How can we strengthen students' social relations in order to reduce school dropout? An intervention development study within four Danish vocational schools.

BACKGROUND: This article describes the rationale and contents of an intervention program aimed at strengthening students' social relations in order to reduce dropout from vocational schools in Denmark. Taking its theoretical cue from the concept of 'social participation', a qualitative study was performed to investigate the specific relationships between the social environment within the schools and the institutional structures in order to analyse reasons for school dropout and their relation to well-being, cigarette smoking and substance use. METHODS: The development study was based on ethnographic methods, including 22 qualitative interviews with students 17-19 years old and fieldwork with participant observations at four vocational schools over 40 days, including informal interviews and discussion meetings with managers, teachers, counselors and students. As part of the fieldwork, four additional qualitative interviews and four group interviews were conducted with students 16-25 years old. RESULTS: The qualitative data collection resulted in seven major themes to be addressed in the intervention: social relations, sole focus on professional skills, institutionalized individualization, importance of the introduction period, physical surroundings and schedules, tobacco and cannabis use and communication about drug use. The program addressing these themes incorporates suggestions that are meant to improve how teachers welcome new students, to enable greater integration of social and educational activities and to enhance the capacity of teachers and counselors to deal with drug use problems among students. CONCLUSION: The development of new intervention programs might benefit from adopting a theoretical and methodological perspective that enables a closer exploration of the everyday social practices in which interventions are embedded. Thus, we aimed to create a comprehensive intervention that worked through organizational changes in everyday school practices. Intervention programs must be planned in dialogue and collaboration with practitioners in the field to ensure the pertinence and usability of the program.

Fracture risk prediction using phalangeal bone mineral density or FRAX(®)?-A Danish cohort study on men and women.

In this prospective study, we investigated the ability of Fracture Risk Assessment Tool (FRAX), phalangeal bone mineral density (BMD), and age alone to predict fractures using data from a Danish cohort study, Danish Health Examination Survey 2007-2008, including men (n = 5206) and women (n = 7552) aged 40-90 yr. Data were collected using a self-administered questionnaire and by phalangeal BMD measurement. Information on incident and prevalent fractures, rheumatoid arthritis, and secondary osteoporosis was retrieved from the Danish National Patient Registry. Survival analyses were used to examine the association between low, intermediate, and high risk by phalangeal T-score or FRAX and incident fractures, and receiver operating characteristic curves were obtained. Mean follow-up time was 4.3 yr, and a total of 395 persons (3.1%) experienced a fracture during follow-up. The highest rate of major osteoporotic fractures was observed in persons with a high combined risk (FRAX ≥20% and T-score ≤-2.5; women: 32.7 and men: 27.6 per 1000 person-yr). This group also had the highest risk of hip fractures (women: 8.1 and men: 7.2 per 1000 person-yr). FRAX and T-score in combination analyzed as continuous variables performed overall best in the prediction of major osteoporotic fractures. In predicting hip fractures, there was a tendency of T-score performing worse than the other methods.

Comparison of different screening tools (FRAX®, OST, ORAI, OSIRIS, SCORE and age alone) to identify women with increased risk of fracture. A population-based prospective study.

PURPOSE: To compare the power of FRAX® without bone mineral density (BMD) and simpler screening tools (OST, ORAI, OSIRIS, SCORE and age alone) in predicting fractures. METHODS: This study was a prospective, population-based study performed in Denmark comprising 3614 women aged 40-90 years, who returned a questionnaire concerning items on risk factors for osteoporosis. Fracture risk was calculated using the different screening tools (FRAX®, OST, ORAI, OSIRIS and SCORE) for each woman. The women were followed using the Danish National Register registering new major osteoporotic fractures during 3 years, counting only the first fracture per person. Area under the receiver operating characteristic curve (ROC) and statistics and Harrell's index were calculated. Agreement between the tools was calculated by kappa statistics. RESULTS: A total of 4% of the women experienced a new major osteoporotic fracture during the follow-up period. There were no differences in the area under the curve (AUC) values between FRAX® and the simpler tools; AUC values between 0.703 and 0.722 (p = 0.86). Also, Harrell's C values were very similar between the tools. Agreement between the tools was modest. CONCLUSION: During 3 years follow-up FRAX® did not perform better in the fracture risk prediction compared with simpler tools such as OST, ORAI, OSIRIS, SCORE or age alone in a screening scenario where BMD was not measured. These findings suggest that simpler models based on fewer risk factors, which would be easier to use in clinical practice by the GP or the patient herself, could just as well as FRAX® be used to identify women with increased risk of fracture. SUMMARY: Comparison of FRAX® and simpler screening tools (OST, ORAI, OSIRIS, SCORE) in predicting fractures indicate that FRAX® did not perform better in fracture risk prediction compared with the simpler tools or even age alone in a screening scenario without bone mineral density assessment.

Risk assessment tools to identify women with increased risk of osteoporotic fracture: complexity or simplicity? A systematic review.

A huge number of risk assessment tools have been developed. Far from all have been validated in external studies, more of them have absence of methodological and transparent evidence, and few are integrated in national guidelines. Therefore, we performed a systematic review to provide an overview of existing valid and reliable risk assessment tools for prediction of osteoporotic fractures. Additionally, we aimed to determine if the performance of each tool was sufficient for practical use, and last, to examine whether the complexity of the tools influenced their discriminative power. We searched PubMed, Embase, and Cochrane databases for papers and evaluated these with respect to methodological quality using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) checklist. A total of 48 tools were identified; 20 had been externally validated, however, only six tools had been tested more than once in a population-based setting with acceptable methodological quality. None of the tools performed consistently better than the others and simple tools (i.e., the Osteoporosis Self-assessment Tool [OST], Osteoporosis Risk Assessment Instrument [ORAI], and Garvan Fracture Risk Calculator [Garvan]) often did as well or better than more complex tools (i.e., Simple Calculated Risk Estimation Score [SCORE], WHO Fracture Risk Assessment Tool [FRAX], and Qfracture). No studies determined the effectiveness of tools in selecting patients for therapy and thus improving fracture outcomes. High-quality studies in randomized design with population-based cohorts with different case mixes are needed.

Phalangeal bone mineral density predicts incident fractures: a prospective cohort study on men and women--results from the Danish Health Examination Survey 2007­2008 (DANHES 2007­2008).

UNLABELLED: This prospective study investigates the use of phalangeal bone mineral density (BMD) in predicting fractures in a cohort (15,542) who underwent a BMD scan. In both women and men, a decrease in BMD was associated with an increased risk of fracture when adjusted for age and prevalent fractures. PURPOSE: The aim of this study was to evaluate the ability of a compact and portable scanner using radiographic absorptiometry (RA) to predict major osteoporotic fractures. METHODS: This prospective study included a cohort of 15,542 men and women aged 18­95 years, who underwent a BMD scan in Danish Health Examination Survey 2007­2008. BMD at the middle phalanges of the second, third and fourth digits of the non-dominant hand was measured using RA (Alara MetriScan®). These data were merged with information on incident fractures retrieved from the Danish National Patient Registry comprising the International Classification of Diseases (ICD-10). Follow-up was 27­45 months. Major osteoporotic fractures (vertebral fractures, humerus fractures, forearm fractures and hip fractures) were used in the analyses. Fracture events were calculated as "persons with fracture" and evaluated using survival analysis. RESULTS: A total of 307 (1.98 %) of the participants had experienced a new fracture during follow-up. BMD was significantly lower in subjects with fracture (0.32 vs. 0.34 g/cm(2); p < 0.001 adjusted for age, gender, prevalent fractures, height, weight and smoking). In both women and men, a 1 SD decrease in BMD (T score units) was associated with an increased risk of fracture when adjusted for age and prevalent fractures (women: HR = 1.39, CI 1.24­1.54, p < 0.001; men: HR = 1.47, CI 1.20­1.79, p < 0.001). CONCLUSION: Phalangeal BMD as measured using RA predicts the incidence of major osteoporotic fractures.