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Deding U, Bøggild H, Kaalby L, Hjelmborg J, Kobaek-Larsen M, Thygesen MK, Schelde-Olesen B, Bjørsum-Meyer T, Baatrup G. Socioeconomic differences in discrepancies between expected and experienced discomfort from colonoscopy and colon capsule endoscopy. Heliyon 2024; 10:e34274. [PMID: 39100485 PMCID: PMC11295845 DOI: 10.1016/j.heliyon.2024.e34274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 03/07/2024] [Accepted: 07/07/2024] [Indexed: 08/06/2024] Open
Abstract
Background Social inequalities in colorectal cancer screening participation are evident. Barriers to screening participation include discomfort from diagnostic modalities. We aimed to describe the discomfort experienced from colonoscopy and colon capsule endoscopy (CCE) and investigate the discrepancy between expected and experienced discomfort stratified by socioeconomic status. Methods A randomised controlled trial was conducted offering half of the colorectal cancer screening invitees the choice between CCE and colonoscopy after a positive faecal immunochemical test. This paper includes those who elected to undergo CCE. A positive CCE elicited referral for a therapeutic colonoscopy. Participants reported their discomfort from CCE and from any following colonoscopies in electronically distributed questionnaires. Discomfort was measured using visual analogue scales and compared between socioeconomic subgroups determined by educational level and income. Results The experienced discomfort from CCE and colonoscopy differed significantly between educational levels but not income levels. The bowel preparation contributed the most to the experienced discomfort in both CCE and colonoscopy. The discrepancy between expected and experienced discomfort from colonoscopy increased with increasing educational and income levels. A similar trend was seen in CCE between educational levels but not income levels. Conclusions None of the results indicated a higher discomfort in lower socioeconomic subgroups. Regardless of the investigation modality, the bowel preparation was the main contributor to experienced discomfort. The discrepancy between expected and experienced discomfort did not seem to be larger in lower socioeconomic subgroups, indicating that this is not a major barrier causing inequalities in screening uptake. This is the first study investigating individual discomfort discrepancy in both CCE and colonoscopy, while being able to stratify by socioeconomic status.
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Affiliation(s)
- Ulrik Deding
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
| | - Henrik Bøggild
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Lasse Kaalby
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
| | - Jacob Hjelmborg
- Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark
| | - Morten Kobaek-Larsen
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
| | - Marianne Kirstine Thygesen
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
| | - Benedicte Schelde-Olesen
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
| | - Thomas Bjørsum-Meyer
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
| | - Gunnar Baatrup
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
| | - CareForColon2015 study group
- Department of Clinical Research, University of Southern Denmark, Denmark
- Department of Surgery, Odense University Hospital, Denmark
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark
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Phillipsen S, Weltz LK, Dressler J, Nielsen MK, Rasmussen M, Jorgensen LN, Johnsen AT. Barriers for Participation in the Danish Colorectal Cancer Screening Program: a Qualitative Study. J Gastrointest Cancer 2023; 54:873-881. [PMID: 36301437 DOI: 10.1007/s12029-022-00876-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The participation rate in the Danish National Screening Program for Colorectal Cancer is around 60%. Since early detection of cancer through the colorectal cancer screening program (CRCS) reduces mortality rates, it is important to understand why people do not participate. The aim of this study was therefore to examine in depth why some people do not participate in the Danish CRCS program. METHODS Individual semi-structured interviews were conducted with 18 people who had not participated in the national CRCS program. Data was analyzed using an inductive hermeneutic approach. RESULTS The analysis uncovered three main themes describing barriers to screening: (a) the accountability for ensuring personal health covered the following sub-themes: (i) when invitation is out of sight it is out of mind, (ii) aversion against own stool sample collection, and (iii) the perceived risk of getting colorectal cancer (CRC); (b) attitudes towards the healthcare system and its organization covered the following sub-themes: (i) positivity towards CRCS, (ii) trust in the healthcare system, (iii) lack of internal communication in the healthcare system, and (iv) wish for involvement of the general practitioner (GP); (c) knowledge about disease and screening covered the following sub-themes: (i) knowledge about CRC and CRCS, (ii) wish for information via new channels, and (iii) CRC is rarely something you talk about. CONCLUSION Among the informants included in this study, lack of participation in the CRCS program was not due to an active opt-out, as most informants had intentions of participating. The informants thought it would motivate them to participate if their GP would remind them of the screening program.
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Affiliation(s)
- Sofie Phillipsen
- Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløvs Vej 19.3, DK-5000, Odense, Denmark.
| | - Louise Kongsmark Weltz
- Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløvs Vej 19.3, DK-5000, Odense, Denmark
| | - Jannie Dressler
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Marie Konge Nielsen
- User Perspectives and Community-Based Interventions, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Nursing, University College Absalon, Slagelse, Denmark
| | - Morten Rasmussen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Anna Thit Johnsen
- Institute of Psychology, University of Southern Denmark, Odense, Denmark
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde and Naestved, Denmark
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van de Schootbrugge-Vandermeer HJ, Lansdorp-Vogelaar I, de Jonge L, van Vuuren AJ, Dekker E, Spaander MCW, Ramakers CRB, Nagtegaal ID, van Kemenade FJ, van Leerdam ME, Toes-Zoutendijk E. Socio-demographic and cultural factors related to non-participation in the Dutch colorectal cancer screening programme. Eur J Cancer 2023; 190:112942. [PMID: 37406529 DOI: 10.1016/j.ejca.2023.112942] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/24/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND High participation rates are essential for a screening programme to be beneficial. To reach non-participants in a targeted manner, insight in characteristics of non-participants is needed. We investigated demographic differences between participants and non-participants in the Dutch faecal immunochemical test-based colorectal cancer (CRC) screening programme. METHODS In this population-based cohort study, we included all invitees for CRC screening in 2018 and 2019. Participation status, birth year, and sex were extracted from the Dutch national screening information system and linked to demographic characteristics from Statistics Netherlands, including migration background, level of education, socioeconomic category, household composition, and household income. A multivariable logistic regression was used to assess the association between demographic factors and participation. RESULTS A total of 4,383,861 individuals were invited for CRC screening in 2018 and 2019, of which 3,170,349 (72.3%) participated. Individuals were less likely to participate when they were single and/or living with others (single with other residents versus couple: odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.31-0.38), had a migration background (e.g. Moroccan migrant versus Dutch background: OR 0.43, 95% CI: 0.42-0.44), or had a low income (lowest versus highest quintile: OR 0.45, 95% CI: 0.44-0.45). Although to a lesser extent, non-participation was also significantly associated with being male, being younger, receiving social welfare benefits and having a low level of education. CONCLUSION We found that individuals who were single and/or living with others, immigrants from Morocco or individuals with low income were the least likely to participate in the Dutch CRC screening programme. Targeted interventions are needed to minimise inequities in CRC screening.
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Affiliation(s)
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Lucie de Jonge
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, AMC, Amsterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Christian R B Ramakers
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Folkert J van Kemenade
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Monique E van Leerdam
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Larsen MB, Hedelund M, Flander L, Andersen B. The impact of pre-notifications and reminders on participation in colorectal cancer screening - A randomised controlled trial. Prev Med 2022; 164:107229. [PMID: 36057390 DOI: 10.1016/j.ypmed.2022.107229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/28/2022] [Accepted: 08/28/2022] [Indexed: 11/29/2022]
Abstract
This study aimed to test whether participation in colorectal cancer (CRC) screening can be increased by combining the standard invitation procedure with a pre-notification and/or an extra reminder. In a non-blinded randomised controlled trial nested in a population-based CRC screening programme employing the faecal immunochemical test, Group I received a three-staged invitation procedure (pre-notification, invitation and one reminder), Group II received a three-staged invitation procedure (invitation and two reminders) and Group III received a four-staged invitation procedure (pre-notification, invitation and two reminders). The control group received the invitation and one reminder (usual procedure). A total of 59,041 participants were included in the analyses. Overall participation rates increased from 66.9% in the control group to 69.8% in the four-staged invitation procedure corresponding to an increase in overall participation rate of 2.9% (95% CI: 1.8 to 4.0). In the age group 50-59 years, the four-staged invitation procedure increased the participation rate by 4.0% (95% CI: 2.4 to 5.6). An extra reminder increased participation with 2.7% (95% CI: 1.1; 4.2) for males compared to 1.1% (95% CI: -0.3; 2.5) for females. In conclusion, the four-staged invitation procedure was the most effective invitation procedure indicating that multiple invitation procedures are most effective, especially in the youngest age group. If a three-staged invitation procedure is applied, a second reminder should be preferred over a pre-notification. Trial registration The project was registered at ClinicalTrials.gov on 26 February 2020 and patient enrolment began in August 2020. ClinicalTrials.gov Identifier: NCT04292366.
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Affiliation(s)
- Mette Bach Larsen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Skovlyvej 15, DK-8930 Randers, NO, Denmark.
| | - Mette Hedelund
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Skovlyvej 15, DK-8930 Randers, NO, Denmark
| | - Louisa Flander
- University of Melbourne, School of Population and Global Health, The University of Melbourne, Victoria 3010, Australia
| | - Berit Andersen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Skovlyvej 15, DK-8930 Randers, NO, Denmark; Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, DK-8200 Aarhus N, Denmark
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Caló RDS, Souza RAGD, Alves MR, Lima FCDSD, Galvão ND, Souza BDSND, Aguilar LB. Trends in the incidence of colorectal cancer in Greater Cuiabá, Mato Grosso (Brazil), from 2000 to 2016. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2022; 25:e220013. [PMID: 35766770 DOI: 10.1590/1980-549720220013.supl.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/15/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze the temporal incidence trend of colorectal cancer (CRC), according to sex and age, in the Greater Cuiabá, Mato Grosso, Brazil, from 2000 to 2016. METHODS Ecological time series study, with cases of CRC (C18 to C21) diagnosed from 2000 to 2016, of residents of the Greater Cuiabá (Cuiabá and Várzea Grande), in Mato Grosso. The information on the cases was obtained from the Population-Based Cancer Registry and population data from the Brazilian Institute of Geography and Statistics (IBGE). The rates were adjusted by world population. The age groups considered ranged from 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years, 70 to 79 years and 80 years and older. Joinpoint regression was used to analyze the trend of incidence. RESULTS A total of 1,715 cases of CRC were registered with information on sex and age, with an adjusted rate of 16.4 new cases/100,000 men and 16.1 new cases/100,000 women. Men presented trend of increasing incidence rates in the age group of 70 to 79 years, with increase of 4.0% per year, while women presented trend of increase in the age group 50 to 59 years, with increase of 2.7% per year. CONCLUSION Older men showed a more significant trend towards an increase in the incidence of CRC, but in women this occurred in a younger age group, highlighting the importance of considering age related information in the analyzes of occurrence of the disease in this population.
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Affiliation(s)
- Romero Dos Santos Caló
- Universidade Federal de Mato Grosso, Institute for Collective Health, Postgraduate Program in Collective Health - Cuiabá (MT), Brazil
| | - Rita Adriana Gomes de Souza
- Universidade Federal de Mato Grosso, Institute for Collective Health, Postgraduate Program in Collective Health - Cuiabá (MT), Brazil
| | - Mario Ribeiro Alves
- Universidade Federal de Mato Grosso, Institute for Collective Health, Postgraduate Program in Collective Health - Cuiabá (MT), Brazil
| | | | - Noemi Dreyer Galvão
- Universidade Federal de Mato Grosso, Institute for Collective Health - Cuiabá (MT), Brazil
- Secretaria de Estado de Saúde de Mato Grosso - Cuiabá (MT), Brazil
| | - Bárbara da Silva Nalin de Souza
- Universidade Federal de Mato Grosso, Institute for Collective Health, Postgraduate Program in Collective Health - Cuiabá (MT), Brazil
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Caló RDS, Souza RAGD, Alves MR, Lima FCDSD, Galvão ND, Souza BDSND, Aguilar LB. Tendência da incidência de câncer colorretal na Grande Cuiabá, Mato Grosso (Brasil), de 2000 a 2016. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2022. [DOI: 10.1590/1980-549720220013.supl.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO: Objetivo: Analisar a tendência temporal da incidência do câncer colorretal (CCR) segundo sexo e faixa etária, na Grande Cuiabá, Mato Grosso (Brasil), de 2000 a 2016. Métodos: Estudo ecológico de séries temporais, com casos de CCR (C18 a C21) diagnosticados de 2000 a 2016 em residentes da Grande Cuiabá (Cuiabá e Várzea Grande), em Mato Grosso. As informações dos casos foram provenientes do Registro de Câncer de Base Populacional e os dados populacionais do Instituto Brasileiro de Geografia e Estatística. As taxas foram ajustadas pela população mundial. Consideraram-se as faixas etárias de 30 a 39 anos, 40 a 49 anos, 50 a 59 anos, 60 a 69 anos, 70 a 79 anos e 80 anos ou mais. Para análise da tendência temporal da incidência, empregou-se a regressão por joinpoint. Resultados: Foram registrados 1.715 casos de CCR com informação de sexo e idade, com taxa ajustada de 16,4 casos novos/100 mil homens e 16,1 casos novos/100 mil mulheres. Os homens apresentaram tendência temporal de aumento das taxas de incidência na faixa etária de 70 a 79 anos, com acréscimo de 4,0% ao ano, e as mulheres apresentaram tendência temporal de aumento na faixa etária de 50 a 59 anos, com acréscimo de 2,7% ao ano. Conclusão: Os homens mais velhos apresentaram tendência temporal de aumento da incidência de CCR de forma mais expressiva, porém nas mulheres isso ocorreu em faixa etária mais jovem, ressaltando a importância de considerar a informação sobre a idade nas análises sobre a ocorrência da doença nessa população.
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Affiliation(s)
| | | | | | | | - Noemi Dreyer Galvão
- Universidade Federal de Mato Grosso, Brazil; Secretaria de Estado de Saúde de Mato Grosso, Brazil
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Deding U, Bjørsum-Meyer T, Kaalby L, Kobaek-Larsen M, Thygesen MK, Madsen JB, Kroijer R, Baatrup G. Colon capsule endoscopy in colorectal cancer screening: Interim analyses of randomized controlled trial CareForColon2015. Endosc Int Open 2021; 9:E1712-E1719. [PMID: 34790535 PMCID: PMC8589533 DOI: 10.1055/a-1546-8727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/22/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims The Danish CareForColon2015 trial, launched in 2020 as part of the Danish Colorectal Cancer Screening program, is the largest randomized controlled trial to date on colon capsule endoscopy (CCE). This paper presents the interim analysis with the objective of ensuring the safety of patients in the intervention group and evaluating the clinical performance of the trial's predefined clinical parameters. Patients and methods We evaluated the initial 234 CCEs according to quality, safety, and completion. The participation rates and preference distribution of all individuals invited were analyzed and sample size calculations were adjusted. Results Fecal immunochemical test and diagnostic participation rates were 62.1 % and 91.1 %, respectively. The completion rate for CCEs was 67.9 % and the rate of conclusive investigations was 80.3 %. The polyp detection rate (PDR) was high (73.5 %), only two (0.85 %) technical failures in 234 videos were observed, and six suspected cancers were identified (2.6 %). No major adverse events were recorded. The required number of invitations had been underestimated due to inaccurate assumptions in sample size calculations. Conclusions The trial was efficient and safe in terms of CCE quality and time to diagnostic investigation. Participation rates and PDRs were high. The proportion of suspected cancers was lower than expected and will be followed. The completion rate for CCEs was acceptable but lower than expected and the CCE procedure was reviewed for potential improvements and Resolor was added to the regime. The number of invitations for the intervention group of the trial has been adjusted from 62,107 to 185,153.
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Affiliation(s)
- Ulrik Deding
- Department of Surgery, Odense University Hospital, Svendborg, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Thomas Bjørsum-Meyer
- Department of Surgery, Odense University Hospital, Svendborg, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lasse Kaalby
- Department of Surgery, Odense University Hospital, Svendborg, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Morten Kobaek-Larsen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marianne Kirstine Thygesen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeppe Buur Madsen
- Department of Biochemistry and Immunology, University Hospital Lillebaelt, Vejle, Denmark
| | - Rasmus Kroijer
- Department of Surgery, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Svendborg, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Deding U, Henig AS, Hindersson P, Torp-Pedersen C, Bøggild H. Determinants of non-participation in colon examination following positive stool sample in colorectal cancer screening. Eur J Public Health 2020; 29:1118-1124. [PMID: 31329870 DOI: 10.1093/eurpub/ckz072] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Social inequalities has been shown for participation in colorectal cancer screening and recently in the initial stool sample blood test. If these differences persist at follow-up colon examination after a positive stool test, it would suggest that social inequality in screening may be greater than the inequality observed in initial stool sample blood test. METHODS All data were derived from national registers. Using logistic regression analyses, odds of non-participation for follow-up colon examination were estimated based on age group, educational level, income quartile, immigration status and marital status in men and in women, who had participated in initial stool sample test for blood with a positive result. RESULTS Among 20 849 men and 16 565 women invited for follow-up colonoscopy in the period 2014-15, 10.63 and 11.37%, respectively, did not attend. In men, odds of non-participation were higher in the eldest, those with lower income and lower educational level, in immigrants and in singles. Odds ratio (OR) in males of highest income quartile was 0.54 [95% confidence interval (CI) 0.46; 0.63] compared with lowest income quartile. In women, the differences were not as large. OR in females of highest income quartile was 0.73 (95% CI 0.61; 0.87) compared with lowest income quartile. CONCLUSION Sociodemographic differences in odds of non-participation exist in follow-up colon examination in the Danish colorectal cancer screening. Differences were evident in all subgroups of the male population. The same patterns were seen in women. Social inequalities in participation for follow-up colon examination can increase overall social inequality and consequently, lead to health disparities.
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Affiliation(s)
- Ulrik Deding
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg Øst, Denmark
| | - Anna Sharon Henig
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg Øst, Denmark
| | - Peter Hindersson
- Clinical Biochemistry, Regional Hospital North, Hjørring, Denmark
| | - Christian Torp-Pedersen
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg Øst, Denmark.,Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Bøggild
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg Øst, Denmark.,Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
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