self-assessed health). Results Overall, 9007 (57.3%) individuals responded to the survey. Nearly 4 in 10 respondents faced difficulties in accessing, understanding, appraising, and applying health information. Notably, 8.18% presented with inadequate health literacy and 30.94% with problematic health literacy. Adjusted for potential confounders, regression analyses showed that males, younger individuals, immigrants, individuals with basic education or income below the national average, and individuals receiving social benefits had substantially higher odds of inadequate health literacy. Among health behavior factors (smoking, high alcohol consumption, and inactivity), only physical behavior [sedentary: OR: 2.31 (95% CI: 1.81; 2.95)] was associated with inadequate health literacy in the adjusted models. The long-term health risk indicator body-weight showed that individuals with obesity [OR: 1.78 (95% CI: 1.39; 2.28)] had significantly higher odds of lower health literacy scores. Poor self-assessed health [OR: 4.03 (95% CI: 3.26; 5.00)] and payments of sickness absence compensation benefits [OR: 1.74 (95% CI: 1.35; 2.23)] were associated with lower health literacy scores. Conclusions Despite a relatively highly educated population, the prevalence of inadequate health literacy is high. Inadequate health literacy is strongly associated with a low socioeconomic position, poor health status, inactivity, and overweight, but to a lesser extent with health behavior factors such as smoking and high alcohol consumption.

AIMS: The usefulness of mortality statistics relies on the validity of death certificate diagnosis. However, diagnosing the causal sequence of conditions leading to death is not simple. We examined diagnostic support for fatal acute myocardial infarction (AMI) and investigated its association with regional variation.METHODS AND RESULTS: From Danish nationwide registers, we identified the study population (N = 3,244,051) of whom 36,669 individuals were recorded with AMI as the underlying cause-of-death between 2002 and 2015. We included clinical diagnoses, procedures, and claimed prescriptions related to atherosclerotic disease to evaluate the level of diagnostic support for fatal AMI in three diagnostic groups (Definite; Plausible; Uncertain). Adjusted mortality rates, rate ratios, and odds ratios were estimated for each AMI category, stratified by hospital region using multivariable regression models. More than one-third (N = 12,827, 35%) of deaths reported as fatal AMI had uncertain diagnostic support. The largest regional variation in AMI mortality rate ratios, varying from 1.16 (95%CI:1.02;1.31) to 1.62 (95%CI:1.43;1.83), was found among cases with uncertain diagnostic supportive data. Substantial inter-regional differences in the degree to which death occurs outside hospital [OR: 1.01 (95%CI:0.92;1.12) - 1.49 (95%CI:1.36;1.63)] and general practitioners determining the cause-of-death at home were present. Minor regional differences [OR: 0.96 (95%CI:0.85;1.07) - 1.16 (95%CI:1.04;1.29)] in in-hospital AMI mortality were observed.CONCLUSION: There is significant regional variation associated with recording AMI as a cause-of-death. This variation is predominately based on death certificate diagnoses without diagnostic supportive evidence. Studies of fatal AMI should include a stratification on supportive evidence of the diagnosis.

Background Barriers such as language and literacy might complicate the participation procedure for immigrants in screening programs. We investigated the delivery of a suitable stool sample for participation in the Danish colorectal cancer screening by immigration background. Methods National administrative registers were used to link results of faecal blood screening with immigrant status, age, sex, education, income, and marital status. Univariate and multivariate logistic regression models were used to estimate the odds of submitting an ineligible sample. Results 558,104 individuals submitted a sample during 2014 and 2015. A total of 2,164 (0.4%) samples were ineligible for faecal analysis. The lowest proportions of ineligible samples were found in the highest educational level (0.2%) and highest income level (0.2%). The highest proportion of ineligible samples was seen in non-Western immigrants (1.6%). After adjustment for age, gender, educational level, income and marital status non-Western immigrants had an increased odds ratio (OR 3.64 CI95% 2.86;4.64) of submitting an ineligible sample, compared to native Danes. Western immigrants did not have an increased odds ratio. Conclusion Non-Western immigrants have more than three times the risk of submitting an ineligible faeces sample for colorectal cancer screening than native Danes. Translation of invitation, information leaflet, and manual into other languages or targeted information for subgroups may help decrease the risk.

Background Hyperkalemia can be harmful, but the effect of correcting hyperkalemia is sparsely studied. We used nationwide data to examine hyperkalemia follow‐up in patients with hypertension. Methods and Results We identified 7620 patients with hypertension, who had the first plasma potassium measurement ≥4.7 mmol/L (hyperkalemia) within 100 days of combination antihypertensive therapy initiation. A second potassium was measured 6 to 100 days after the episode of hyperkalemia. All‐cause mortality within 90 days of the second potassium measurement was assessed using Cox regression. Mortality was examined for 8 predefined potassium intervals derived from the second measurement: 2.2 to 2.9 mmol/L (n=37), 3.0 to 3.4 mmol/L (n=184), 3.5 to 3.7 mmol/L (n=325), 3.8 to 4.0 mmol/L (n=791), 4.1 to 4.6 mmol/L (n=3533, reference), 4.7 to 5.0 mmol/L (n=1786), 5.1 to 5.5 mmol/L (n=720), and 5.6 to 7.8 mmol/L (n=244). Ninety‐day mortality in the 8 strata was 37.8%, 21.2%, 14.5%, 9.6%, 6.3%, 6.2%, 10.0%, and 16.4%, respectively. The multivariable analysis showed that patients with concentrations >5.5 mmol/L after an episode of hyperkalemia had increased mortality risk compared with the reference (hazard ratio [HR], 2.27; 95% CI, 1.60–3.20; P P P 5.0 mmol/L were associated with increased risk of cardiovascular death. Conclusions Overcorrection of hyperkalemia to levels 5.5 mmol/L were also associated with an increased all‐cause and cardiovascular mortality.

Background: Early-life socioeconomic position (SEP) is associated with lifestyle-related diseases in adulthood. However, evidence is lacking on the extent to which adult SEP mediates this association.Methods: Time to either chronic obstructive pulmonary disease (COPD), cardiovascular disease or diabetes were assessed in the Danish population born between 1961 and 1971 (n = 793 674) from age 30 until 2015. Early-life position was assessed in 1981 (by parental) and again at age 30 (own) by four markers; income, occupation, education-divided into high, middle, low-and a combined score for all markers. Using a counterfactual approach, we estimated the total effect of early-life position on disease onset and the degree to which adult position mediated this effect.Results: Results of the time-to-event analysis showed a gradient of all early-life markers on the risk of developing all lifestyle-related diseases. Notably, comparing those in the lowest to the highest educational position, the hazard of COPD was 130% higher for women [hazard ratio = 2.30(95% confidence interval = 2.20-2.41)] and 114% higher for men [2.14 (2.05-2.25)]. About 67%(63-70%) of the effect of educational position was mediated through adult position for COPD, 55% for cardiovascular disease and 50% for diabetes. For the combined score 44, 29 and 33%, respectively, was mediated.Conclusion: About one-tenth to two-thirds of the effect of early-life position is mediated by the position attained in adulthood. The degree mediated depend on the outcome investigated, gender and the social position marker used indicating that alternative pathways may play a key role in developing effective policies targeting early-life behaviours.

Background Rapid infant weight gain (RIWG) is a very strong predictor of childhood overweight and obesity (COO). Socioeconomic position (SEP) is also related to the risk of COO and parents of different SEP may differ in their reaction to accelerated infant weight gain. Together this could lead to differences in how weight gain and COO risk relate across SEP. This study aimed to analyse possible interaction of SEP and RIWG on COO risk. Methods A register-based longitudinal cohort study followed 19,894 healthy, term infants, born in Denmark between December 2011 and May 2015. Logistic regression models were used to estimate odds ratios (OR) of COO risk at 2 years (22–26 months) of age with 95% confidence intervals (95% CI) for categories of infancy weight gain based on changes in weight-for-age z-scores between 0 and 8–10 months of age (slow ( 0.67–1.34) and very rapid (> 1.34)). Possible multiplicative and additive interaction of SEP (based on household income and maternal education) on the relationship between infancy weight gain and COO were analysed. Results In total, 19.1 and 15.1% experienced rapid or very rapid weight gain, respectively, and 1497 (7.5%) children were classified with COO at follow-up. These prevalences were higher in those with lower levels of SEP. Adjusted OR for COO were 3.09 (95% CI [2.66–3.59]) and 7.58 (95% CI [6.51–8.83]) for rapid and very rapid weight gain, respectively, when household income was included in the model. Results were similar in the model including maternal education. No signs of interactions were detected on a multiplicative scale. Weak signs of additive interaction were present, but these values did not reach significance. Conclusion Both rapid and very rapid weight gain were associated with substantially higher risks of COO but these associations were not modified by SEP. This indicates that promotion of healthy weight gain should take place in all population groups irrespective of their SEP. Electronic supplementary material The online version of this article (10.1186/s12889-019-7537-z) contains supplementary material, which is available to authorized users.

Background: Shift work is associated with increased risk of cardiovascular disease, but the causes have not yet been fully established. It has been proposed that the coronary risk factors are more hazardous for shift workers, resulting in a potential interaction effect with shift work. Objective: To analyse interaction effects of work schedule and established risk factors for coronary artery disease on the risk of myocardial infarction. Methods: This analysis was conducted in SHEEP/VHEEP, a case-control study conducted in two counties in Sweden, comprising all first-time cases of myocardial infarction among men and women 45–70 years of age with controls stratified by sex, age, and hospital catchment area, totalling to 4648 participants. Synergy index (SI) was used as the main outcome analysis method for interaction analysis. Results: There was an interaction effect between shift work and physical inactivity on the risk of myocardial infarction with SI of 2.05 (95% CI 1.07 to 3.92) for male shift workers. For female shift workers, interaction effects were found with high waist-hip ratio (SI 4.0, 95% CI 1.12 to 14.28) and elevated triglycerides (SI 5.69, 95% CI 1.67 to 19.38). Conclusion:Shift work and some established coronary risk factors have significant interactions.

Purpose: To investigate the effect of sending out reminders for colorectal cancer screening on socioeconomic and demographic inequalities in screening uptake. Methods: All citizens aged 50–74 in Denmark are invited every 2 years for colorectal cancer screening. Non-participants receive an electronically distributed reminder. Data for these analyses were derived from national registers. Socioeconomic status was measured by income and educational level. Demographic variables included age, gender and marital status, and the analyses were stratified by immigration status. Logistic regression analyses were conducted to estimate the odds of non-participation for invited citizens and for reminded citizens divided by socioeconomic and demographic predictors. Results: Of 763,511 native Danes invited for screening from 2014 to 2015, 387,116 (50.70%) participated after the initial invitation and 133,470 after receiving a reminder. Differences in participation were present in relation to all subgroups among both the invited citizens and reminded citizens. Differences persisted after full model adjustments with reductions for demographic variables. Odds ratio (OR) for non-participation in the eldest age group was 0.32 (95% CI, 0.32; 0.33) before and 1.11 (95% CI 1, 0.08; 1.14) after the reminder, compared to those under 55 years. OR for the 4th income quartile was 0.54 (95% CI, 0.53; 0.55) before and 0.44 (95% CI, 0.43; 0.45) after the reminder, compared to 1st quartile. Conclusions: Reminders increased the overall participation, and the inequalities in participation in relation to demographic factors were reduced after the distribution of reminders. The age differences were especially reduced. The inequalities in participation related to socioeconomic status were, however, slightly increased after reminder distribution.

Summary Introduction Fecal and urinary incontinence are common disorders in children. Obesity and its associated comorbidities have become increasingly common, and a relation between obesity, nocturia, incontinence, and nocturnal enuresis has been suggested. Objective This large scale population study aims to determine the prevalence of fecal incontinence (FI), daytime urinary incontinence (DUI), nocturnal enuresis (NE), and nocturia in children at school entry and in adolescence and to clarify whether obesity is associated to any of the aforementioned symptoms. Study design First-grade children and their parents and adolescents in the seventh to ninth grades were interviewed in relation to school nurse visits. The interview included questions on whether incontinence or nocturia were experienced at least once per month. The participants' age was recorded, and weight and height were measured. Body mass index (BMI) was calculated and age standardized by the use of BMI-standard deviation score (SDS), with reference to World Health Organization normative BMI data. Obesity was defined as BMI-SDS >2. Associations between obesity and incontinence and nocturia were quantified by odds ratio (OR). Results Completed interview questionnaires and measurements were obtained from 4002 children (95.1%) in the child population and 2801 adolescents (84.4%) in the adolescent population. The mean age of children was 6.45 ± 0.39 years, and 4.4% were obese. Overall 11.2% reported FI, 21.8% DUI, 16.8% NE, and 31.4% experienced nocturia. Obesity was associated with FI in first-grade boys (OR 1.86 compared with normal weight). Mean age of adolescents was 13.9 ± 0.85 years, and 7.6% of adolescent boys and 5.5% of the girls were obese. Fecal incontinence was reported by 2.1% of the adolescents, 4.5% had DUI, 1.0% stated to have NE, and 32.3% reported nocturia. Obesity was significantly associated with nocturia in adolescents (OR 1.74–2.01). Discussion The prevalence of nocturia seems constant throughout childhood and adolescent life; this has not previously been documented. Incontinence is very common at school entry, with DUI reported more frequently than enuresis by both children and adolescents. Obesity is associated with nocturia in adolescents and FI in first-grade boys, but no significant association between obesity and NE or DUI is found. Strength of this study is the very high participation rates, but the study does not reveal information on previous treatment, subtype, or severity of symptoms. Conclusions Incontinence is very common in children. One-third of both children and adolescents experience nocturia. Obesity is associated with FI in first-grade boys and nocturia in adolescents.

Health-risk behaviour like physical inactivity is more evident in deprived neighbourhoods than in nondeprived neighbourhoods, and in the former knowledge is lacking as to what causes effects in interventions on physical activity. A possible contribution to physical activity interventions is community engagement, which has been shown to be effective for changing health-risk behaviour, but more knowledge is needed on "the active ingredients" or mechanisms that make interventions work. The aim of this study was to give more insight into the possible mechanisms within an intervention on physical activity using community engagement. The study applied a theory-based evaluation approach using theory of change to uncover the underlying mechanisms of a community-based fitness centre in a deprived Danish neighbourhood. Data were gathered from documents about the intervention, semistructured interviews with three front-line workers on the intervention and ten residents participating in the centre as either volunteer instructors or members. The following mechanisms of the intervention to improve participation and health were anticipated by the front-line workers; the creation of meaningful communities through social interaction, the presence of relatable role models, residents taking responsibility and feeling co-ownership and the experience of being of value as an instructor. Interviews with members and volunteer instructors showed that the anticipated mechanisms did facilitate participation and improved health; however, with some individual variations and with the physical and mental benefits of the particular activities also functioning as mechanisms for participation and engagement. Furthermore, the study found potential unintended consequences related to engagement, such as difficulties in balancing the needs of others with own needs. Findings indicate that both the social aspect and the activities should be prioritised, as should a continued focus on the inclusion of different residents in the area. Furthermore, unintended consequences should be considered and prevented through support for volunteering residents.

Health information knowledge may affect attitude toward colorectal cancer screening, but the participation of health educated citizens are unknown. Therefore, we investigated non-participation in a sample of 886,088 invited participants, based on educational length, type, and level. Logistic regression analyses were conducted to estimate the odds of non-participation in Danish men and women based on educational type and length. Models were adjusted for age, income, marital status and immigration status. Information was derived from National registers. Men with long educational length level had increased odds of non-participation if their education was within the field of medicine/medical science (OR 1.87) or belonged to other long health educations, but not in nursing and health care, compared to other long educations after full model adjustment. Women with long educational length level had increased odds of non-participation if they were educated in the field of medicine/medical science (OR 1.47), whereas they had decreased odds in the fields of nursing and health care and other long health educations, compared to other long educations after full model adjustment. Men within short educational length level did not have different odds of nonparticipation, after full model adjustments, whereas women within short health educations were at increased odds in the youngest age group and at decreased odds in the eldest age group. Having an education in the field of medicine/medical science is associated with non-participation in colorectal cancer screening in Denmark 2014–2015. Opposite, an educational background in nursing and health care increased participation in women, but not in men.

Background Frequent attendance to primary care constitutes a large use of resources for the health care system. The association between frequent attendance and illness-related factors has been examined in several studies, but little is known about the association between frequent attendance and individual social capital. The aim of this study is to explore this association. Methods The analysis is conducted on responders to the North Denmark Region Health Profile 2010 (n = 23,384), individually linked with information from administrative registers. Social capital is operationalized at the individual level, and includes cognitive (interpersonal trust and norms of reciprocity) as well as structural (social network and civic engagement) dimensions. Frequent attendance is defined as the upper-quartile of the total number of measured consultations with a general practitioner over a period of 148 weeks. Results Using multiple logistic regression, we found that frequent attendance was associated with a lower score in interpersonal trust [OR 0.86 (0.79–0.94)] and social network [OR 0.88 (0.79–0.98)] for women, when adjusted for age, education, income and SF12 health scores. Norms of reciprocity and civic engagement were not significantly associated with frequent attendance for women [OR 1.05 (0.99–1.11) and OR 1.01 (0.92–1.11) respectively]. None of the associations were statistically significant for men. Conclusion This study suggests that for women, some aspects of social capital are associated with frequent attendance in general practice, and the statistically significant dimensions belonged to both cognitive and structural aspects of social capital. This association was not seen for men. This indicates a multifaceted and heterogeneous relationship between social capital and frequent attendance among genders. Electronic supplementary material The online version of this article (10.1186/s12889-018-5230-2) contains supplementary material, which is available to authorized users.

Background Although unemployment and high levels of perceived stress have been associated in cross-sectional studies, the direction of causation is unknown. We prospectively examined if high levels of perceived everyday life stress increased the risk of subsequent unemployment and further if differences existed between socioeconomic status-groups. Methods We included 9335 18–64-year-old employed respondents of a health survey (North Denmark Health Profile 2010) in which Cohen’s Perceived Stress Scale was used to assess the level of perceived stress. Data were linked individually to national administrative registers. Cox proportional hazards model was used to investigate the association between perceived stress quintiles and risk of unemployment during 98 weeks of follow-up. Analyses were further performed in subgroups defined by education and income. Results In total, 224 people (10.4%) of the high stress group became unemployed during follow-up, which was higher than the lower stress groups. After adjusting for gender, age, education and income, the risk of unemployment was 1.64 (95% CI: 1.28;2.11) in the high stress group compared to the low stress group. After adjusting for gender and age, a similar trend was observed across different education levels and among the lower income groups, but no higher risk of unemployment due to perceived stress was found among the higher income groups. However, there was no statistically significant interaction between perceived stress and income level (p = 0.841) or perceived stress and education level (p = 0.587). Conclusion Perceived everyday life stress nearly doubled the risk of subsequent unemployment in a working population. No statistically significant interactions between SES and perceived stress were found. This indicates that stress prevention among the working population should not solely focus on stress in the workplace but also include stress from everyday life. Electronic supplementary material The online version of this article (10.1186/s12889-018-5618-z) contains supplementary material, which is available to authorized users.

PurposeColorectal cancer screening by inviting citizens tocomplete a test for blood in faeces was initiated in Denmarkin 2014. We have examined sociodemographic predictors thatinfluence participation to identify factors that could betargeted to increase compliance.MethodsNational registers were used to link data on invita-tions for colorectal cancer screening in Denmark from 2014 to2015. Region of residence, age, gender, immigration status,income, educational level and marital status were identified.Logistic regression analysis was used to estimate the risk ofnon-participation for invited citizens while adjusting for allother sociodemographic variables.ResultsA total of 854,237 individuals were included in theanalysis. The national participation proportion was 65.33%,with significant differences between sociodemographicgroups. Participation proportions were the lowest in non-Western immigrants (53.00%), individuals without a partner(54.05%) and those in the lowest income quartile (54.65%),with subgroup participation as low as 40.56%. The highestparticipation proportion was seen in individuals in the highestincome quartile (71.56%). Region of residence, age, gender,educational level, income quartile, marital status and immigra-tion status all had statistically significant independent differ-ences in risk of non-participation after full model adjustment.ConclusionParticipation in colorectal cancer screening washigh in Denmark in 2014 and 2015. Large differences in par-ticipation were seen between sociodemographic subgroups,potentially resulting in social inequality in the benefits fromscreening. Future efforts to increase participation should focuson the low compliance subgroups, such as singles, non-Western immigrants and people from the lowest socioeco-nomic groups.

Background— First-time syncopal episodes usually occur in adults of working age, but their impact on occupational safety and employment remains unknown. We examined the associations of syncope with occupational accidents and termination of employment. Methods and Results— Through linkage of Danish population-based registers, we included all residents 18 to 64 years from 2008 to 2012. Among 3 410 148 eligible individuals, 21 729 with a first-time diagnosis of syncope were identified, with a median age 48.4 years (first to third quartiles, 33.0–59.5), and 10 757 (49.5%) employed at time of the syncope event. Over a median follow-up of 3.2 years (first to third quartiles, 2.0–4.5), 622 people with syncope had an occupational accident requiring hospitalization (2.1/100 person-years). In multiple Poisson regression analysis, the incidence rate ratio in the employed syncope population was higher than in the employed general population (1.44; 95% confidence interval [CI], 1.33–1.55) and more pronounced in people with recurrences (2.02; 95% CI, 1.47–2.78). The 2-year risk of termination of employment was 31.3% (95% CI, 30.4%–32.3%), which was twice the risk of the reference population (15.2%; 95% CI, 14.7%–15.7%), using the Aalen–Johansen estimator. Factors associated with termination of employment were age Conclusions— In this nationwide cohort, syncope was associated with a 1.4-fold higher risk of occupational accidents and a 2-fold higher risk of termination of employment compared with the employed general population.

OBJECTIVE Dyspepsia is a common condition and has a huge impact on quality of life and working capacity, but its causes are not well understood. An association between stress and dyspepsia has been debated for decades, but the issue has not been resolved. We examined the 3-year risk of redeeming a proton-pump inhibitor or an H2-receptor antagonist as a proxy of dyspepsia according to the level of perceived stress. PARTICIPANTS AND METHODS Perceived stress was measured in a general health survey of 16 124 Danes aged older than 16 years of age in 2010 using Cohen's Perceived Stress Scale. Data were linked individually to national registries, including the Danish National Prescription Registry. The risk of redeeming a proton-pump inhibitor or an H2-receptor antagonist for quintiles of stress level was estimated using Cox proportional hazard regression. RESULTS In total, 2703 redeemed one of these drugs during the 33 months of follow-up. The cumulative incidence proportion of dyspepsia increased gradually, from 11.6 to 24.9%, with quintiles of stress. After full model adjustment, the four highest stress quintiles had a statistically significantly increased risk of redeeming a drug compared with the lowest stress quintile. The hazard ratios were 1.16 [95% confidence interval (CI): 1.00-1.34] for the second quintile, 1.21 (95% CI: 1.06-1.39) for the third quintile, 1.20 (95% CI: 1.05-1.38) for the fourth quintile, and 1.30 (95% CI: 1.12-1.50) for the fifth quintile. CONCLUSION Higher levels of self-reported perceived everyday life stress increased the risk of redeeming a drug for dyspepsia significantly during 33 months of follow-up.

Background: Some studies have found positive associations between physical fitness and academic achievements. Pupils' academic achievements should indicate scholastic abilities to commence a post-compulsory education. However, the effect magnitude of physical fitness and academic achievements on commencement in post-compulsory education is unknown. We examined the pathways between physical fitness and academic achievement on pupils' commencement in post-compulsory education. Methods: This historical cohort study followed 530 girls and 554 boys from the Danish municipality of Aalborg in the period 2008-2014, 13 to 15 years old in 2010. Physical fitness was assessed through a watt-max cycle ergometer test represented as VO2max (mL·kg-1·min-1). Academic achievement, commencement status and information on covariates were obtained from Danish nationwide registers. Causal inference based mediation analysis was used to investigate the indirect and direct pathways by separating the total effect of physical fitness on post-compulsory education commencement. Results: Adjusting for sex, age, ethnicity and socioeconomic status, the overall mediation analysis showed an odds ratio (OR) of 1.87 (95% confidence interval (CI): 1.30; 2.73) for the total effect, corresponding to an increase in odds of post-compulsory education commencement when the physical fitness was increased by 10 units of VO2max. The separated total effect showed a natural direct OR of 1.36 (95% CI: 0.93; 1.98) and a natural indirect (i.e., through academic achievement) OR of 1.37 (95% CI: 1.20; 1.57). Thus, 51% (95% CI: 27%; 122%) of the effect of physical fitness on post-compulsory education commencement was mediated through academic achievement. Conclusion: Physical fitness had a positive effect on post-compulsory education commencement. A substantial part of this effect was mediated through academic achievement.

OBJECTIVE: To investigate the implications of low and moderate preoperative alcohol consumption on postoperative mortality and morbidity after primary hip and knee arthroplasty.METHODS: A total of 30,799 patients who underwent primary hip or knee arthroplasty between January 1st, 2005 and October 8th, 2011 with information on preoperative alcohol consumption (0 grams of pure alcohol/week, >0-168 g/week, >168-252 g/week, and >252 g/week) were identified through the Danish Anesthesia Database. The 90-day and 1-year risks of mortality (primary outcomes), 1-year risk of prosthetic infection, and 30-day risks of cardiovascular disease and deep venous thrombosis (secondary outcomes) were estimated by Cox regression analysis.RESULTS: We identified 285 (0.9%) deaths within the first 90 days and 694 (2.3%) within the first year. Within the first 30 days, 209 (0.7%) and 270 (0.9%) patients had acquired cardiovascular disease and deep venous thrombosis, respectively, and 514 (1.7%) patients developed prosthetic infection within the first year. The adjusted mortality models yielded hazard ratios of 0.55 (95% confidence interval [CI] 0.41 to 0.74) at 90 days and 0.61 (95% CI 0.51 to 0.73) at 1 year for the group consuming >0-168 g/week when compared to abstainers. Adjusted hazard ratios showed that the group consuming >0-168 g/week had a 0.91 (95% CI 0.75 to 1.11) risk of prosthetic infection, 0.68 (95% CI 0.50 to 0.92) risk of cardiovascular disease and 0.88 (95% CI 0.67 to 1.15) risk of deep venous thrombosis when compared to abstainers.CONCLUSIONS: This study demonstrates that low-to-moderate alcohol consumption prior to primary hip or knee arthroplasty is associated with lower risks of mortality at both 90 days and 1 year after surgery and of cardiovascular disease after 30 days. More research from longitudinal studies is needed to identify specific causal relations and explanations.

BACKGROUND: Previous studies have shown that compared with abstinence and heavy drinking, moderate alcohol consumption is associated with a reduced risk of mortality among the general population and patients with heart failure and myocardial infarction. We examined the association between alcohol consumption and mortality in coronary artery bypass graft (CABG) patients.METHOD: We studied 1,919 first-time CABG patients using data on alcohol consumption and mortality obtained from Danish national registers from March 2006 to October 2011. Alcohol consumption was divided into the following groups: abstainers (0 units/week), moderate consumers (1-14 units/week), moderate-heavy drinkers (15-21 units/week) and heavy drinkers (>21 units/week). Hazard ratios (HR) of all-cause mortality were calculated using Cox proportional hazard regression analysis.RESULTS: The median follow-up was 2.2 years [IQR 2.0]. There were 112 deaths, of which 96 (86 %) were classified as cardiovascular. Adjustments for age and sex showed no increased risk of all-cause mortality for the abstainers (HR 1.61, 95 % CI, 1.00-2.58) and moderate-heavy drinkers (HR 1.40, 95 % CI, 0.73-2.67) compared with moderate consumers. However, heavy drinkers had a high risk of all-cause mortality compared with moderate consumers (HR 2.44, 95 % CI, 1.47-4.04). A full adjustment showed no increase in mortality for the abstainers (HR 1.59, 95 % CI, 0.98-2.57) and moderate-heavy drinkers (HR 1.68, 95 % CI, 0.86-3.29), while heavy drinkers were associated with an increased mortality rate (HR 1.88, 95 % CI, 1.10-3.21). There was no increased risk of 30-day mortality for the abstainers (HR 0.74, 95 % CI, 0.23-2.32), moderate-heavy drinkers (HR 0.36, 95 % CI, 0.07-1.93) and heavy drinkers (HR 2.20, 95 % CI, 0.65-7.36).CONCLUSION: There was no increased risk of mortality for abstainers (0 units/week) or moderate-heavy drinkers (15-21 units/week) following a CABG. Only heavy drinking (>21 units/week) were significantly associated with an increased mortality rate. These results suggest that only heavy drinking present a risk factor among CABG patients.

Background: Prevalence of mental disorders at work is commonly reported on the subclinical level. Data on clinical caseness as to ICD-10 among employees is scarce. Aims: (i) To establish the prevalence of psychiatric morbidity in the Danish workforce in large enterprises based on a self-report measure. (ii) To verify the screening results by use of a structured diagnostic interview. (iii) To analyze associations with demographics and work- and health-related characteristics. Methods: A two-phase design study was carried out in three Danish counties. Ten large enterprises within private and public sectors participated. A questionnaire was administrated to 1,500 employees. The Present State Examination (PSE) interview was conducted with selected respondents according to their scores on Symptom Checklist 90-revised (SCL-90R) and CAGE. Results: Nine hundred and seventy six (65%) employees responded. A large proportion (28.6%) was identified as sub-cases and 77 as cases as to ICD-10. Absenteeism and work dissatisfaction were associated with ICD-10 diagnoses. Conclusions: Common mental disorders caseness as to ICD-10 provides evidence for the clinical nature of occupational mental health phenomena. There were strong associations between some demographic and work- and health-related factors.

Purpose This study explores the applicability of registry data as a proxy for perceived stress by examining the association between perceived stress measured in health surveys and registry data. Methods Of 35,700 randomly invited participants from the 2010 Health Survey in the North Denmark Region (age 16–99 years), 21,842 answered 10 items from Cohen's Perceived Stress Scale. Respondents were divided into quartiles based on their stress score. Survey information was individually linked to national registries containing information on prescribed psychiatric medication and consultations with psychologists or psychiatrists from 2009 to 2011. Results The percentage of persons with prescriptions or consultations was higher (37.6%) in the highest stress score group, compared with the lowest stress score group (7.7%). Odds ratio (95% confidence interval) for the highest score compared with the lowest score was 7.3 (6.5–8.1). Different combinations of treatment showed low sensitivity (8.7%–37.6%), positive predictive value (49.4%–56.8%), and positive agreement (16.2%–42.7%) were found, whereas specificity (88.5%–98.0%) and negative agreement (85.5%–87.2%) were higher. Kappa measure showed slight to fair agreement (0.104–0.285). Conclusions Participants reporting high perceived stress were more often prescribed medications and referred for consultations with psychologists or psychiatrists. However, due to low predictive values, registry data may not be suitable as a proxy for perceived stress.

BACKGROUND Time spent on physical activity in elementary school has been altered to improve core academics. However, little is known about the relationship between physical fitness and academic achievement. We examined the association between physical fitness and academic achievement and investigated the influence of parental socioeconomic status and ethnicity. METHODS Participants were 542 girls and 577 boys aged 13 to 15 residing in the Danish municipality of Aalborg. A watt-max cycle ergometer test was completed to evaluate physical fitness as represented by VO2max (mL·kg−1·min−1). Academic achievement was measured 1 school year later through a series of mandatory exams within the humanities, sciences, and all obligatory defined exams. Parental income and education were drawn from nationwide registers. Linear regression models were used to investigate the association. RESULTS Adjusting for ethnicity and parental socioeconomic status, the effect size of the humanities was 0.08 grad/VO2max (95% Cl: 0.05 to 0.11) for girls and 0.06 grad/VO2max (95% Cl:0.03 to 0.08) for boys. The effect size of the sciences was 0.09 grad/VO2max (95% Cl:0.05 to 0.13) for girls and 0.06 grad/VO2max (95% Cl:0.03 to 0.09) for boys. The effect size of the defined exams was 0.09 grad/VO2max (95% Cl:0.06 to 0.11) for girls and 0.06 grad/VO2max (95% Cl:0.03 to 0.08) for boys. CONCLUSION We found a statistically significant positive association between physical fitness and academic achievement after adjusting for ethnicity and parental socioeconomic status.

Background Education is a key determinant of future employment and income prospects of young people. Poor mental health is common among young people and is related to risk of dropping out of school (dropout). Educational level and gender might play a role in the association, which remains to be studied. Methods Mental health was measured in 3146 Danish inhabitants aged 16–29 years using the 12-Item Short-Form Health Survey and examined across genders and educational levels. For students, educational level at baseline was used; for young people who were not enrolled in school at baseline (non-students), the highest achieved educational level was used. The risk of dropout in students was investigated in administrative registers over a 4.8–year period (1st March 2010–31th December 2014). Odds ratios (OR) and 95 % confidence intervals (CI) were calculated for mental health and in relation to dropout in logistic regression models, adjusting for age, gender, educational level, parental education, parental income and ethnicity. Results Poor mental health was present in 24 % (n = 753) of the participants, 29 % (n = 468) in females and 19 % (n = 285) in males (p

INTRODUCTION: The risk of upper-respiratory tract viral infections is reduced with increased physical activity, but little information is available regarding bacterial infections. We examined the relationship between leisure-time physical activity and suspected bacterial infections.METHODS: Information on leisure-time physical activity was obtained from the 2007 and 2010 North Denmark Region Health Surveys of 18,874 Danes and linked to data from nationwide administrative registries. Suspected bacterial infections were determined based on filled prescriptions for antibiotics. Adjusted estimates were calculated using logistic regression models.RESULTS: During a one-year follow-up, 5,368 participants filled at least one antibiotic prescription. There was a statistically significant difference between physical activity level and filling any antibiotic prescriptions among women (p=0.003) but not among men (p=0.191). Logistic regression analysis showed that compared with sedentary behaviour, all levels of leisure-time physical activities lowered the likelihood of filling an antibiotic prescription. However, after multivariable adjustments, only estimates of low physical activity were significant (OR 0.90; 95% CI 0.82; 0.99). Multivariable adjusted subgroup analyses of suspected cystitis showed a decreased likelihood of engaging in low (OR 0.79; 95% CI 0.65; 0.95) and moderate (OR 0.68; 95% CI 0.54; 0.87) physical activity.CONCLUSION: Low leisure-time physical activity is associated with a statistically significant 10% lower risk of suspected bacterial infections over a one-year follow-up compared with sedentary behaviour. Further, low and moderate physical activity was associated with statistical significant reduction of suspected cystitis. No reduction in suspected respiratory tract infections was statistical significant associated with physical activity compared to sedentary behaviour.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Background Socioeconomic inequalities in mortality pose a serious impediment to enhance public health even in highly developed welfare states. This study aimed to improve the understanding of socioeconomic disparities in all-cause mortality by using a comprehensive approach including a range of behavioural, psychological, material and social determinants in the analysis. Methods Data from The North Denmark Region Health Survey 2007 among residents in Northern Jutland, Denmark, were linked with data from nationwide administrative registries to obtain information on death in a 5.8-year follow-up period (1stFebruary 2007- 31stDecember 2012). Socioeconomic position was assessed using educational status as a proxy. The study population was assigned to one of five groups according to highest achieved educational level. The sample size was 8,837 after participants with missing values or aged below 30 years were excluded. Cox regression models were used to assess the risk of death from all causes according to educational level, with a step-wise inclusion of explanatory covariates. Results Participants’ mean age at baseline was 54.1 years (SD 12.6); 3,999 were men (45.3%). In the follow-up period, 395 died (4.5%). With adjustment for age and gender, the risk of all-cause mortality was significantly higher in the two least-educated levels (HR = 1.5, 95%, CI = 1.2-1.8 and HR = 3.7, 95% CI = 2.4-5.9, respectively) compared to the middle educational level. After adjustment for the effect of subjective and objective health, similar results were obtained (HR = 1.4, 95% CI = 1.1-1.7 and HR = 3.5, 95% CI = 2.0-6.3, respectively). Further adjustment for the effect of behavioural, psychological, material and social determinants also failed to eliminate inequalities found among groups, the risk remaining significantly higher for the least educated levels (HR = 1.4, 95% CI = 1.1-1.9 and HR = 4.0, 95% CI = 2.3-6.8, respectively). In comparison with the middle level, the two highest educated levels remained statistically insignificant throughout the entire analysis. Conclusion Socioeconomic inequality influenced mortality substantially even when adjusted for a range of determinants that might explain the association. Further studies are needed to understand this important relationship. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1813-3) contains supplementary material, which is available to authorized users.

Objectives Both shift work and other work environment factors have been shown to be related to heart disease. This study examined whether shift work is associated with other work environment factors related to heart disease in a random sample of the population. If so, shift work could be acting as a proxy for work environment differences. Methods Data on 5940 employees in the Danish Work Environment Cohort Study from 1990 were reanalyzed. The information included work schedules [permanent day work, irregular workhours (including morning work), 2-shift or fixed evening and 3-shift or fixed night], length of workweek, physical factors (noise, heat, dust, passive smoking, walking, standing and monotonous repetitive tasks), and psychosocial factors (including demands and control dimensions, social support, conflicts and job insecurity). Results At least 1 group of shift workers had a higher prevalence of nearly every unfavorable work environment factor investigated. Exceptions were dust exposure and quantitative demands. Especially conflicts at work and low decision latitude were higher among all the groups of shift workers, and all-day walking or standing work and part-time jobs were more often found among female shift workers. The 3 different shiftwork groups were exposed to different parts of the work environment, and also men and women in shift work differed in relation to the work environment. Age and social class influenced the relationship, but not in any particular pattern. Conclusions In a heterogenous population shift work was found to be associated with other work environment factors suspected to cause heart disease.

Exact cause and manner of death determination improves legislative safety for the individual and for society and guides aspects of national public health. In the International Classification of Diseases, codes R00-R99 are used for "symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified" designated as "ill-defined" or "with unknown etiology". The World Health Organisation recommends avoiding the use of ill-defined and unknown causes of death in the death certificate as this terminology does not give any information concerning the possible conditions that led to the death. Thus, the aim of the study was, firstly, to analyse the frequencies of R00-R99-coded deaths in mortality statistics in Finland and in Denmark and, secondly, to compare these and the methods used to investigate the cause of death. To do so, we extracted a random 90% sample of the Finnish death certificates and 100% of the Danish certificates from the national mortality registries for 2000, 2005 and 2010. Subsequently, we analysed the frequencies of forensic and medical autopsies and external clinical examinations of the bodies in R00-R99-coded deaths. The use of R00-R99 codes was significantly higher in Denmark than in Finland; OR 18.6 (95% CI 15.3-22.4; p

OBJECTIVE: Our aim was to review published literature on the association between shift work and gastrointestinal (GI) disorders. METHODS: A systematic review of the literature was conducted of studies that have reported GI symptoms and diseases among shift workers. We used Medline to search for articles from 1966–2009. Next, we manually searched articles in the reference list of each article and previous reviews. RESULTS: Twenty studies met the inclusion criteria. Four of six studies showed a significant association between shift work and GI symptoms, and five of six studies reported an association between shift work and peptic ulcer disease. Two of three studies showed an association between shift work and functional GI disease. Only a few studies have examined gastroesophageal reflux disease, chronic inflammatory bowel diseases, or GI cancers in relation to shift work. CONCLUSIONS: Our general judgment is that shift workers appear to have increased risk of GI symptoms and peptic ulcer disease. However, control for potential confounders (eg, smoking, age, socioeconomic status, and other risk factors) was often lacking or insufficient in many of the studies we examined.

To study the association between fluoride concentration in drinking water and dental caries in Danish children.The study linked registry data on fluoride concentration in drinking water over a 10-year period with data on dental caries from the Danish National Board of Health database on child dental health for 5-year-old children born in 1989 and 1999, and for 15-year-old children born in 1979 and 1989. The number of children included in the cohorts varied between 41.000 and 48.000. Logistic regression was used to assess the correlations, adjusting for gender and taxable family income as a proxy variable for socioeconomic status. Fluoride concentration in drinking water varied considerably within the country from very low (0.10 mg/l) to more than 1.5 mg/l. Only little variation was found over the 10-year study period. Dental caries in both 5-year-olds and 15-year-olds decreased over the study period. An inverse relation between the risk of dental caries and fluoride concentration in drinking water was found in both primary and permanent teeth. The risk was reduced by approximately 20% already at the lowest level of fluoride exposure (0.125-0.25mg/l). At the highest level of fluoride exposure (1 mg/l), a reduction of approximately 50% was found. Similar findings were found if analysis was limited to children residing in the same place during the entire study period.The study confirmed previous findings of an inverse relation between fluoride concentration in the drinking water and dental caries in children. This correlation was found in spite of the extensive use of fluoridated toothpaste and caries-preventive programs implemented by the municipal dental services in Denmark. Linking Danish health registers with environmental and administrative registers offers an opportunity for obtaining sample sizes large enough to identify health effect, which otherwise could not be identified.

Background: The body of evidence verifies the predictive value of certain work characteristics for mental health problems and that various levels of adaptation mechanisms are employed when dealing with adversity. Data on the relationships between employees’ mental health status, their perceptions of work, and their psychological defences are scarce. Aims: To examine the role that personal defences play in the relationship between psychiatric symptoms among working people and their working environment. Methods: Nine hundred and seventy six employees (mean age = 42.4 years, SD = 11.3) participated in a questionnaire study that included the Defence Style Questionnaire, the Symptom Checklist 90 revised, and the Copenhagen Psychosocial Questionnaire . Results: Data showed that greater maturity of psychological defences was associated with higher level of psychological functioning and there were strong associations between presence of psychopathology and the three defence clusters. Results indicated a strong positive correlation between the mature defence style and the perception of a satisfactory workplace. There was no interaction between psychopathology and defences in relation to work environment. Conclusion: Psychopathology and defences were significantly associated with work conditions, which could suggest that adaptation mechanisms and psychopathology are two independent forms of adjustment to the rapidly changing world of work.

Udgivelsesdato: 2009 AIM: To investigate if a pending application for disability pension had an influence on the applicant's purchase of medical drugs, with a particular focus on musculoskeletal disorders and the use of painkillers. METHODS: We performed a registry-based follow-up study including 12,020 applicants for disability pension in a Danish county from 1995 to 2000 and linked this information to a database of drug prescriptions. Purchase of drug was calculated for the 6-month period just before the decision and for the 6-month period 2 years later. Changes in a 2-year time period were estimated by differences in purchase rates. Furthermore, the proportion of applicants with an increased purchase of drugs and the proportion of applicants who ceased buying drugs were estimated. The results were stratified by diagnosis and result of application (awarded/rejected). The analyses were furthermore restricted to musculoskeletal disorders and the use of painkillers. Results and CONCLUSIONS: At baseline 81% had a purchase and after the 2-year time period 11% ceased buying prescribed drugs. Half of all applicants increased the purchase of drugs. For musculoskeletal disorders one third had an increased purchase rate of painkillers while one fourth ceased purchase of drugs with variations in different diagnostic subgroups. The major changes of drug purchase after a pending application for disability pension are probably ascribed to characteristics of the diseases underlying the disability.

This study examined the relationship between shift work-specific locus of control (SH-LOC), active choice of work schedule and health outcomes, personal initiatives and coping behaviours in 1611 Danish Health Service shift workers. The 20-item SH-LOC scale was administered as part of a battery of measures. Multivariate analysis of covariance (controlling for age, workplace experience and weekly work hours) tested for differential responses to shift working and coping strategies. Interactive effects of internality and type of work rota were examined. Higher internality was linked to better tolerance to shift work. This did not appear to be a result of greater personal action in higher internals. The importance of control as a potential moderating factor to shift work exposure and the possible use of this measure in the process of shift worker monitoring is highlighted.

In the public health system we study medical treatment which is ideally provided according to need and independently of economic means. We report use of prescription drugs according to socioeconomic classifications in North Jutland County in Denmark in 1999.We conducted a register-based cross-sectional study of 385,879 persons aged 18 years or older. Data from the computerized accounting system from the pharmacies were linked with records of socioeconomic status (SES) in the Prevention Registry at Statistics Denmark. We identified all prescriptions redeemed in North Jutland County from 1 January through 31 December 1999 and classified the socioeconomic status for each individual based on the annual registration of income/social benefits, employer, occupation and education. We computed the proportion of persons redeeming at least one prescription and computed weighted averages of prescription proportions for each SES.The highest prevalence of medication use was by persons in early retirement, old age pensioners, people on disability pension and others outside the workforce. We found only minor differences among different economically active groups with slightly more male top managers using cardiovascular drugs. People in the upper half of the socioeconomic scale were somewhat less likely to redeem prescriptions for treating muscle, joints and bone, and central nervous system.Social or economic barriers in buying medicine are generally small in Denmark and do probably not provide a likely explanation for the social differences in morbidity and mortality.

This article describes the incidence of first contacts with the psychiatric hospital services in the County of North Jutland (NJA) and the Municipality of Copenhagen (KK), Denmark, from 1 January 1994 to 31 December 2002.All persons age 18 and over living in NJA and KK in the period from 1 January 1994 to 31 December 2002 were identified through the Central Office of Civil Registration. First contacts with the psychiatric hospital services in the two areas were identified through the Danish Psychiatric Central Research Register.Standardised incidence rates of psychiatric diagnoses were generally higher in KK than in NJA. Overall, for all diagnoses, there were 37 first contacts for men per 10,000 person-years in KK and 21 in NJA. For women, there were 40 contacts in KK and 26 in NJA. For diagnoses in the F0 group, the frequency was higher in NJA, with 6.7 first contacts per 10,000 person-years for men and 7.3 for women in NJA, compared with 4.5 for men and 3.9 for women in KK. For women with F6 diagnoses, the frequency was also higher in NJA than in KK: 2.7 first contacts per 10,000 person-years in NJA compared with 1.6 in NJA. Outpatient diagnosis of first-contact patients was more frequent in NJA than in KK (66% in NJA and 59% in KK).The incidence of psychiatric diagnoses was higher in the urban area of KK than in the rural area of NJA. The higher incidence of F0 diagnoses in NJA may be due to differences in ways of registration. This might also explain why, in this investigation, more diagnoses after outpatient evaluation were made in NJA than in KK. We believe it is essential that continuing work on guidelines for registration of illness treatment in Denmark be performed.

Nursing staff are exposed to stressful work load which in turn is associated with poor physical and psychological health, sickness absence and job exit. The effort-reward imbalance (ERI) model is a validated approach to measure chronic psychosocial work stress by identifying nonreciprocity between occupational efforts spent and rewards received, and has been found to predict poor health. The aim of this cross-sectional study (n = 367 nurses and nurses aides) was first to test the psychometric properties of the Danish questionnaire measuring ERI, and secondly to analyse whether psychosocial work stress is associated with six indicators of poor self-rated health. Results derived from confirmatory factor analysis indicate satisfying psychometric properties. Elevated risks of poor self-rated health (odds ratios varying from 1.92 to 4.76) are observed in nursing staff characterized by high effort in combination with low reward. Effects are enhanced in those respondents who additionally exhibit a high level of work-related overcommitment. In conclusion, despite methodological limitations, this study contributes to the validation of the ERI questionnaire in Danish language. Furthermore, by documenting associations with poor self-rated health, it supports efforts of theory-guided prevention of work stress in health care professions.

Aims Socioeconomic inequalities in statin use are a public health concern but they may also confound observational studies of statins’ effectiveness. We conducted a population-based cross-sectional study in Denmark to examine the association between socioeconomic status (SES) and statin use. Methods We obtained data on socioeconomic status of all persons in North Jutland County, Denmark, between 1995 and 1999 from the Prevention Registry at Statistics Denmark. Data on filled statin prescriptions were identified through the County Prescription Database. We compared the 1-year prevalence proportions of statin use for different socioeconomic groups, adjusted for age and urbanization. Separate analyses were done for patients with a history of cardiovascular disease as recorded in the County Hospital Discharge Registry. Results Among men with cardiovascular disease, statin use in 1995 was higher in those with the highest socioeconomic status (adjusted relative prevalence proportion (RPP) among top managers 1.86, 95% CI: 1.17–2.96), and lower among retired men (RPP (95% CI) 0.63 [0.43–0.93] in old-age pensioners, and 0.66 [0.45–0.98] in the early retired), when compared with basic-level workers. The socioeconomic differences in statin use among men decreased in magnitude over time but remained throughout the study period. We found no clear social gradient in statin use among women. Conclusions Even in a health care system that claims to ensure a high degree of equity in medical care, we found clear indications of a socioeconomic gradient in statin use among men in the years after the launching of these drugs.

The aim was to identify socio-economic risk indicators among the Danish work force (aged 18 to 59) for being granted disability pension.A closed cohort study based on a random 10% sample of the Danish workforce defined in 1994 and followed in registers from 1995 to 98 for disability pension. The study population included 254,905 persons. Citizens in Denmark have a unique personal identification number so socio-economic data at individual levels from Statistics Denmark were linked with the Disability Pension Registry. All persons but 39 could be traced throughout the study or until the event of disability pension, emigration or death. Cox regression was used to calculate the hazard rate ratio of being granted disability pension.4443 persons were granted disability pension. The risk of being granted disability pension increased significantly with low social class. Comparing unskilled workers to managers showed that workers had 1.6 (95% confidence interval: 1.4-1.9) times greater risk of disability pension. For female unskilled workers the risk was 1.9 (1.6-2.2). Men with seven years' schooling had 3.1 (2.3-4.3) times higher risk of disability pension than men with a university degree, and women with seven years' schooling had 3.8 (2.5-5.8) greater risk. Having been on sick leave more than 13 weeks compared to sick leave less than four weeks increased the risk by 11.5 (10.1-13.1) for men and 11.2 (9.9-12.8) for women. High age, unemployment, living alone and receiving social benefits were also risk indicators for disability pension.The study identified reliable estimates of socioeconomic risk indicators, e.g. low level of education, low social class, and unemployment for leaving the workforce with disability pension.

A systematic review of arthrosis of finger joints in relation to occupational exposure revealed 11 epidemiological studies and 13 case reports. All studies but one were cross-sectional rendering demonstration of causation problematic. The reviewed literature also had drawbacks relating to exposure classification, confounding and non-attendance. Four studies showed an association between extensive use of precision grip and development of arthrosis of the distal interphalangeal joints of fingers. Two studies found an association between forceful gripping and the occurrence of arthrosis involving the metacarpophalangeal joints. Arthrosis of the proximal interphalangeal joints and first carpo-metacarpal joints was not related to any specific occupational task. Well-designed studies are needed to further elucidate this possible occupational hazard.

OBJECTIVE: The study examines the implications for shiftworkers of applying different numbers of teams in the organization of shiftwork. METHODS: The participating operators came from five different companies applying continuous shift rotation systems. The companies shared the same product organization and a common corporate culture belonging to the same multinational company. Each company had a shift system consisting of four, five or six teams, with the proportion of shifts outside day work decreasing as the number of teams increased. Questionnaire and documentary data were used as data sources. RESULTS: Operators in systems with additional teams had more daywork but also more irregular working hours due to both overtime and schedule changes. Operators using six teams used fewer social compensation strategies. Operators in four teams were most satisfied with their work hours. Satisfaction with the time available for various social activities outside work varied inconsistently between the groups. CONCLUSIONS: In rotating systems the application of more teams reduces the number of shifts outside day work. This apparent improvement for shiftworkers was counteracted by a concomitant irregularity produced by greater organizational requirements for flexibility. The balance of this interaction was found to have a critical impact on employees.OBJETIVOS: Investigar as implicações para trabalhadores em turnos do uso de um número distinto de turmas de trabalho na organização dos turnos. MÉTODOS: Participaram do estudo operadores de cinco empresas que usavam sistemas contínuos de turnos alternantes. As empresas tinham em comum a organização de produtos e cultura empresarial e pertenciam a uma mesma empresa multinacional. Cada uma das empresas tinha um sistema de turnos que compreendia quatro, cinco ou seis turmas de trabalho, sendo que a proporção de turnos fora dos horários diurnos diminuía à medida que aumentava o número de turmas. Foram usados dados de questionários e documentação como fontes de pesquisa. RESULTADOS: Os operadores de sistemas com turmas extras apresentaram uma quantidade maior de trabalho diurno, assim como mais horas irregulares de trabalho em decorrência de horas extras e mudanças de horário. Os operadores que contavam com seis turmas usaram menos recursos de compensação social. Os que trabalharam com quatro turmas ficaram mais satisfeitos com os horários de trabalho. A satisfação com o tempo disponível para diversas atividades sociais fora do trabalho variou de modo inconsistente entre as turmas estudadas. CONCLUSÕES: Nos sistemas com turnos rodiziantes, o uso de um número maior de turmas reduz o número de turnos não-diurnos. Esta aparente vantagem aos trabalhadores em turnos foi neutralizada pela concomitante irregularidade resultante de maiores exigências organizacionais para permitir flexibilidade. Verificou-se que o equilíbrio desta interação teve um impacto fundamental sobre os trabalhadores.

Background. Certain occupational groups have formerly been identified as having higher risks of suffering from chronic inflammatory bowel diseases. These were evaluated in an independent data set. Methods. A cohort, comprising all 2 273 872 male and female Danes aged 20-59 years on 1 January 1981, and a cohort of 2 387 620 men and women 1 January 1986 were followed up for hospitalizations due to chronic inflammatory bowel disease until 31 December 1990. Results. From 1981 to 1990 6296 first time admissions occurred. The incidence increased from 1981-1985 to 1986-1990. Of 363 male and 213 female occupational groups eight and five groups respectively had statistically significant raised standardized hospitalization ratios. Among 15 groups previously found to have significant odds ratios only female office staff and health occupations were found to have statistically significant raised standardized hospitalization ratios. Ratios for occupational groups with non-daytime work were not statistically significant. Compared to occupations without sedentary work occupations with predominantly sedentary work had a standardized hospitalization ratio of 125 (95% confidence interval [95% Cl] : 116.9-133.1). Self-employed had low hospitalization rates, while 'other salaried staff' and 'not economically active' had high rates. Conclusions. We found no consistent pattern of occupations at increased risk except that sedentary work may increase the risk of attracting chronic inflammatory bowel disease.

Background Poor mental health is a major problem in most western societies, especially predominant among young adults. However, associations of self-reported poor mental health with subsequent psychiatric or medical treatment are unknown. We examined the relation between self-reported mental health and redeeming prescriptions of antidepressants among three age groups. Methods We analyzed data from 16,233 individuals aged 16 years and over randomly selected to participate in the 2010 North Denmark Region Health Survey completed in February 2010. Mental health was defined according to the Short-Form 12 instrument (SF-12) and dichotomized into poor and good. Outcome data were retrieved from administrative information on redeemed prescriptions of antidepressants between February 2010 and December 2012. Crude cumulative incidence curves were produced to illustrate the probability of redeeming new prescriptions of antidepressants over time. Cox regression analysis was used to estimate risk of redeeming prescriptions of antidepressants when having poor mental health, adjusted for preselected explanatory covariates. Results Among the young (16–29 years-old), 620 (23 %) participants suffered from poor mental health. Among the adults (30–59 years-old) and elderly (60 years-old or over), 1592 (18 %) participants and 723 (15 %) reported poor mental health, respectively. Overall, women were more likely than men to rate their mental health as poor. For all age groups, there was an increased probability for redeeming prescriptions of antidepressants when having poor mental health. The hazard ratio [HR] for redeeming prescriptions of antidepressants for those reporting poor versus good mental health, adjusted for sex, ethnicity, marital status, education level, occupational status, smoking and physical activity was 3.1 (95 % confidence interval [CI] 2.20–4.29) for young participants. For adults, the HR was 2.3 (95 % CI 1.86–2.78) and for elderly, it was 3.5 (95 % CI 2.66–4.57). Conclusion Self-reported poor mental health was more frequent among younger than older participants. Overall, antidepressants were the most often used treatment. An increased probability of redeeming antidepressant prescriptions when having self-reported poor mental health was observed in all age groups. These findings suggest that frequent reporting of poor mental health is a common issue for all age groups that needs more attention. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-0893-7) contains supplementary material, which is available to authorized users.

OBJECTIVES: Shift work has been associated with an increased risk of ischaemic heart disease (IHD). Most published studies have had potential problems with confounding by social class. This study explores shift work as a risk factor for IHD after controlling for social class. METHODS: The Copenhagen male study is a prospective cohort study established in 1970-1 comprising 5249 men aged 40-59. Information obtained included working time, social class, and risk factors for IHD. A second baseline was obtained in 1985-6. The cohort was followed up for 22 years through hospital discharge registers for IHD, and cause of death was recovered from death certificates. RESULTS: One fifth of the cohort was shift working at entry with a significantly larger proportion of shift workers in lower social classes. Risk of IHD and all cause mortality over 22 years, adjusted for age only, for age and social class, and finally for age, social class, smoking, fitness, height, weight, and sleep disturbances, did not differ between shift and day workers. The relative risk of IHD, adjusted for age and social class was 1.0 (95% confidence interval (95% CI) 0.9-1.2). Men being shift workers in both 1971 and 1985 had the same risk as ex-shift workers in an 8 years follow up from the 1985-6 baseline. CONCLUSIONS: The present study questions shift work as an independent risk factor for IHD. The results of the study emphasise the importance of controlling adequately for the interplay of shift work and social class.