Estimating the causal effects of work-related and non-work-related stressors on perceived stress level: A fixed effects approach using population-based panel data.

OBJECTIVES: Prolonged or excessive stress can have a negative impact on health and well-being, and stress therefore constitutes a major public health issue. A central question is what are the main sources of stress in contemporary societies? This study examines the effects of work-related and non-work-related stressors and perceived social support on perceived stress within a causal framework. METHODS: Panel data were drawn from two waves (2013 and 2017) of the population-based health survey "How are you?" conducted in the Central Denmark Region. The analytical sample comprised 9,194 subjects who had responded to both surveys. Work-related and non-work-related stressors included major life events, chronic stressors, daily hassles and lack of social support. Perceived stress was measured with the 10-item Perceived Stress Scale (PSS). Data were analysed using fixed effects regression in a fully balanced design. RESULTS: The largest effects on PSS were seen in own disease, work situation and lack of social support. Other stressors affecting the perceived stress level were financial circumstances, relationship with partner, relationship with family and friends, and disease among close relatives. Most variables had a symmetrical effect on PSS. CONCLUSIONS: The results point to the need for comprehensive policies to promote mental health that span life domains and include both the individual and the group as well as organizational and societal levels. The study indicates that there are multiple potential entry points for stress prevention and stress management. However, it also shows that disease, work situation and social support weigh heavily in the overall picture. This points to the healthcare system and workplace as key institutional venues for action.

The relative importance of work-related and non-work-related stressors and perceived social support on global perceived stress in a cross-sectional population-based sample.

BACKGROUND: High levels of perceived stress have a negative bearing on health and well-being, and stress is a major public health issue. According to the Stress Process Model, stressors are socially patterned and combine to produce strain. Despite this, most studies on stress have focused on work-related stressors leaving non-work determinants under-investigated. The aim of the present study was to determine the relative importance of work-related and non-work-related stressors and perceived social support for the overall perceived stress level. METHODS: Self-reported data were drawn from the 2017 population-based health survey "How are you?" conducted in the Central Denmark Region (N = 32,417). Data were linked with data drawn from national administrative registers. Work- and non-work-related stressors assessed included major life events, chronic stressors and daily hassles. Perceived social support was assessed using a single question. Overall perceived stress was assessed by the 10-item Perceived Stress Scale. We conducted dominance analyses based on a multiple linear regression model to determine the most important explanatory variables of overall perceived stress. Analyses were weighted and adjusted. RESULTS: Work- and non-work-related stressors along with perceived social support explained 42.5% of the total variance (R2) in overall perceived stress. The most important explanatory variables were disease, perceived social support and work situation. The stratified analyses produced slightly varying results ("dominance profiles") of perceived stress between subgroups. Work situation was the most important explanatory variable in the employed group. However, adding non-work-related explanatory variables to the analysis tripled the explained variance. CONCLUSIONS: The overall level of perceived stress can be statistically explained by a combination of work- and non-work-related stressors and perceived social support both at population level and in subgroups. The most important explanatory variables of overall perceived stress are disease, perceived social support and work situation. Results indicate that public health strategies aiming to reduce stress should take a comprehensive approach and address a variety of stressor domains rather than focus on a single domain. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency (r. no. 2012-58-0006) and registered in the Central Denmark Region (r. no. 1-16-02-593-16).

Population differences in health-related quality of life between cancer survivors and controls: Does low educational attainment widen the gap?

Aims: This study aimed to compare health-related quality of life (HRQOL) among cancer survivors and controls in the Danish population, with special attention given to the impact of low educational attainment. Comparisons were made at population level and for subgroups stratified by education. Furthermore, comparisons were made for all cancer diagnoses combined and for the 14 most prevalent cancer sites and 'other cancer sites'. Finally, the importance of time since initial diagnosis was examined. Methods: HRQOL was measured using the physical component score (PCS) and mental component score (MCS) of the 12-item Short-Form Health Survey version 2 in a population-based survey. By linking data with the Danish Cancer Registry, 11,166 cancer survivors and 151,117 individuals with no history of cancer were identified. Results: HRQOL was reduced in cancer survivors for all cancers combined and most cancer sites. Differences were found at population level and stratified by educational attainment. PCS was reduced to a similar extent in the three educational groups, whereas MCS was reduced slightly more in the low than in the high educational attainment group. HRQOL increased with time since initial diagnosis during the first years. Conclusions: Cancer survivors had lower HRQOL than controls, and HRQOL was lower in the low than in the high educational attainment group. However, low educational attainment did not widen the gap in HRQOL following a cancer diagnosis. Despite this, the combined effect of low educational attainment and a cancer diagnosis markedly reduced HRQOL in some cancer survivors. The study identified groups of cancer survivors with low HRQOL who may have unmet rehabilitation needs.

Physical Activity as an Effect Modifier of the Association Between Obesity and Venous Thromboembolism: A Danish Population-Based Cohort Study.

PURPOSE: Obesity is an established risk factor for venous thromboembolism (VTE), while studies on physical inactivity and VTE risk show conflicting results. We examined whether physical activity modified the association between obesity and VTE. PATIENTS AND METHODS: We conducted a population-based cohort study by combining data on outcome diagnoses, comorbidities and medication from nationwide registries with self-reported lifestyle data from an extensive Danish lifestyle questionnaire (2001-2015). We computed incidence rates (IRs) and hazard ratios (HRs) of VTE for categories of body mass index (BMI), among the total study population (n=57,523) and for physically active (n=25,387) and inactive individuals (n=30,902) separately. RESULTS: Obesity (BMI ≥30 kg/m2) was as expected associated with increased VTE risk compared with normal weight (HR 1.62, 95% confidence interval (CI): 1.26-2.09). Independent of BMI category, the rate of VTE was higher for inactive than active individuals. Thus, among obese individuals, the IR per 1000 person-years was 2.03 (95% CI: 1.60-2.57) for inactive and 1.44 (95% CI: 0.97-2.15) for active individuals. In contrast, the HR for VTE comparing obese with normal weight individuals were higher for active (HR 2.19, 95% CI: 1.35-3.58) than inactive individuals (HR 1.36, 95% CI: 1.00-1.84). CONCLUSION: Physical activity acts as an effect measure modifier of the association between obesity and VTE. Thus, physical activity reduced the absolute rate of VTE among obese individuals but increased the relative rate of VTE among obese compared with normal weight individuals.

Medication adherence, biological and lifestyle risk factors in patients with myocardial infarction: a ten-year follow-up on socially differentiated cardiac rehabilitation.

Objective: There is strong evidence that medication adherence and lifestyle changes are essential in patients undergoing secondary cardiovascular disease prevention. Cardiac rehabilitation (CR) increases medication adherence and improves lifestyle changes. Patients with cardiac diseases and a low educational level and patients with little social support are less responsive to improve medication adherence and to adapt lifestyle changes. The aim of the present study was to investigate the long-term effects of a socially differentiated CR intervention on medication adherence as well as changes in biological and lifestyle risk factors at two- five- and ten-year follow-up. Design: A prospective cohort study. Setting: The cardiac ward at Aarhus University Hospital, Denmark. Intervention: A socially differentiated CR intervention in addition to the standard CR program. Subjects: Patients admitted with first-episode myocardial infarction between 2000 and 2004, N = 379. Patients were defined as socially vulnerable or non-socially vulnerable according to their educational level and extent of social network. Main outcome measures: Primary outcome was medication adherence to antithrombotics, beta-blockers, statins and angiotensin-converting enzyme inhibitors. Secondary outcomes were biological and lifestyle risk factors defined as; total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, glycated hemoglobin, blood pressure and smoking status. Results: No significant long-term effect of the intervention was found. Conclusions: The results indicate a non-significant effect of the intervention. However, it was found that equality in health was improved in the study population except concerning smoking. General practitioners manage to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status. Key points The socially differentiated intervention did not significantly improve medication adherence or biological and lifestyle risk factors. Despite the non-significant effect of the intervention, equality in health was improved except concerning smoking. General practitioners managed to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.

Expanded cardiac rehabilitation in socially vulnerable patients with myocardial infarction: a 10-year follow-up study focusing on mortality and non-fatal events.

OBJECTIVE: Cardiac rehabilitation (CR) has been shown to reduce cardiovascular risk. A research project performed at a university hospital in Denmark offered an expanded CR intervention to socially vulnerable patients. One-year follow-up showed significant improvements concerning medicine compliance, lipid profile, blood pressure and body mass index when compared with socially vulnerable patients receiving standard CR. The aim of the study was to perform a long-term follow-up on the socially differentiated CR intervention and examine the impact of the intervention on all-cause mortality, cardiovascular mortality, non-fatal recurrent events and major cardiac events (MACE) 10 years after. DESIGN: Prospective cohort study. SETTING: The cardiac ward at a university hospital in Denmark from 2000 to 2004. PARTICIPANTS: 379 patients aged <70 years admitted with first episode myocardial infarction (MI). The patients were defined as socially vulnerable or non-socially vulnerable according to their educational level and their social network. A complete follow-up was achieved. INTERVENTION: A socially differentiated CR intervention. The intervention consisted of standard CR and additionally a longer phase II course, more consultations, telephone follow-up and a better handover to phase III CR in the municipal sector, in general practice and in the patient association. MAIN OUTCOME MEASURES: All-cause mortality, cardiovascular mortality, non-fatal recurrent events and MACE. RESULTS: There was no significant difference in all-cause mortality (OR: 1.29, 95% CI 0.58 to 2,89), cardiovascular mortality (OR: 0.80, 95% CI 0.31 to 2.09), non-fatal recurrent events (OR:1.62, 95% CI 0.67 to 3.92) or MACE (OR: 1.31, 95% CI 0.53 to 2.42) measured at 10-year follow-up when comparing the expanded CR intervention to standard CR. CONCLUSIONS: Despite the significant results of the socially differentiated CR intervention at 1-year follow-up, no long-term effects were seen regarding the main outcome measures at 10-year follow-up. Future research should focus on why it is not possible to lower the mortality and morbidity significantly among socially vulnerable patients admitted with first episode MI.

Does perceived stress increase the risk of atrial fibrillation? A population-based cohort study in Denmark.

BACKGROUND: Psychological stress is associated with increased risk of acute cardiovascular diseases, as myocardial infarction. We recently found a higher risk of atrial fibrillation following an acute stressful life event, but it remains unknown whether this also applies to common and less acute stress exposures. METHODS: We investigated the risk of incident atrial fibrillation in people with high levels of perceived stress by following a population-based cohort of 114,337 participants from the Danish National Health Survey from 2010 to 2014. The survey holds information on lifestyle factors and perceived stress measured by Cohen's 10-item Perceived Stress Scale (PSS). We obtained information on atrial fibrillation, comorbidities and socioeconomic status from Danish nationwide registers. We identified 2172 persons with a first episode of atrial fibrillation during 424,839 person-years of follow-up. The hazard ratio (HR) of atrial fibrillation with 95% confidence interval (CI) was calculated with Cox proportional hazard model. RESULTS: The risk of atrial fibrillation increased with increasing PSS score; persons in the highest perceived stress quintile had 28% (95% CI, 12%-46%) higher risk of atrial fibrillation compared with persons in the lowest perceived stress quintile. However, the association disappeared when adjusting for comorbidities, socioeconomic status and lifestyle factors; HR was 1.01 (95% CI, 0.88-1.16) when comparing persons in the highest and the lowest perceived stress quintile. CONCLUSIONS: This large population-based cohort study did not reveal a higher risk of atrial fibrillation among persons with a high degree of perceived stress after adjustment for participants' baseline characteristics.

Lifestyle, socioeconomic characteristics, and medical history of elderly persons who receive seasonal influenza vaccination in a tax-supported healthcare system.

BACKGROUND: Observational studies on effectiveness of influenza vaccination in the elderly are thought to be biased by healthier lifestyles and higher socioeconomic status among vaccinated vs. unvaccinated persons. We examined this hypothesis in a uniform tax-supported health care system with free-of-charge influenza vaccination to the elderly. METHODS: We conducted a cross-sectional study among Danes aged 65-79years participating in a survey. We compared elderly persons with and without a recent (within six months) influenza vaccination in terms of (i) lifestyle and socioeconomic characteristics obtained from the survey and (ii) health factors including medical history provided by Danish registries. We compared the prevalence of study variables among vaccinated and unvaccinated persons using age- and sex-adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs). RESULTS: Among the 4237 elderly persons completing the survey, 1718 (41%) had received an influenza vaccination. Vaccinated persons had more comorbidity than unvaccinated persons (aPR for high comorbidity level: 1.51 95% CI 1.24-1.84), were less likely to never have smoked (aPR: 0.88, 95% CI 0.80-0.97), and had a higher prevalence of physical inactivity (aPR: 1.08, 95% CI 1.03-1.13). Levels of education and income were similar in the two groups. Vaccinated persons had a higher prevalence of major physical limitations (aPR: 1.40, 95% CI 1.17-1.66) and need for assistance with activities of daily living (aPR: 1.29, 95% CI 1.13-1.47). CONCLUSION: Elderly influenza vaccinated persons were not healthier in terms of lifestyle and burden of disease, did not have a higher socioeconomic status, and were more frail than unvaccinated persons.

A Latent Class Analysis of Multimorbidity and the Relationship to Socio-Demographic Factors and Health-Related Quality of Life. A National Population-Based Study of 162,283 Danish Adults.

OBJECTIVES: To identify patterns of multimorbidity in the general population and examine how these patterns are related to socio-demographic factors and health-related quality of life. STUDY DESIGN AND SETTING: We used latent class analysis to identify subgroups with statistically distinct and clinically meaningful disease patterns in a nationally representative sample of Danish adults (N = 162,283) aged 16+ years. The analysis was based on 15 chronic diseases. RESULTS: Seven classes with different disease patterns were identified: a class with no or only a single chronic condition (59% of the population) labeled "1) Relatively Healthy" and six classes with a very high prevalence of multimorbidity labeled; "2) Hypertension" (14%); "3) Musculoskeletal Disorders" (10%); "4) Headache-Mental Disorders" (7%); "5) Asthma-Allergy" (6%); "6) Complex Cardiometabolic Disorders" (3%); and "7) Complex Respiratory Disorders" (2%). Female gender was associated with an increased likelihood of belonging to any of the six multimorbidity classes except for class 2 (Hypertension). Low educational attainment predicted membership of all of the multimorbidity classes except for class 5 (Asthma-Allergy). Marked differences in health-related quality of life between the seven latent classes were found. Poor health-related quality of life was highly associated with membership of class 6 (Complex Cardiometabolic Disorders) and class 7 (Complex Respiratory Disorders). Despite different disease patterns, these two classes had nearly identical profiles in relation to health-related quality of life. CONCLUSION: The results clearly support that diseases tend to compound and interact, which suggests that a differentiated public health and treatment approach towards multimorbidity is needed.

The Association Between Perceived Stress and Mortality Among People With Multimorbidity: A Prospective Population-Based Cohort Study.

Multimorbidity is common and is associated with poor mental health and high mortality. Nevertheless, no studies have evaluated whether mental health may affect the survival of people with multimorbidity. We investigated the association between perceived stress and mortality in people with multimorbidity by following a population-based cohort of 118,410 participants from the Danish National Health Survey 2010 for up to 4 years. Information on perceived stress and lifestyle was obtained from the survey. We assessed multimorbidity using nationwide register data on 39 conditions and identified 4,229 deaths for the 453,648 person-years at risk. Mortality rates rose with increasing levels of stress in a dose-response relationship (P-trend < 0.0001), independently of multimorbidity status. Mortality hazard ratios (highest stress quintile vs. lowest) were 1.51 (95% confidence interval (CI): 1.25, 1.84) among persons without multimorbidity, 1.39 (95% CI: 1.18, 1.64) among those with 2 or 3 conditions, and 1.43 (95% CI: 1.18, 1.73) among those with 4 or more conditions, when adjusted for disease severities, lifestyle, and socioeconomic status. The numbers of excess deaths associated with high stress were 69 among persons without multimorbidity, 128 among those with 2 or 3 conditions, and 255 among those with 4 or more conditions. Our findings suggested that perceived stress contributes significantly to higher mortality rates in a dose-response pattern, and more stress-associated deaths occurred in people with multimorbidity.

The construct validity of the Perceived Stress Scale.

OBJECTIVE: Stress impacts the quality of life and is associated with increased risk of mental and physical disorders. The Perceived Stress Scale (PSS) is widely used for measuring psychological distress. Although the instrument was originally defined as a single construct, several studies based on classical test theory suggest that a two-dimensional structure is more dominant. We aimed to explore the construct validity and dimensionality of the PSS-10 using modern test theory to determine if the scale is predominantly for a one- or a two-dimensional model. METHODS: The study population consisted of 32,374 citizens who completed the PSS-10 as part of the Danish National Health Survey in 2010. We investigated the construct validity of the PSS-10 by CFA. We examined the scalability by investigating the fit of the data distribution in a unidimensional Rasch model and performing modification of response categories, persons and items. The scale dimensionality was additionally assessed by Mokken and Rasch analysis. RESULTS: The PSS-10 did not fit the Rasch model. Item four indicated the largest misfit, and items four and seven displayed disordered thresholds. Unidimensionality could not be established although the data showed improved fit to the Rasch model for the two dimensions respectively with the positive and negative items. Mokken analysis revealed fit to the unidimensional model, but disordered thresholds were shown for item four. CONCLUSION: Our large population-based study indicated scalability problems in the current version of the PSS-10. The conducted analysis overall revealed better statistical fit for a two-dimensional than a unidimensional model.

Do stress, health behavior, and sleep mediate the association between loneliness and adverse health conditions among older people?

INTRODUCTION: Prior research has established an association between loneliness and a variety of negative health conditions among older people. However, little is known about the mechanisms underlying this association. OBJECTIVE: Building on the Loneliness Model, Hawkley and Cacioppo (2010) identified possible pathways through which loneliness may affect the development of adverse health conditions. The present study was designed to test the pathways proposed by Hawkley and Cacioppo. METHODS: The sample consisted of 8593 elderly ranging from 65 to 102 years of age participating in the 2013 Public Health Survey "How are you?". RESULTS: Findings show that loneliness was significantly associated with cardiovascular disease, diabetes, and migraine. In addition high perceived stress, physical inactivity, daily smoking, and poor sleep mediated the association between loneliness and adverse health conditions. Moreover, findings demonstrate several gender differences in the association between loneliness and various adverse condition and the indirect mechanisms affecting these associations. CONCLUSION: The findings largely support the pathways proposed by Hawkley and Cacioppo.

A National Population Study of the Co-Occurrence of Multiple Long-Term Conditions in People With Multimorbidity, Denmark, 2013.

The objective of this study was to describe the prevalence of pairwise combinations of 17 long-term conditions. Data were obtained from a national, representative population-based study including 162,283 Danish citizens aged 16 years or older. We calculated the prevalence of each long-term condition given the presence of another long-term condition. Compared with the general population, people with angina pectoris had more than twice the odds of having 12 of the 16 other long-term conditions, and inversely, people with cancer, tinnitus, or cataracts did not have notably higher odds for any of the other long-term conditions.

The development in body mass index, overweight and obesity in three regions in Denmark.

BACKGROUND: The prevalence of overweight and obesity has increased markedly the past decades. However, recent studies have indicated that the development differ between different socio-economic groups and different geographic regions. The aim of this study was to assess the development in prevalence of overweight and obesity from 2006/2007 to 2010 by age, gender, socio-economic factors and geographical regions. METHODS: Two cross-sectional surveys in three regions in Denmark (The Capital Region of Denmark, The Central Denmark Region and The North Denmark Region) were performed in 2006/2007 and 2010. A random sample of citizens aged more than or equal to 25 years was invited to participate. The overall response rate was 57.5% (n = 177 076). Data from questionnaire and central registers were included. RESULTS: In 2006/2007, the prevalence of overweight, including obesity, was 54.3% and 36.8% among men and women, respectively. Of the overweight men 12.8% were obese and 11.8% women were obese. The prevalence was highest in the Northern region and among those who were older, had short education, was outside labour market, had low income and residents in rural areas. In 2010, the prevalence of overweight had increased to 56.3% and 39.6% in men and women, respectively (P < 0.0001). However, overweight increased the most in the Northern Region whereas no significant increase in body mass index was found among men in the Capital Region. Among women prevalence of overweight increased but not in those retired or above 60 years, and with high income. CONCLUSION: The prevalence of overweight and obesity was high and increased. The development, however, was heterogenic.

Use of selective serotonin reuptake inhibitors and lifestyle among women of childbearing age: a Danish cross-sectional survey.

OBJECTIVE: To examine the use of selective serotonin reuptake inhibitors (SSRIs) among Danish women of childbearing age according to lifestyle factors. DESIGN: Cross-sectional survey. SETTING: The Central Denmark Region. PARTICIPANTS: 4234 women (71.5% of the invited women) aged 25-44 years who participated in a public health survey in 2006. OUTCOME MEASURES: Prevalence and prevalence ratios (PRs) of current and former SSRI use among women characterised by selected lifestyle factors. We obtained information on SSRI use through linkage to the Aarhus University Prescription Database covering all pharmacies in the region. RESULTS: Of the 4234 women in the study, 161 (3.8%) were current SSRI users, 60 (1.4%) were recent users, 223 (5.3%) were former users and 3790 (89.5%) were never users. Current use of SSRIs was more prevalent in obese women than in non-obese women (PR 1.5, 95% CI 1.0 to 2.3), in current smokers compared with non-current smokers (PR 1.6, 95% CI 1.1 to 2.2), in women who drank more than seven alcoholic drinks weekly compared with women who drank seven or fewer drinks weekly (PR 1.8, 95% CI 1.2 to 2.8) and in women with an unhealthy diet compared with women with a healthy diet (PR 1.7, 95% CI 1.2 to 2.6). Prevalence of former use of SSRIs was similarly increased except in those with an unhealthy diet (PR 1.1, 95% CI 0.8 to 1.7). SSRI use did not differ according to participation in regular physical activity. CONCLUSIONS: Women with an unhealthy lifestyle were about 1.5-fold more likely to be current or former users of SSRIs than those with a healthy lifestyle. These findings may be useful for quantitative assessment of the contribution of lifestyle factors to uncontrolled confounding in studies of SSRI use in pregnancy.

The Danish National Health Survey 2010. Study design and respondent characteristics.

AIMS: In 2010 the five Danish regions and the National Institute of Public Health at the University of Southern Denmark conducted a national representative health survey among the adult population in Denmark. This paper describes the study design and the sample and study population as well as the content of the questionnaire. METHODS: The survey was based on five regional stratified random samples and one national random sample. The samples were mutually exclusive. A total of 298,550 individuals (16 years or older) were invited to participate. Information was collected using a mixed mode approach (paper and web questionnaires). A questionnaire with a minimum of 52 core questions was used in all six subsamples. Calibrated weights were computed in order to take account of the complex survey design and reduce non-response bias. RESULTS: In all, 177,639 individuals completed the questionnaire (59.5%). The response rate varied from 52.3% in the Capital Region of Denmark sample to 65.5% in the North Denmark Region sample. The response rate was particularly low among young men, unmarried people and among individuals with a different ethnic background than Danish. CONCLUSIONS: The survey was a result of extensive national cooperation across sectors, which makes it unique in its field of application, e.g. health surveillance, planning and prioritizing public health initiatives and research. However, the low response rate in some subgroups of the study population can pose problems in generalizing data, and efforts to increase the response rate will be important in the forthcoming surveys.

Socially differentiated cardiac rehabilitation: can we improve referral, attendance and adherence among patients with first myocardial infarction?

AIM: The comprehensive cardiac rehabilitation (CR) programme after myocardial infarction (MI) improves quality of life and results in reduced cardiac mortality and recurrence of MI. Hospitals worldwide face problems with low participation rates in rehabilitation programmes. Inequality in recruitment and participation among low educated and socially vulnerable patients must be addressed to lower inequality in post-MI health. Our aim was to improve referral, attendance, and adherence rates among socially vulnerable patients by systematic screening and by offering a socially differentiated cardiac rehabilitation programme. METHODS: From 1 September 2002 to 31 December 2005, 388 first-incidence MI patients ≤75 years were hospitalised. Register check for newly hospitalised MI patients, screening interview, and systematic referral were conducted by a project nurse. Patients were referred to a standard rehabilitation programme (SRP). If patients were identified as socially vulnerable, they were offered an extended version of the rehabilitation programme (ERP). Excluded patients were offered home visits by a cardiac nurse. Concordance principles were used in the individualised programme elements. Adherence was registered until the 1-year follow up. RESULTS: 86% were referred to the CR. A large share of elderly patients and women were excluded. The attendance and adherence rates were 80% and 71%, respectively among all hospitalised patients. Among referred patients, the attendance rate was 93%. Patients were equally distributed to the SRP and the ERP. No inequality was found in attendance and adherence among referred patients. CONCLUSIONS: It seems possible to overcome unequal referral, attendance, and adherence in cardiac rehabilitation by organisation of systematic screening and social differentiation.

Do immigrants from Turkey, Pakistan and Yugoslavia receive adequate medical treatment with beta-blockers and statins after acute myocardial infarction compared with Danish-born residents? A register-based follow-up study.

PURPOSE: We undertook a study investigating whether immigrants from Turkey, Pakistan and Yugoslavia received adequate medical treatment with beta-blockers and statins after acute myocardial infarction (AMI) when compared with Danish-born residents and explored whether associations between patient origin and medical treatment were mediated by socioeconomic status (SES). METHODS: This register-based follow-up study consisted of individuals >17 years of age, admitted to hospital with AMI between 2001 and 2005 (n=25,443). Danish-born residents were compared with immigrants from Turkey, Pakistan and Yugoslavia. Individuals were identified by civil registration number, and data were obtained through linkage to the national registers of hospitalisations and drug prescriptions. Odds of initiating treatment and hazard ratios (HR) of terminating treatment were estimated. Mediators such as income and employment were included in the models. RESULTS: Pakistanis were less likely than Danish-born residents to initiate treatment with beta-blockers after AMI [odds ratio 0.52; 95% confidence interval (CI) 0.34-0.80]. Immigrants from Turkey (HR 1.36; 95% CI 1.07-1.73) and Pakistan (HR 1.59; 95% CI 1.21-2.08) were more likely to terminate treatment with beta-blockers before being recommended to do so. Estimates did not change markedly when income and education were included in the models. CONCLUSIONS: The results of this study suggest that immigrants from Pakistan and Turkey do not receive adequate medical treatment with beta-blockers after a first AMI compared with Danish-born residents. Mediators such as income and employment may not be sufficient indicators of SES when the effect of patient origin on medical treatment is explored. A lower SES of immigrants, communication problems between doctor and patient and doctors' attitudes towards immigrants may explain ethnic differences in medical treatment after AMI.

Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a population-based survey.

BACKGROUND: Social consequences of disease may be subject to register based follow-up. A Danish database, DREAM, allows weekly follow-up of any public transfer payment. This study aimed to evaluate the feasibility of the register for use in public health research. MATERIAL AND METHODS: The DREAM database includes information on all public transfer payments administered by Danish ministries, municipalities, and Statistics Denmark for all Danish citizens on a weekly basis since 1991. The DREAM database was compared with self-reported information on sources of income in a population survey from 2001 with about 5000 participants. RESULTS: According to DREAM, 80.2% of respondents had received some kind of transfer income since 1991. For the week they filled in the questionnaire, 9.0% had a record of labour-market-related benefit (unemployment benefit, social assistance, wage subsidy), 6.4% a health-related benefit (sickness benefit, vocational rehabilitation allowance, salary from subsidized jobs for persons with limited work capacity, anticipatory pension), 10.1% a voluntary retirement pension, while 74.4% had no record of transfer payment for that week. The predictive value of DREAM was 74.8% for health-related transfer payment and 98.2% for self-support. Among persons with a record of sickness benefit, 52.4% reported no transfer payment. CONCLUSION: The DREAM database is feasible for follow-up of social and economic consequences of disease. Respondents may be unaware of payments transferred by the public authorities to the employer, and in such cases DREAM may be the best source of information. The database is useful for public health research, but may also be useful for socioeconomic analyses of selection bias and dropout from other studies.