[Quality of life more than five years after breast cancer--secondary publication]. / Livskvalitet mere end fem år efter brystkraeft--sekundaerpublikation.

In this national survey, long-term breast cancer survivors (BCS) (n = 1,316) reported quality of life comparable to data from the general Danish female population, but a significantly higher prevalence of chronic pain (42% versus 32%). Paraesthesia, phantom sensation, allodynia, and swelling of arm/shoulder were also reported, and every fifth woman felt that these sequelae limited her daily activities. Health care utilization indicated chronic morbidity. Relatively young age, short education, and former radiotherapy were risk factors for issues such as pain.

[Practice staff's participation in preventive measures among adult patients in general practice]. / Personalets deltagelse i forebyggelse blandt voksne patienter i almen laegepraksis.

INTRODUCTION: Prevention of lifestyle-related diseases and related complications represent an increasing part of daily work in general practice. In relation to selected doctor and patient characteristics we analyzed 1) the practice staff's current involvement in preventive measures, and 2) the doctors' wishes for increased involvement. MATERIALS AND METHODS: In total, 378 out of 381 general practitioners from ten counties participating in "Audit on prevention in general practice 2004" filled in a two-page questionnaire. RESULTS: Almost all (377/378) had staff employed. More than half of the doctors stated that the staff performed tasks in connection with weight control, vaccination of adults, blood pressure checks, lung function tests, alcohol abuse treatment and dietary counselling. A total of 72% of the doctors wished for greater staff involvement within one or more areas, especially dietary counselling and smoking cessation support. The staff was more frequently involved in the tasks for doctors who had a nurse employed compared with doctors who did not. Except for skin prick tests no connection was found between the staff's participation and the doctor's sex and age, the type and size of the practice, and the extent of the regional lack of doctors. CONCLUSION: Staff in general practice perform many preventive tasks related to the eight common chronic diseases, but most frequently in practices where there is a nurse employed. Although the participating doctors may have a special interest in the topic, there seems to be a basis for further staff involvement in this type of tasks. Further studies should, however, elucidate whether the participation of the staff substitutes the doctor's work to the extent desired and with sufficient quality.

Health-related quality of life in long-term breast cancer survivors: nationwide survey in Denmark.

AIM: To investigate health-related quality of life (HRQOL) in a nationally representative sample of long-term breast cancer survivors (BCS) in Denmark. PARTICIPANTS AND METHODS: An age-stratified random sample of 2,000 female BCS > or = 5 years after primary surgery without recurrence was drawn from the Danish Breast Cancer Cooperative Group register, which is representative regarding long-term BCS in Denmark, and compared with 3,104 women of the nationally representative Danish Health and Morbidity Survey 2000. The Short Form-36 questionnaire assessed HRQOL and its association with BCS' sociodemography, type of surgery, systemic therapy, radiotherapy, time since operation, receptor status, and low/high risk protocol. RESULTS: The response rate was 79%. BCS tended to rate HRQOL better than the general female population. BCS reported significantly less "bodily pain" (P < 0.0001), better "general health" (P < 0.0001), but worse "mental health" (P < 0.0001). Age interacted significantly with four other subscales (P < 0.05): Younger BCS reported worse HRQOL than equally aged women of the general population, while older BCS reported better HRQOL. Poor HRQOL was significantly associated with being single (all subscales: P < 0.05), short education (all subscales: P < 0.05, except "social function"), and high body mass index ("physical function", "role physical": P < 0.05). Breast cancer (low/high risk, receptor status) and treatment did not affect HRQOL. CONCLUSION: HRQOL was similar between BCS and women of the general population. Potential long-term effects of breast cancer (low/high risk, receptor status) and treatment did not seem to impact HRQOL. However, predictors for worse HRQOL in BCS were being single, and having a short education.

Severity of self-reported diseases and symptoms in Denmark.

OBJECTIVE: To estimate and rank the relative severity of self-reported diseases and symptoms in Denmark. METHOD: The 1994 Danish Health and Morbidity Survey collected data from 5,472 Danes older than 16 years of age. Interviews (response frequency: 79%) gave information on diseases and symptoms; a self-administered SF-36 questionnaire (response frequency: 64%) provided information on health-related quality of life. The severity of diseases and symptoms was represented by the health-related quality of life scores that individuals suffering from particular diseases and symptoms obtained on the single dimensions of the SF-36 and on a combined sum of all dimensions. We applied logistic regression to control for the influence of sex, age and socio-economic status on the SF-36 score. We also analysed the interaction between socio-economic status and diseases on the SF-36 score. RESULTS: Females, more frequently than males, reported on all symptoms and all disease groups except injuries. People with relatively low levels of education reported most diseases, especially musculoskeletal and cardiovascular diseases, more frequently than people with higher education. Age-adjusted mean SF-36 scores for all dimensions combined showed that the symptoms of melancholy/depression and breathing difficulties, psychiatric disorders and respiratory diseases scored lowest (i.e. were most often associated with worse health). Females had lower SF-36 combined scores (worse health) than males on all symptoms. We found interaction between socio-economic status and respiratory diseases and musculoskeletal diseases on the SF-36 score. SF-36 scores also indicated significantly worse health among Danes with low education and income levels compared to those with higher education and income. CONCLUSION: In 1994 the Danes most frequently reported musculoskeletal symptoms and diseases. Psychiatric disorders and respiratory diseases were identified as the most severe reported diseases. Due to the interaction between socio-economic status and some diseases, severity estimates should be interpreted with caution or stratified by socio-economic groups.

Social gradient in life expectancy and health expectancy in Denmark.

OBJECTIVES: Health status of a population can be evaluated by health expectancy expressed as average lifetime in various states of health. The purpose of the study was to compare health expectancy in population groups at high, medium and low educational levels. METHODS: Health interview data were combined with life table figures using Sullivan's method. RESULTS: Life expectancy was 4.3 years longer for 30-year-old men with a high educational level than for those with a low level. At age 30, the proportion of expected lifetime in self-rated good health was 67.7%, 76.1% and 82.3% for men with a low, medium and high educational level, respectively. Among women, life expectancy differed by 2.7 years between low and high educational level, and the proportion of expected lifetime in self-rated good health was 62.5% at the low and 80.5% at the high educational level. CONCLUSIONS: Educational level and life expectancy are clearly related. The social gradient in terms of health expectancy is even greater than that in terms of life expectancy.

Patterns of psychotropic medicine use and related diseases across educational groups: national cross-sectional survey.

OBJECTIVE: To analyse whether the use of different groups of psychotropic medicines among educational groups in a general population was congruent with the occurrence of related diseases. METHODS: Data from The Danish Health and Morbidity Survey 2000 were analysed. The survey was conducted by face-to-face interviews with a representative sample of the Danish population aged 16 years and above ( n=16,690). The prevalence of four different types of psychotropic medicine use and related diseases in educational groups was analysed by indirect standardisation. Age and gender standardised prevalence ratios (SPRs) and 95% confidence intervals were calculated based on the total study population. RESULTS: In general, respondents in the two least-educated groups used psychotropic medicines more often and had a higher proportion reporting the related disease than could be expected according to indirect standardisation. The opposite picture appeared for respondents in the two highest educated groups (SPR<100). The overall patterns were similar for all four groups of psychotropic medicine users, although some of the SPRs were not significant. CONCLUSIONS: The results documented an uneven distribution of health problems in the general population. Psychotropic medicine use was congruent with the distribution of related health problems, which means that the least-educated groups in most need of treatment also had the most-frequent medicine use. Expenses incurred by the individual user did not seem to be a barrier to access to medicines, not even for specific groups of medicine ineligible for reimbursement in Denmark.

Identifying a long-term/chronic, non-cancer pain population using a one-dimensional verbal pain rating scale: an epidemiological study.

The usefulness of the verbal pain rating scale (VRS) included in the Short Form 36 (SF-36) in identifying characteristics of long-term pain conditions, was analyzed using data from the 1994 Danish Health and Morbidity Survey. Based on the rating of pain intensity during a 4-week recall period the respondents were categorized into three groups: a high pain group (HPG) consisting of persons reporting moderate to severe pain (VRS 4-6), a low pain group (LPG) who rated their pain as very mild or mild (VRS 2-3), and a control group (CG) with no pain (VRS 1). The investigated sample comprised 3992 persons (HPG=563 persons, LPG=1714, and CG=1715 persons). Older age, educational level (< 10 years of schooling), cohabitation status (divorce/separation), and moderate to severe physical job strain were found to be significant risk factors for reporting high pain intensity (HPG). Only minor differences were observed between the LPG and CG. The proportion of respondents with good perceived health was significantly lower in the HPG compared with LPG and CG. The dominant complaints in the HPG were related to the musculoskeletal system. During a 14-day period prior to the interview persons in the HPG had a mean of 1.19 working days lost due to illness compared with a mean of 0.2 for the LPG and CG. Analyzing the use of medical services during the year before the interview, persons belonging to the HPG had an average number of nine contacts to general practitioners and specialized doctors in the primary sector as compared to six for the LPG and four for the CG. Mean numbers of hospital admissions were 0.29 for the HPG, 0.15 for the LPG and 0.10 for the CG. Mean numbers of in-hospital days were 1.60, 0.80, and 0.43 for the HPG, LPG, and CG, respectively. Our study suggest that one-dimensional pain intensity scoring using a simple VRS-scoring is useful as a screening instrument for identifying persons suffering from pain of a more complex nature. High intensity scores on a pain intensity scale should indicate to the investigator that she/he might be facing a person whose pain complaints and behavior are not only based on a pure biological background, but in whom also severe psychological and social problems might be present.

Use of hormone replacement therapy among Danish nurses at increased risk of osteoporosis.

Observational studies and recent randomized trials have shown that postmenopausal hormone replacement therapy (HRT) may reduce the risk of osteoporotic fractures by about 30 to 40%. In this study we used a log linear graphical model to determine whether women with a known increased risk of osteoporosis were more likely to use HRT than other women and to examine whether women at increased risk modified this risk through their lifestyle. Cox regression analysis was used to analyze if women at risk of osteoporosis used HRT longer than women not at risk. Participants were Danish female nurses who, in 1993, were between 50 and 69 years of age (N=14,865). Data were collected from postal questionnaires. We concluded that nurses with a known family history of osteoporosis more often used HRT than nurses without this risk. No other direct associations were found between biological risk factors and ever use of HRT. The presence of biological risk factors of osteoporosis was not consistently modified by a healthier lifestyle. Nurses with a low body mass index (BMI) with a known family history of osteoporosis continued to use HRT longer than nurses without these risk factors.

Prescription and non-prescription medicine use in Denmark: association with socio-economic position.

OBJECTIVE: To analyse the association among different types of medicine use and different measures of socio-economic position (SEP) in one and the same general population. METHODS: Data from The Danish Health and Morbidity Survey 2000 were analysed. The survey was conducted by face-to-face interviews with a representative sample of the adult Danish population (n=16,690). The associations between prescription and over-the-counter (OTC) medicine use and education, occupation and income were assessed by logistic regression analyses. All analyses were adjusted for age, gender and two measures of health status. RESULTS: This cross-sectional analysis of medicine use in a large representative sample of the Danish population found greater use of prescription medicines among disability pensioners and "others" than in salaried employees. Disability pensioners and self-employed individuals used less OTC medicine than salaried employees. Individuals with low income used more prescription medicines but not more OTC medicines, than those with high income. No major differences were found in prescription medicine use with respect to education, but men within the two middle educational groups tended to use prescription medicine less frequently than both lower and higher educated men. A similar trend was not found for women. OTC medicine use was not associated with education for either gender. CONCLUSIONS: The prevalence of prescription medicine use increases with declining SEP, after adjusting for health status. Such an association does not exist for OTC medicine use. The results show that the least affluent have access to prescription medicine. The difference between prescription and OTC medicine use may be explained by a compensation mechanism.

The Danish National Cohort Study (DANCOS).

This article gives an overview of a nationally representive public health research database in Denmark, the Danish National Cohort Study (DANCOS). DANCOS combines baseline data from health interview surveys with both pre- and post-baseline data from national health registries with date from a re-interview survey. As part of the national health interview survey programme, three nation-wide surveys were conducted in 1986/1987, 1991 and 1994. The samples in the three cohorts consisted of 23,096 adult Danes ages 16 years and older, and 18,296 (79.2%) were personally interviewed on socio-economic status; living conditions; health behaviour; self-rated health; morbidity; utilization of health services; and the consequences of illness and disability. Each Dane is equipped with a unique identification number that allows highly accurate linkage of data in the health surveys and in the national health and administrative registries. All respondents and non-respondents were followed through 2002, a total of 3,796 had died and 249 had emigrated. The specific cause of death for 2,485 people was recorded in the Danish Register of Causes of Death, updated through 1998. For 1978-1977, the Danish National Hospital Register contained information about 16,503 persons who had been hospitalized for any illness or related health problems, accounting for 70,925 hospital admissions. For 1970-1997, the Danish Psychiatric Central Register comprised information on 1691 persons. For 1990-1997, the Danish National Health Service Register recorded 980,043 contacts with general practitioners and specialist physicians. For 1943-1996, the Danish cancer Registry contained information about one or more cancer diseases among 1,432 people. A total of 4,334 people in the 1994 cohort were re-interview in 2000. DANCOS allows for a wide range of analysis in a historical prospective design of determinants of morbidity and mortality, of health care utilization and of the social effects of ill health. DANCOS also allows studies of methodological issues, including analyzing the characteristics of non-respondents.

Measuring well-being rather than the absence of distress symptoms: a comparison of the SF-36 Mental Health subscale and the WHO-Five Well-Being Scale.

The health status questionnaire Short-Form 36 (SF-36) includes subscales measuring both physical health and mental health. Psychometrically, the mental health subscale contains a mixture of mental symptoms and psychological well-being items, among other things, to prevent a ceiling effect when used in general population studies. Three of the mental health well-being items are also included in the WHO-Five well-being scale. In a Danish general population study, the mental health subscale was compared psychometrically with the WHO-Five in order to evaluate the ceiling effect. Tests for unidimensionality were used in the psychometric analyses, and the sensitivity of the scales in differentiating between changes in self-reported health over the past year has been tested. The results of the study on 9,542 respondents showed that, although the WHO-Five and the mental health subscale were found to be unidimensional, the WHO-Five had a significantly lower ceiling effect than the mental health subscale. The analysis identified the three depression symptoms in the mental health subscale as responsible for the ceiling effect. The WHO-Five was also found to be significantly superior to the mental health subscale in terms of its sensitivity in differentiating between those persons whose health had deteriorated over the past year and those whose health had not. In conclusion, the WHO-Five, which measures psychological well-being, reflects aspects other than just the absence of depressive symptoms.

Reducing social inequalities in health: evidence, policy, and practice.

Many policy documents have expressed concerns and intentions for action regarding inequity in health. However, the evidence on how to establish effective and acceptable interventions is rather scarce. During an international conference in Copenhagen September 2000 organised by the City of Copenhagen and the Danish Ministry of Health the present evidence was presented and possible policy measures and intervention strategies were discussed. This special issue of the Scandinavian Journal of Public Health includes selected papers and presentations from the conference. Four main arenas for interventions were outlined: the workplace; healthcare services; local communities and families; and urban development. Public health will have to move out of the present reactive position to say what its contribution is to shaping the society of the future with less inequity in health. The papers show that a number of theories, concepts, and tools are available, but also that we still have much to learn and do. At the end of the conference a final declaration on reducing social inequalities was endorsed outlining important general themes that have universal relevance for action.

Analysing changes of health inequalities in the Nordic welfare states.

This study examined changes over time in relative health inequalities among men and women in four Nordic countries, Denmark, Finland, Norway and Sweden. A serious economic recession burst out in the early 1990s particularly in Finland and Sweden. We ask whether this adverse social structural'development influenced health inequalities by employment status and educational attainment, i.e. whether the trends in health inequalities were similar or dissimilar between the Nordic countries. The data derived from comparable interview surveys carried out in 1986/87 and 1994/95 in the four countries. Limiting long-standing illness and perceived health were analysed by age, gender, employment status and educational attainment. First, age-adjusted overall prevalence percentages were calculated. Second, changes in the magnitude of relative health inequalities were studied using logistic regression analysis. Within each country the prevalence of ill-health remained at a similar level, with Finns having the poorest health. Analysing all countries together health inequalities by employment status and education showed no major changes. There were slightly different tendencies among men and women in inequalities by both health indicators, although these did not reach statistical significance. Among men there was a suggestion of narrowing health inequalities, whereas among women such a suggestion could not be discerned. Looking at particular countries some small changes in men's as well as women's health inequalities could be found. Over a period of deep economic recession and a large increase in unemployment, particularly in Finland and Sweden, health inequalities by employment status and education remained broadly unchanged in all Nordic countries. Thus, during this fairly short period health inequalities in these countries were not strongly influenced by changes in other structural inequalities, in particular labour market inequalities. Institutional arrangements in the Nordic welfare states, including social benefits and services, were cut during the recession but nevertheless broadly remained, and are likely to have buffered against the structural pressures towards widening health inequalities.