Unravelling networks in local public health policymaking in three European countries - a systems analysis

BACKGROUND

Facilitating and enhancing interaction between stakeholders involved in the policymaking process to stimulate collaboration and use of evidence, is important to foster the development of effective Health Enhancing Physical Activity (HEPA) policies. Performing an analysis of real-world policymaking processes will help reveal the complexity of a network of stakeholders. Therefore, the main objectives were to unravel the stakeholder network in the policy process by conducting three systems analyses, and to increase insight into the similarities and differences in the policy processes of these European country cases.

METHODS

A systems analysis of the local HEPA policymaking process was performed in three European countries involved in the 'REsearch into POlicy to enhance Physical Activity' (REPOPA) project, resulting in three schematic models showing the main stakeholders and their relationships. The models were used to compare the systems, focusing on implications with respect to collaboration and use of evidence in local HEPA policymaking. Policy documents and relevant webpages were examined and main stakeholders were interviewed.

RESULTS

The systems analysis in each country identified the main stakeholders involved and their position and relations in the policymaking process. The Netherlands and Denmark were the most similar and both differed most from Romania, especially at the level of accountability of the local public authorities for local HEPA policymaking. The categories of driving forces underlying the relations between stakeholders were formal relations, informal interaction and knowledge exchange.

CONCLUSIONS

A systems analysis providing detailed descriptions of positions and relations in the stakeholder network in local level HEPA policymaking is rather unique in this area. The analyses are useful when a need arises for increased interaction, collaboration and use of knowledge between stakeholders in the local HEPA network, as they provide an overview of the stakeholders involved and their mutual relations. This information can be an important starting point to enhance the uptake of evidence and build more effective public health policies.

Discounts on fruit and vegetables combined with a space management intervention increased sales in supermarkets

BACKGROUND/OBJECTIVES

To examine the effects of two interventions on consumer purchases of fruits and vegetables (F&V) on the Danish island of Bornholm: a 20% discount on F&V combined with improved shelf-space allocation, and improved shelf-space allocation alone.

SUBJECTS/METHODS

A space management intervention to promote F&V sales was performed in two large discount supermarkets on Bornholm in Denmark for 3 months (September-November 2012). In addition, a 20% discount on F&V was introduced for 3 months in one of the supermarkets ('space + price'). The effect was evaluated using sales data from the two intervention supermarkets and three control supermarkets from the same supermarket chain but in Odsherred, Denmark (control area). Both the effect on sales of fresh F&V and potential unhealthy substitution effects were evaluated using multi-level regression analyses.

RESULTS

During the price intervention period, the index number for sales of fresh vegetables increased by 22.2% (P=0.001) in the 'space + price' intervention supermarket compared with the control supermarkets. Furthermore, the index number for the sale of organic fresh fruit and vegetables increased by 12.1% (P=0.04) and the sale of the total amount of fruit and vegetables (fresh, frozen, dried and canned) increased by 15.3% (P=0.01) compared with the control supermarkets. In the 'space only' intervention supermarket no significant increase in the sale of fruit and vegetables was found. No unhealthy substitution effects were found.

CONCLUSIONS

In conclusion, a 20% price reduction on F&V significantly increased sales of F&V. The effect was most pronounced on vegetables and no negative/unhealthy substitution effects were found.

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.

SOS2 and ACP1 Loci Identified through Large-Scale Exome Chip Analysis Regulate Kidney Development and Function

Genome-wide association studies have identified >50 common variants associated with kidney function, but these variants do not fully explain the variation in eGFR. We performed a two-stage meta-analysis of associations between genotypes from the Illumina exome array and eGFR on the basis of serum creatinine (eGFRcrea) among participants of European ancestry from the CKDGen Consortium (n_Stage1: 111,666; n_Stage2: 48,343). In single-variant analyses, we identified single nucleotide polymorphisms at seven new loci associated with eGFRcrea (PPM1J, EDEM3, ACP1, SPEG, EYA4, CYP1A1, and ATXN2L; P_Stage1<3.7×10^-7), of which most were common and annotated as nonsynonymous variants. Gene-based analysis identified associations of functional rare variants in three genes with eGFRcrea, including a novel association with the SOS Ras/Rho guanine nucleotide exchange factor 2 gene, SOS2 (P=5.4×10^-8 by sequence kernel association test). Experimental follow-up in zebrafish embryos revealed changes in glomerular gene expression and renal tubule morphology in the embryonic kidney of acp1- and sos2-knockdowns. These developmental abnormalities associated with altered blood clearance rate and heightened prevalence of edema. This study expands the number of loci associated with kidney function and identifies novel genes with potential roles in kidney formation.

Temporal changes in sugar-sweetened soft drink intake and variation across municipalities in the Capital Region of Denmark

We aimed to examine the changes in sugar-sweetened soft drink intake across the Capital Region of Denmark from 2007 to 2013 and to examine the association between intake and neighbourhood socioeconomic status. The study included data from three health surveys in 2007 (n = 30,426), 2010 (n = 42,218) and 2013 (n = 34,330) in the Capital Region of Denmark. Frequency of soft drink intake was derived from questionnaires among residents aged 25-79 years and linked with information from central registers. Municipality social groups (MSG) 1-4 of decreasing affluence were defined as a composite measure. Logistic regression analyses were conducted for individuals with an appropriate soft drink intake (< once/week) and for individuals with a frequent soft drink intake (≥ 3 times/week). The proportion of individuals reporting an appropriate soft drink intake increased by 71% during 2007-2013 (p < 0.0001). A corresponding decrease was found in the proportion of individuals reporting a frequent soft drink intake. Compared to MSG 1, odds of an appropriate soft drink intake were significantly lower in MSG 3-4: OR = 0.87 (95%CI 0.83-0.91) and OR = 0.89 (95%CI 0.85-0.92), respectively. Compared to MSG 1, odds of a frequent soft drink intake were significantly higher in MSG 3-4: OR = 1.24 (95%CI 1.63-1.31) and 1.17 (95%CI 1.10-1.25), respectively. A significant interaction between MSG and educational level was found among individuals reporting a frequent soft drink intake (p = 0.02). The results show an encouraging reduction in frequency of soft drink intake among capital residents in the period of 2007-2013. A social gradient was observed in soft drink intake across MSG.

Substituting sugar confectionery with fruit and healthy snacks at checkout - a win-win strategy for consumers and food stores? a study on consumer attitudes and sales effects of a healthy supermarket intervention

Background

The widespread use of in-store marketing strategies to induce unhealthy impulsive purchases has implications for shopping experience, food choice and possibly adverse health outcomes. The aim of this study was to examine consumer attitudes and evaluate sales effects of a healthy checkout supermarket intervention. The study was part of Project Sundhed & Lokalsamfund (Project SoL); a Danish participatory community-based health promotion intervention.

Methods

Consumer attitudes towards unhealthy snack exposure in supermarkets were examined in a qualitative pre-intervention study (29 short in-store interviews, 11 semi-structured interviews and three focus group interviews). Findings were presented to food retailers and informed the decision to test a healthy checkout intervention. Sugar confectionery at one checkout counter was substituted with fruit and healthy snacking items in four stores for 4 weeks. The intervention was evaluated by 48 short exit interviews on consumer perceptions of the intervention and by linear mixed model analyses of supermarket sales data from the intervention area and a matched control area.

Results

The qualitative pre-intervention study identified consumer concern and annoyance with placement and promotion of unhealthy snacks in local stores. Store managers were willing to respond to local consumer concern and a healthy checkout intervention was therefore implemented. Exit interviews found positive attitudes towards the intervention, while intervention awareness was modest. Most participants believed that the intervention could help other consumers make healthier choices, while fewer expected to be influenced by the intervention themselves. Statistical analyses suggested an intervention effect on sales of carrot snack packs when compared with sales before the intervention in Bornholm control stores (P < 0.05). No significant intervention effect on sales of other intervention items or sugar confectionery was found.

Conclusions

The present study finds that the healthy checkout intervention was positively evaluated by consumers and provided a ‘responsible’ branding opportunity for supermarkets, thus representing a win-win strategy for store managers and consumers in the short term. However, the intervention was too modest to draw conclusions on long-term sales and health implications of this initiative. More research is needed to assess whether retailer-researcher collaborations on health promotion can be a winning strategy for public health.

Mental health associations with eczema, asthma and hay fever in children: a cross-sectional survey

OBJECTIVE

This study aimed to examine the association of eczema, asthma and hay fever with mental health in a general child population and to assess the influence of parental socioeconomic position on these associations.

METHODS

We conducted a cross-sectional health survey of children aged 3, 6, 11 and 15 years in the City of Copenhagen, Denmark. Individual questionnaire data on eczema, asthma, and hay fever and mental health problems assessed using the Strengths and Difficulties Questionnaire (SDQ) was linked to register data on demographics and parental socioeconomic position. 9215 (47.9%) children were included in the analyses.

RESULTS

Linear regression analyses showed that children with current eczema symptoms had higher SDQ scores (mean difference, 95% CI) of emotional problems (0.26, 0.12 to 0.39), conduct problems (0.19, 0.09 to 0.29) and hyperactivity problems (0.32, 0.16 to 0.48); children with current asthma symptoms had higher SDQ scores of emotional problems (0.45, 0.32 to 0.58), conduct problems (0.28, 0.18 to 0.38) and hyperactivity problems (0.52, 0.35 to 0.69); and children with current hay fever symptoms had higher SDQ scores of emotional problems (0.57, 0.42 to 0.72), conduct problems (0.22, 0.11 to 0.33), hyperactivity problems (0.44, 0.26 to 0.61) and peer problems (0.14, 0.01 to 0.26), compared with children without current symptoms of the relevant disease. For most associations, parental socioeconomic position did not modify the effect.

CONCLUSIONS

Children with eczema, asthma or hay fever had more emotional, conduct and hyperactivity problems, but not peer problems, compared with children without these diseases. Atopic diseases added equally to the burden of mental health problems independent of socioeconomic position.

Effect of general health screening and lifestyle counselling on incidence of diabetes in general population: Inter99 randomised trial

We aimed to examine the effect of a large population-based multifactorial screening and lifestyle intervention programme on 10-year incidence of diabetes. In a randomised trial of the general Danish population initiated in 1999-2001 59,616 men and women aged 30-60years were assigned to a five year screening and lifestyle counselling programme (n=11,629) or control group (n=47,987) and followed for ten years in nationwide registers. Intention to treat was applied and risk of diabetes was modeled by Cox regression and expressed as hazard ratios (HRs). We found that 1692 individuals had diabetes at baseline. Among 57,924 individuals without diabetes at baseline, 1267 emigrated, 2593 died and 3369 (Intervention group=684, Control group=2685) developed diabetes. We saw no significant difference in diabetes incidence between the groups after 10-year follow-up (Grey's test: p=0.22). In the first year of follow-up, incidence of diabetes was significantly higher in the intervention group than the control group (HR=1.68, 95%CI 1.29 to 2.29). We observed no difference in incidence of diabetes between the groups in the follow-up intervals from 1 to 6years or after 6-10years (HR=0.94, 0.83 to 1.06; HR=1.03, 0.91 to 1.17). Inviting the general population to participate in a repeated screening and lifestyle counselling programme over five years did not result in lower incidence of diabetes after 10years of follow-up. As expected, significantly more individuals were diagnosed with diabetes in the intervention group during the first year, but this was not followed by a decrease in the following years.

TRIALS REGISTRATION

Clinical trials NCT00289237.

Health service use among children with and without eczema, asthma, and hay fever

BACKGROUND

Atopic diseases, for example, eczema, asthma, and hay fever, are among the most common chronic diseases of childhood. Knowledge on health service use among children with atopic disease is limited. This study aimed to investigate the total use and costs of health services for children with and without eczema, asthma, and hay fever in a Danish general population.

METHODS

We conducted a health survey with four complete birth cohorts from the City of Copenhagen. Individual questionnaire data on eczema, asthma, and hay fever for children aged 3, 6, 11, and 15 years were linked to register information on use and costs of health services and prescribed medication and parental education. In total 9,720 children participated (50.5%).

RESULTS

We found increased health service use (number of additional consultations per year [95% confidence interval]) among children with current eczema symptoms (1.77 [1.29-2.26]), current asthma symptoms (2.53 [2.08-2.98]), and current hay fever symptoms (1.21 [0.74-1.67]), compared with children without these symptoms. We also found increased use of prescribed medication and most subtypes of health services. Current asthma symptoms and current eczema symptoms, but not current hay fever symptoms, increased the health service costs with at least €300 per year per child.

CONCLUSION

Children with eczema, asthma, and hay fever used health services and prescribed medication more than children without these diseases.

Catalog of 199 register-based definitions of chronic conditions

INTRODUCTION

The aim of the current study was to present and discuss a broad range of register-based definitions of chronic conditions for use in register research, as well as the challenges and pitfalls when defining chronic conditions by the use of registers.

MATERIALS AND METHODS

The definitions were defined based on information from nationwide Danish public healthcare registers. Medical and epidemiological specialists identified and grouped relevant diagnosis codes that covered chronic conditions, using the International Classification System version 10 (ICD-10). Where relevant, prescription and other healthcare data were also used to define the chronic conditions.

RESULTS

We identified 199 chronic conditions and subgroups, which were divided into four groups according to a medical judgment of the expected duration of the conditions, as follows. Category I: Stationary to progressive conditions (maximum register inclusion time of diagnosis since the start of the register in 1994). Category II: Stationary to diminishing conditions (10 years of register inclusion after time of diagnosis). Category III: Diminishing conditions (5 years of register inclusion after time of diagnosis). Category IV: Borderline conditions (2 years of register inclusion time following diagnosis). The conditions were primarily defined using hospital discharge diagnoses; however, for 35 conditions, including common conditions such as diabetes, chronic obstructive lung disease and allergy, more complex definitions were proposed based on record linkage between multiple registers, including registers of prescribed drugs and use of general practitioners' services. CONCLUSIONS THIS STUDY PROVIDED A CATALOG OF REGISTER-BASED DEFINITIONS FOR CHRONIC CONDITIONS FOR USE IN HEALTHCARE PLANNING AND RESEARCH, WHICH IS, TO THE AUTHORS' KNOWLEDGE, THE LARGEST CURRENTLY COMPILED IN A SINGLE STUDY.

Functional and genetic epidemiological characterisation of the FFAR4 (GPR120) p.R270H variant in the Danish population

BACKGROUND

p.R270H (rs116454156) in the long chain fatty acid 7TM receptor FFAR4 (GPR120) which results in impaired Gαq (Gq) coupled signalling, has been associated with obesity. We aimed to extend the functional in vitro analyses of p.R270H and to investigate the association with obesity and glucose-related traits in the Danish population.

METHODS

Surface expression, Gq and Gi coupled signalling as well as β-arrestin recruitment were examined in vitro. p.R270H was genotyped using the exome chip array in 11 479 Danish adult individuals. Of these 4391 were obese and 4415 were normal weight. Association with quantitative metabolic traits comprised 8720 non-diabetic individuals.

RESULTS

p.R270H showed reduced surface expression of FFAR4. Ligand-independent activity was eliminated and strongly impaired through the Gq and Gi signalling pathways, respectively. The ligand-induced maximal signalling efficacy of p.R270H was reduced only through the Gq pathway. The p.R270H variant did not affect β-arrestin recruitment. p.R270H was not associated with increased risk of obesity nor increased fasting plasma glucose levels in the Danish study populations. Nor was it associated with these two traits in the European Network for Genetic and Genomic Epidemiology consortium data (N=34 901-71 175; p>0.70). It was also not associated with waist-hip ratio, glucose metabolism during an oral glucose tolerance test, lipid levels or with markers of adiposity (leptin, adiponectin), inflammation (high-sensitive C reactive protein; hs-CRP) and liver function (alanine aminotransferase) in the Danish population (p>0.05).

CONCLUSIONS

We demonstrate that p.R270H of FFAR4 impairs Gq and Gi signalling of FFAR4 in vitro; however, this impaired signalling for p.R270H does not translate into associations with human metabolic phenotypes in the investigated populations.

The association between accessibility of local convenience stores and unhealthy diet

BACKGROUND

High accessibility of unhealthy food stores may contribute to a poor dietary quality. Research on the link between neighbourhood food environment and consumption is limited, especially in a European context. The objective of this study was to examine the relationship between convenience stores (CS) and dietary quality within the Capital Region of Denmark.

METHOD

Cross-sectional study of the geographic food environment in the Capital Region of Denmark based on 47 623 subjects (age 16+ years) with complete information on retail food environment and dietary quality. A categorization procedure to identify CS from a government list of inspected food stores (the Smiley register) was developed. Using GIS network analyses, density of CS within 0.25 km and 0.5 km network buffers from residency was calculated for participants in metropolitan and non-metropolitan areas, respectively. Information on dietary intake and confounders is derived from a questionnaire survey. Multi-level analyses were performed, adjusting for age, sex, individual socio-economic factors and area socio-economic status.

RESULTS

In the non-metropolitan population, the odds of having an unhealthy diet increased significantly (P < 0.0001) with increased density of CS. Compared to individuals who did not have a CS within 0.5 km from their home, the odds ratios were 1.20 (95% CI: 1.09-1.33) and 1.37 (95% CI: 1.19-1.57) for individuals having 1 or ≥2 CS, respectively. In the fully adjusted model, the overall association remained significant (P = 0.015) and odds ratios diminished to 1.14 (1.02-1.27) and 1.18 (1.01-1.38).

CONCLUSION

High accessibility of CS in neighbourhoods is associated with less healthy dietary habits among residents.

What is wrong with non-respondents? Alcohol-, drug- and smoking-related mortality and morbidity in a 12-year follow-up study of respondents and non-respondents in the Danish Health and Morbidity Survey

AIM

Response rates in health surveys have diminished over the last two decades, making it difficult to obtain reliable information on health and health-related risk factors in different population groups. This study compared cause-specific mortality and morbidity among survey respondents and different types of non-respondents to estimate alcohol-, drug- and smoking-related mortality and morbidity among non-respondents.

DESIGN

Prospective follow-up study of respondents and non-respondents in two cross-sectional health surveys.

SETTING

Denmark.

PARTICIPANTS

A total sample of 39 540 Danish citizens aged 16 years or older.

MEASUREMENTS

Register-based information on cause-specific mortality and morbidity at the individual level was obtained for respondents (n = 28 072) and different types of non-respondents (refusals n = 8954; illness/disabled n = 731, uncontactable n = 1593). Cox proportional hazards models were used to examine differences in alcohol-, drug- and smoking-related mortality and morbidity, respectively, in a 12-year follow-up period.

FINDINGS

Overall, non-response was associated with a significantly increased hazard ratio (HR) of 1.56 [95% confidence interval (CI) = 1.36-1.78] for alcohol-related morbidity, 1.88 (95% CI = 1.38-2.57) for alcohol-related mortality, 1.55 (95% CI = 1.27-1.88) for drug-related morbidity, 3.04 (95% CI = 1.57-5.89) for drug-related mortality and 1.15 (95% CI = 1.03-1.29) for smoking-related morbidity. The hazard ratio for smoking-related mortality also tended to be higher among non-respondents compared with respondents, although no significant association was evident (HR = 1.14; 95% CI = 0.95-1.36). Uncontactable and ill/disabled non-respondents generally had a higher hazard ratio of alcohol-, drug- and smoking-related mortality and morbidity compared with refusal non-respondents.

CONCLUSION

Health survey non-respondents in Denmark have an increased hazard ratio of alcohol-, drug- and smoking-related mortality and morbidity compared with respondents, which may indicate more unfavourable health behaviours among non-respondents.

Prescription pain medications and chronic headache in Denmark: implications for preventing medication overuse

PURPOSE

The aim of the present paper is to study which prescription pain medications are most commonly dispensed to people with chronic headache (CH), particularly those with medication-overuse headache (MOH).

METHODS

This cross-sectional study analysed prescription pain medications dispensed within 1 year to 68,518 respondents of a national health survey. Participants with headache ≥ 15 days per month for 3 months were classified as having CH. Those with CH and over-the-counter analgesic use ≥ 15 days per month or purchase of ≥ 20 or ≥ 30 defined daily doses (DDDs) of prescription pain medication per month (depending on the drug) were classified as having MOH. Associations between CH and other chronic pain conditions were analysed by logistic regression.

RESULTS

Among those with CH (adjusted prevalence 3.3%, CI 3.2-3.5%), pain medications most commonly dispensed were paracetamol, tramadol, ibuprofen and codeine. CH was associated with osteoarthritis, back pain, and rheumatoid arthritis. Among those with MOH, 32.4% were dispensed an opioid at least once within 1 year. Only 5.1% of people with CH were dispensed triptans.

CONCLUSIONS

High prevalence of opioid use among people with CH may be due to inappropriate headache treatment or development of MOH among those treated for other pain conditions. While there were cases of triptan overuse, triptans remain underutilized among those with CH, suggesting that migraine may be under-recognized and inappropriately treated, leading to overuse of other medications. Education of physicians on appropriate headache management is essential for MOH prevention. There is a need to increase universal awareness about MOH as an adverse effect of long-term analgesic use.

Medication overuse, healthy lifestyle behaviour and stress in chronic headache: Results from a population-based representative survey

Aim

This cross-sectional study investigated associations between chronic headache (CH) with and without medication overuse, healthy lifestyle behaviour, and stress.

Methods

Questionnaires were sent to 129,150 adults. Those with headache ≥15 days per month for three months were classified as having CH then further described as having medication-overuse headache (MOH) or CH without medication overuse. Associations between headache and daily smoking, physical inactivity, obesity, excessive drinking, illicit drug use, and high stress were analysed by logistic regression.

Results

CH with and without medication overuse (prevalence 1.8% and 1.6%, respectively) had strong, graded associations with stress. Associations with daily smoking, physical inactivity, and obesity were significant only for MOH. Odds for MOH were highest among people who had all three factors compared to those who had none (OR 2.8 in women and 5.1 in men). High stress plus any of these three factors had synergistic effects in MOH but not clearly in those who had CH without overuse. Associations between CH subtypes and excessive drinking or illicit drug use were not statistically significant.

Conclusion

Results suggest strong links between healthy lifestyle behaviour and stress in MOH. Stress reduction and promoting healthy behaviour are highly relevant in MOH management.