Evaluation of competence in ultrasound-guided procedures-a generic assessment tool developed through the Delphi method

OBJECTIVES

To develop a generic and objective tool for assessing competence in percutaneous ultrasound-guided procedures.

METHODS

Interventional ultrasound experts from the Nordic countries were invited to participate in a three-round Delphi process. A steering committee was formed to manage the process. In round 1, the experts were asked to suggest all aspects to consider when assessing competence in US-guided procedures. Suggestions were analyzed and condensed into assessment items. In round 2, the expert panel rated these items on a 1-5 scale and suggested new items. Items with a mean rating of ≤ 3.5 were excluded. In round 3, the expert panel rated the list items and suggested changes to the items.

RESULTS

Twenty-five experts were invited, and response rates in the three rounds were 68% (17 out of 25), 100% (17 out of 17), and 100% (17 out of 17). The three-round Delphi process resulted in a 12-item assessment tool, using a five-point rating scale. The final assessment tool evaluates pre-procedural planning, US technique, procedural technique, patient safety, communication, and teamwork.

CONCLUSIONS

Expert consensus was achieved on a generic tool for assessment of competence in percutaneous ultrasound-guided procedures-the Interventional Ultrasound Skills Evaluation (IUSE). This is the initial step in ensuring a valid and reliable method for assessment of interventional US skill.

KEY POINTS

• Through a Delphi process, expert consensus was achieved on the content of an assessment tool for percutaneous ultrasound-guided procedures-the Interventional Ultrasound Skills Evaluation (IUSE) tool. • The IUSE tool is comprehensive and covers pre-procedural planning, US technique, procedural technique, patient safety, communication, and teamwork. • This is an important step in ensuring valid and reliable assessment of interventional US skills.

Training and assessment of competence in resuscitative endovascular balloon occlusion of the aorta (REBOA) - a systematic review

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving but high-risk emergency procedure in patients with haemorrhagic shock. Lack of physicians with competence in the procedure is a barrier to implementation of REBOA. It is currently unclear how training and assessment of competence should be done.

OBJECTIVES

To report and evaluate research in training and assessment of competence in REBOA and femoral arterial access with the aim to investigate the effect of simulation-based training in the procedure and to provide suggestions for the future design of training programs and assessment tools.

METHODS

Following PRISMA guidelines, PubMed, Embase, and Cochrane Library databases were searched for studies on training or assessment of competence in REBOA and femoral arterial access. Bias assessment was done using the Medical Education Research Study Quality Instrument. Evidence level was assessed using GRADE.

RESULTS

Sixteen studies were included, six of them published as abstracts. Full-text studies included 189 trainees ranging in experience level from military medics to surgical specialists. Outcome measures were heterogenous; the most used were rater checklists, knowledge testing, and procedure time. All studies confirmed an effect of training of REBOA on procedural competence in a simulation setting but had a high degree of bias. No study developed or used an assessment tool supported by validity evidence and no study investigated mid and long-term outcomes.

CONCLUSION

Simulation-based training of REBOA improves skills, however, the evidence level is very low and data cannot answer important questions on effect size, skill transfer and retention, and optimal course design. To advance research and training programmes, an assessment tool supported by validity evidence with broad applicability is needed.

Renal trauma: a 6-year retrospective review from a level 1 trauma center in Denmark

Background: Management of renal trauma injuries is shifting towards more conservative approaches in hemodynamically stable adult patients, even for high grade and/or penetrating trauma. The objective of this study was to analyze the patterns of injury, management and complications in renal trauma patients at a Danish university hospital with a level 1 trauma center.Method: Patients diagnosed with renal trauma at Rigshospitalet, Copenhagen, Denmark, between January 2010 and December 2015 were identified retrospectively by the ICD-10 code. Data were collected from electronic patient records. Imaging was classified by radiologists.Results: Out of 107 patients identified, blunt injuries comprised 93%. Median age was 28. The distribution of injury grade according to AAST was 20% grade I, 4% grade II, 33% grade III, 33% grade IV and 10% grade V. All patients with grade I-III were managed conservatively. Two patients were treated with angioembolization (1 with grade IV and 1 with grade V). Five patients with grade IV were treated with an internal ureteral stent and one patient with grade IV blunt trauma had an emergency nephrectomy performed. Overall complication rate was 7%. No patient died due to their renal injury. Renal function was normal in all patients at discharge, assessed by eGFR measurement. Of the 50% of patients who were followed up with a renography, none developed obstruction due to the renal trauma.Conclusion: The vast majority of renal injuries were due to blunt trauma. Hemodynamically stable patients, even with penetrating and/or high-grade blunt trauma, were managed non-operatively and there was a low rate of complications.

Simulation-Based Training of Ultrasound-Guided Procedures in Radiology - A Systematic Review

PURPOSE

 To perform a systematic review of the effect of simulation-based training (SBT) of percutaneous abdominal and thoracic ultrasound-guided procedures and to assess the transfer of procedural competence to a clinical context.

MATERIALS AND METHODS

 This systematic review was conducted in accordance with the PRISMA statement. Pubmed, Embase, Web of Science, and the Cochrane Library were searched for studies assessing procedural competence after SBT. Two authors independently reviewed all studies and extracted data. Risk of bias was assessed using the Cochrane tool for randomized studies (RoB) and non-randomized studies (ROBINS-I). Quality of evidence was assessed using the GRADE approach.

RESULTS

 42 studies were included. 6 were randomized controlled, 3 non-randomized controlled, and 33 non-randomized non-controlled. 26 studies examined US-guided abdominal procedures, 13 examined thoracic procedures, and 3 examined both. The results favored SBT compared to other educational interventions and found that training was superior to no training. Only two studies examined the transfer of procedural skills to a clinical context. All studies had a high or critical risk of bias. Thus, the quality of evidence for the effect of SBT on procedural competence was low, and evidence for its transfer to a clinical context was very low.

CONCLUSION

 The evidence supporting SBT of percutaneous abdominal and thoracic US-guided procedures remains insufficient due to methodological problems and a high risk of bias. Future studies should be randomized and single-blinded, use assessment tools supported by validity evidence, compare different educational strategies, and examine the transfer of skills to a clinical setting.

Importance of questionnaire context for a physical activity question

Adequate information about physical activity habits is essential for surveillance, implementing, and evaluating public health initiatives in this area. Previous studies have shown that question order and differences in wording result in systematic differences in people's responses to questionnaires; however, this has never been shown for physical activity questions. The aim was to study the influence of different formulations and question order on self-report physical activity in a population-based health interview survey. Four samples of each 1000 adults were drawn at random from the National Person Register. A new question about physical activity was included with minor differences in formulations in samples 1-3. Furthermore, the question in sample 2 was included in sample 4 but was placed in the end of the questionnaire. The mean time spent on moderate physical activity varied between the four samples from 57 to 100 min/day. Question order was associated with the reported number of minutes spent on moderate-intensity physical activity and with prevalence of meeting the recommendation, whereas physical inactivity was associated with the differences in formulation of the question. Questionnaire context influences the way people respond to questions about physical activity significantly and should be tested systematically in validation studies of physical activity questionnaires.

Chronic pain and other sequelae in long-term breast cancer survivors: nationwide survey in Denmark

OBJECTIVES

To investigate self-reported chronic pain and other sequelae in a nationally representative sample of long-term breast cancer survivors (BCS).

DESIGN

Age-stratified random sample of 2,000 female BCS 5 years after primary surgery without recurrence drawn from the Danish Breast Cancer Cooperative Group register, which is representative regarding long-term BCS in Denmark.

ASSESSMENT

Self-administered questionnaire including questions on sociodemography, chronic pain (6 months), health-related quality of life (HRQOL) and other sequelae related to breast cancer. Associations with treatment were investigated. Report of chronic pain was compared to normative data.

RESULTS

The response rate was 79%. Chronic pain prevalence of 42% was significantly higher in BCS compared to general population women (SRR: 1.32; 95% CI: 1.23-1.42). Sequelae related to breast cancer were paraesthesia 47%, chronic pain 29%, arm/shoulder swelling 25%, phantom sensations 19%, and allodynia 15%. Chronic pain related to breast cancer was significantly associated with poorer HRQOL and higher medicine consumption, and, in multiple logistic regression analysis, with age (<70 years), short education, being single (divorced, widowed, separated), radiotherapy, and time since operation <10 years. Radiotherapy and younger age were significantly associated with most sequelae.

CONCLUSION

Chronic pain was more prevalent in BCS compared to the general population. Significant predictors for sequelae related to breast cancer were radiotherapy and younger age. Future research should therefore prioritize sequelae prevention.

Use of six main drug therapeutic groups across educational groups: self-reported survey and prescription records

OBJECTIVES

To assess whether the use of six main therapeutic groups was congruent with the occurrence of related diseases across educational groups.

METHODS

Two data sources were analysed: (i) Interview data from The Danish Health and Morbidity Survey 2000 on a representative sample of the Danish population ages 16 years and above (n = 16,690); (ii) Prescription records linked to a health survey on a representative sample of the population of Funen County 2000-2001 (n = 3,422). The use of six therapeutic main groups (ATC groups A, B, C, M, N and R) and related diseases in educational groups was analysed by indirect standardization. Age and gender standardized prevalence ratios (SPRs) and 95% confidence intervals were calculated on the basis of the total study population.

RESULTS

In general, respondents in the two least educated groups used medicines more frequently and a higher proportion of them reported the related disease than could be expected from indirect standardization. The opposite picture appeared for respondents in the two highest educational groups (SPR < 100). The overall patterns were similar for the six medicine groups, although some of the SPRs were not significant.

CONCLUSION

The results show the uneven distribution of disease in the general population. The distribution of medicine use generally followed this pattern, which means that those in the greatest medical need used the most medicine. Hence, individual co-payment for medicine did not seem to be a barrier to access to medicine in any of the educational groups.

Trends in smoking behaviour between 1985 and 2000 in nine European countries by education

OBJECTIVE

To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group.

DESIGN

Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points.

SETTING

Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain.

PARTICIPANTS

451 386 non-institutionalised men and women 25-79 years old.

MAIN OUTCOME MEASURES

Smoking status, daily quantity of cigarettes consumed by smokers.

RESULTS

Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups.

CONCLUSIONS

Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.

Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries

BACKGROUND

Few studies have compared socioeconomic inequalities in the prevalence of both fatal and non-fatal diseases. This paper aims to give the first international overview for several common chronic diseases.

METHODS

Micro-level data were pooled from non-standardized national health surveys conducted in eight European countries in the 1990s. Surveys ranged in size from 3700 to 41 200 participants. The prevalence of 17 chronic disease groups were analysed in relation to education. Standardized prevalence rates and age-adjusted odds ratios (ORs) were calculated.

RESULTS

Most diseases showed higher prevalence among the lower education group. Stroke, diseases of the nervous system, diabetes, and arthritis displayed relatively large inequalities (OR > 1.50). No socioeconomic differences were evident for cancer, kidney diseases, and skin diseases. Allergy was more common in the higher education group. Relative socioeconomic differences were often smaller among the 60-79 age group as compared with the 25-59 age group. Cancer was more prevalent among the lower educated in the 25-59 age group, but among the higher educated in the 60-79 age group. For diabetes, hypertension, and heart disease, socioeconomic differences were larger among women as compared with men. Inequalities in heart disease were larger in northern European countries as compared with southern European countries.

CONCLUSION

There are large variations between chronic diseases in the size and pattern of socioeconomic differences in their prevalence. The large inequalities that are found for some specific fatal diseases (e.g. stroke) and non-fatal diseases (e.g. arthritis) require special attention in equity-oriented research and policies.

[Small changes in health differences in the Nordic countries during the 1980s and 1990s]

The study examined changes over time in health inequality in Denmark, Finland, Norway and Sweden. Data derive from comparable interview surveys carried out in 1986/87 and 1994/95. Limiting long-standing illness and perceived ill health were analysed regarding age, gender; educational attainment, and employment status. Age adjusted prevalence rates were calculated. Changes in differences in health were found in education and employment status groups. There was little or no change in the prevalence of ill health during the time period studied. Despite social and economic changes differences in health remained broadly stable in the examined countries.

Socioeconomic position and smoking behaviour in Danish adults

AIMS

The associations between smoking and various socioeconomic indicators may have different implications and causes, which may also vary according to sex and birth cohort. This study analyses how two dimensions of socioeconomic position, an individual (education) and a structural (occupation) indicator, are associated with ever, current and ex-smoking.

METHODS

Data on smoking behaviour were collected in five cross-sectional surveys of random samples of the general Danish population aged 20 years or more at intervals between 1982 and 1994. In total, 8,054 men and 8,281 women participated. Logistic regression was used to analyse the influence of education and occupation on smoking behaviour controlling for sex and birth cohort.

RESULTS

In cohorts born after 1930 ever and current smoking were related to years of school education and current occupation. The prevalences of ever and current smoking were highest among the least educated, unskilled workers, unemployed persons and persons who received welfare benefits. A significant interaction between birth cohort and education indicated that the educational difference in ever and current smoking increased significantly with increasing year of birth. In multivariate analysis controlling for sex and birth cohort, ex-smoking seemed to be more strongly associated with education than occupation. Those with 12 or more years of school education had twice as high a chance of being ex-smokers as those with 7 years of school or less.

CONCLUSION

Smoking behaviour is strongly associated with both individual and structural indicators of socioeconomic position in Danish adults in all cohorts except for those born before 1930.

Social differences in illness and health-related exclusion from the labour market in Denmark from 1987 to 1994

OBJECTIVE

The objectives were first to analyse differences in long-standing illness, limiting long-standing illness, and perceived health as below good in relation to different indicators of social class over time; and secondly to analyse the association of long-standing illness, educational level, age, and gender with employment status.

SUBJECTS AND METHODS

Self-reported information on illness, educational level, employment status, and occupational class was obtained in two nationally representative Danish health interview surveys in 1987 (n=4753) and 1994 (n=4668).

RESULTS

There was a marked increase in long-standing illness from 1987 (33%) to 1994 (38%), especially among women with higher education (13% in 1987 to 26% in 1994). The prevalence of perceived health below good was unchanged (c. 20%) during the same period. Among employed men in 1987 the lowest prevalence of long-standing illness was seen in upper salaried employees (21%) and the highest in skilled workers (35%). In 1994, the difference had diminished and the prevalence rates for the same classes were 28% and 29%, respectively. Among employed women, a similar pattern was seen. The lowest rate in 1987 was seen among self-employed with subordinates (15%) and the highest in self-employed without subordinates (28%). In 1994, the difference was reduced with prevalence rates of 23% and 32%, respectively. In addition, substantial differences in health status between groups with different educational backgrounds were found. The proportion of the population with long-standing illnesses was clearly higher in the group with low education compared with the group with high education. A similar social gradient was found for perceived health as below good. Those with the highest odds ratio of being a disability pensioner are women with long-standing illness, only basic education, and above 55 years of age.

CONCLUSION

In conclusion, the study showed that the prevalence of long-standing illness increased from the mid-1980s to the mid-1990s, whereas perceived health below good was unchanged. In 1994, there was a remarkable difference in health between employed and non-employed people, indicating a health-related exclusion from the labour market. This may explain why, in 1994, smaller occupational class differences were found in the prevalence of long-standing illness among employed people compared with the findings in 1987, whereas the health differences remained in the different educational groups. Women above 54 years of age with basic education only and long-standing illness have the highest odds ratio of permanent exclusion from the labour market.

Persistent variations in average height between countries and between socio-economic groups: an overview of 10 European countries

PRIMARY OBJECTIVES

This paper aims to provide an overview of variations in average height between 10 European countries, and between socio-economic groups within these countries.

DATA AND METHODS

Data on self-reported height of men and women aged 20-74 years were obtained from national health, level of living or multipurpose surveys for 1987-1994. Regression analyses were used to estimate height differences between educational groups and to evaluate whether the differences in average height between countries and between educational groups were smaller among younger than among older birth cohorts.

RESULTS

Men and women were on average tallest in Norway, Sweden, Denmark and the Netherlands and shortest in France, Italy and Spain (range for men: 170-179 cm; range for women: 160-167 cm). The differences in average height between northern and southern European countries were not smaller among younger than among older birth cohorts. In most countries average height increased linearly with increasing birth-year (approximately 0.7-0.8 cm/5 years for men and approximately 0.4 cm/5 years for women). In all countries, lower educated men and women on average were shorter than higher educated men (range of differences: 1.6-3.0 cm) and women (range of differences: 1.2-2.2 cm). In most countries, education-related height differences were not smaller among younger than among older birth cohorts.

CONCLUSIONS

The persistence of international differences in average height into the youngest birth cohorts indicates a high degree of continuity of differences between countries in childhood living conditions. Similarly, the persistence of education-related height differences indicates continuity of socio-economic differences in childhood living conditions, and also suggests that socio-economic differences in childhood living conditions will continue to contribute to socio-economic differences in health at adult ages.

Educational differences in smoking: international comparison

OBJECTIVE

To investigate international variations in smoking associated with educational level.

DESIGN

International comparison of national health, or similar, surveys.

SUBJECTS

Men and women aged 20 to 44 years and 45 to 74 years.

SETTING

12 European countries, around 1990.

MAIN OUTCOME MEASURES

Relative differences (odds ratios) and absolute differences in the prevalence of ever smoking and current smoking for men and women in each age group by educational level.

RESULTS

In the 45 to 74 year age group, higher rates of current and ever smoking among lower educated subjects were found in some countries only. Among women this was found in Great Britain, Norway, and Sweden, whereas an opposite pattern, with higher educated women smoking more, was found in southern Europe. Among men a similar north-south pattern was found but it was less noticeable than among women. In the 20 to 44 year age group, educational differences in smoking were generally greater than in the older age group, and smoking rates were higher among lower educated people in most countries. Among younger women, a similar north-south pattern was found as among older women. Among younger men, large educational differences in smoking were found for northern European as well as for southern European countries, except for Portugal.

CONCLUSIONS

These international variations in social gradients in smoking, which are likely to be related to differences between countries in their stage of the smoking epidemic, may have contributed to the socioeconomic differences in mortality from ischaemic heart disease being greater in northern European countries. The observed age patterns suggest that socioeconomic differences in diseases related to smoking will increase in the coming decades in many European countries.

Use of hormone replacement therapy among Danish nurses in 1993

BACKGROUND

To describe the prevalence of women using systemic hormone replacement therapy in various age groups. To identify their reasons for choosing or not choosing the therapy, reasons for discontinuing the treatment, the prevalence of side effects among current users, and to estimate the duration of treatment.

METHODS

The study is based on postal questionnaires sent to 23,000 female Danish nurses above the age of 44 years. Out of these 19,953 (86%) responded. The questionnaire gave information on age, use of hormone replacement therapy, use of oral contraceptives, family predisposition and diseases. Duration of hormone replacement therapy was calculated by Cox regression analysis. Chi square tests were used to evaluate differences and 5% was used as the level of significance.

RESULTS

Overall, 6673 (33%) had ever used hormone replacement therapy. The prevalence was highest in the age group 55-59, where 29.3% were currently using hormones. The most cited reasons for choosing hormone replacement therapy were vasomotor symptoms (62%) and prevention of osteoporosis (44%). Among never users 43% had not experienced climacteric symptoms, 24% found the therapy unnatural, and 22% were afraid of side effects. It was estimated that 70% still were using hormones five years after the start of therapy, 57% after ten years, and 48% after fifteen years. Women with a family history of osteoporosis used hormones longer than women without this predisposition.

CONCLUSIONS

One third of all the women had ever used hormone replacement therapy and more than half of ever users used the therapy for more than ten years.

How well do patient and general practitioner agree about the content of consultations?

OBJECTIVE

To analyse agreement between patients' and general practitioners' perception of content of consultations.

DESIGN

Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs).

SETTING

General practices in the County of Funen, Denmark.

SUBJECTS

All 291 GPs in the County were invited to join the investigation, and 137 accepted. All patients who consulted the participating GPs in a 3 day period were included in the investigation. The GPs registered 6021 patients, of whom 3578 (59%) returned the completed questionnaire.

MAIN OUTCOME MEASURES

GPs and patients were asked about the urgency of the consultation, number of problems presented, duration of consultation, and quality of communication. The GPs' and patients' answers were matched, and variables of agreement were made. Patients were furthermore asked about their satisfaction with the consultation.

RESULTS AND CONCLUSION

Agreement for the four matched answers varied from 69% to 83%. Disagreement was observed more often in consultations where the patient's self-evaluated health was poor, the patient was female, had a chronic disease, expected a prescription or felt that the GP had little knowledge of his/her life circumstances. Agreement concerning urgency, number of problems and quality of communication was associated with a higher degree of patient satisfaction.

[Self-reported health and morbidity among adult Danes 1987-1994]

Developments in morbidity among adult Danes were studied by means of representative national health interview surveys conducted in 1987, 1991, and 1994. Each health interview survey was based on personal interviews with a sample of 6000 Danes. Response rates were about 80%. From 1987 to 1994 prevalence of long-standing illness increased from 33 to 38%, prevalence of health-related restrictions of daily activities increased from 11 to 14%, while prevalence of perceived poor health decreased slightly and prevalence of not feeling well enough to do what you want to do decreased from 22 to 19%. In 1994 16% reported reduced psychological well-being within a four week period, and 23% had due to emotional problems accomplished less than they desired at work or in other daily activities. The prevalence of self-reported morbidity and ill-health increased with increasing age, and for most of the indicators prevalence was higher among women than among men.

Differences in self reported morbidity by educational level: a comparison of 11 western European countries

STUDY OBJECTIVE

To assess whether there are variations between 11 Western European countries with respect to the size of differences in self reported morbidity between people with high and low educational levels.

DESIGN AND METHODS

National representative data on morbidity by educational level were obtained from health interview surveys, level of living surveys or other similar surveys carried out between 1985 and 1993. Four morbidity indicators were included and a considerable effort was made to maximise the comparability of these indicators. A standardised scheme of educational levels was applied to each survey. The study included men and women aged 25 to 69 years. The size of morbidity differences was measured by means of the regression based Relative Index of Inequality.

MAIN RESULTS

The size of inequalities in health was found to vary between countries. In general, there was a tendency for inequalities to be relatively large in Sweden, Norway, and Denmark and to be relatively small in Spain, Switzerland, and West Germany. Intermediate positions were observed for Finland, Great Britain, France, and Italy. The position of the Netherlands strongly varied according to sex: relatively large inequalities were found for men whereas relatively small inequalities were found for women. The relative position of some countries, for example, West Germany, varied according to the morbidity indicator.

CONCLUSIONS

Because of a number of unresolved problems with the precision and the international comparability of the data, the margins of uncertainty for the inequality estimates are somewhat wide. However, these problems are unlikely to explain the overall pattern. It is remarkable that health inequalities are not necessarily smaller in countries with more egalitarian policies such as the Netherlands and the Scandinavian countries. Possible explanations are discussed.

Knowledge, attitudes and cardiovascular risk factors in Danish adults

A community cardiovascular disease (CVD) prevention programme was undertaken in 1989 in a Danish County (Vejle). A random sample of 5192 adults were asked to complete a mailed questionnaire on knowledge, attitudes, and behaviour in relation to CVD risk factors. The response rate was 56%. The questionnaire produced baseline data for programme planning and measuring the success of on-going interventions. Smoking, overweight, and unhealthy food habits were the most prevalent CVD risk factors. A CVD risk score was calculated from the data on smoking, food habits, exercise, stress, overweight, self-reported presence of hypertension, diabetes, and gender. A high score was commoner in men, in the least educated, in groups who judged their own risk as high, and in groups with negative health beliefs. The level of knowledge about CVD risk factors was high in general. Low knowledge was commonest in the youngest age group, in the least educated, in unskilled workers, and in groups with negative health beliefs. As social position and personality factors seem to play an important role in actions people may take in prevention of CVD, they should be considered in the planning of the health promotion activities in Vejle.

[Smoking habits among adults--attitude and behavior in relation to prevention of cardiovascular diseases]

During the autumn 1989, a material of 1,330 men and 1,561 women aged 20-65 years and resident in the County of Vejle replied to a questionnaire about their smoking habits and knowledge in connection with the prophylaxis of cardiovascular disease. 47% of the men and 39% of the women stated that they smoked. During the past year, 44% of the male and 51% of the female smokers and ex-smokers had altered or considered altering their smoking habits. The main motives for altering smoking habits were health or financial reasons. The main reasons that an attempt to alter smoking habits did not succeed were side effects (restlessness/nervousness), the force of habit or that the desire was too great. The attitude that smoking was of significance for cardiovascular disease was related to non-smokers. In addition, a connection was observed between the knowledge that smoking is a risk factor for cardiovascular disease that the fact that these participants did not smoke. No interactions were observed between knowledge, attitudes and smoking habits i.e. that the attitude that it was important to stop smoking was identical among smokers and non-smokers, regardless of whether smoking was deleterious to health. On the basis of previous attempts to alter smoking habits, the conclusion was drawn that this is a difficult task. One of the reasons is that the cause of smoking are partially unknown and that smoking is probably an important factor in various social situations. In addition, the motivation to alter smoking habits is more than dominated by the discomfort involved.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiovascular risk factors--extent and self-assessed risk in relation to prevention of cardiovascular diseases. A questionnaire among 3,956 men and women aged 24-65 years in Vejle County, Slangerup and Helsinge municipalities]

In autumn 1989, a material of 1,330 men and 1,561 women aged 20-65 years and resident in the County of Vejle replied to a standardized questionnaire about their knowledge and behaviour in relation to prophylaxis of cardiovascular disease. During the same period, 501 men 565 women in the Municipalities of Helsinge and Slangerup participated in a similar investigation. It was investigated whether the behaviours of the participants as regards tobacco, physical activity, diet, experience of stress and overweight were unsuitable in relation to prevention of cardiovascular disease. 22% of the men and 11% of the women had unfavourable behaviour in more than two of these factors. The percentage proportion with many unfavourable factors was greatest among persons with the lowest school education. The majority of the participants were aware of the factors which are of significance for the development of cardiovascular disease. The general level of knowledge was high. A majority of the participants with many unfavourable factors assessed their own risk of development of cardiovascular disease as great. The proportion of the participants who were aware that a personal effort was of significance to retain health was greatest in the group where the behaviour was most suitable both where men an women were concerned.

[Occurrence of colds and coughs among adult Danes. Epidemiological data from the DIKE (Danish Institute for Clinical Epidemiology) population study]

The occurrence of upper respiratory symptoms among adult Danes was examined by the use of data from the Danish Health and Morbidity Survey 1986-1987. In this study, 14.0 per cent of 6,672 individuals reported complaints of colds or coughs (CC) during the two-week period preceding the interview. Reporting of CC decreased with age, but there was no sex difference. A multivariate analysis, including a number of suspected exposure variables, showed that CC was reported significantly more frequently (OR 1.42) by individuals also reporting exposure to external health risks in their homes. The reporting of CC was not associated with occupational exposure, psychological stress, spare time physical activity or smoking habits. Using bivariate analysis, it was shown that exposure to external health risks in the home was reported more frequently among women than men. The results indicate, that exposure to external health risks in dwellings contributes significantly to the total morbidity among adult Danes. However, improvement of the validity of information about exposure by means of more objective methods is required.

[The distribution effects of the Danish 800 crown rule. Preliminary results of the DIKE study. Choice of drugs and drugs used by the population]

During the period 1 July 1989 to 31 December 1990, patients had to pay the full price for subsidized medicine up to DDK 800 (66 pounds) per calendar year. The consequences for the population were examined by a representative national survey (January 1990) and for the patients by interviews at pharmacies (December 1989 and April 1990). Fourteen percent of the population had exceeded the limit of DDK 400 (33 pounds) for the second half of 1989. By the end of December 1989, 53% of patients at pharmacies had exceeded the limit. According to the national health survey (1986) 51% of the population took medicine during a period of two weeks; 58% female, 42% male. In 1990, 41% of the population had no medicine expenses. Among the other fraction 15% had expenses of DDK 200 (16 pounds) or more, monthly. Among patients at pharmacies 22-25% had expenses to that amount. More than 90% of the patients at pharmacies bought the prescribed medicine or the medicine normally used. Less than 10% asked the physician to prescribe a cheaper medicine. The new regulation on medicine reimbursement has not yet induced greater price-consciousness in the users. Whether this is possible by economic means, is an open question.

[Food habits and knowledge among adults in the county of Vejle in relation to prevention of cardiovascular disease]

During autumn 1989, 1,330 men and 1,561 women aged 20-65 years residing in Vejle replied to a questionnaire about dietary habits and knowledge concerning prevention of cardio-vascular disease. The majority ate fresh fruit and potatoes and drank coffee daily. More than one third ate vegetables daily and also whole-fat cheese. Over one quarter drank whole milk while less than 10% ate fish or fish spreads, eggs, cakes and sweets. Men ate potatoes and drank whole milk more frequently than women who ate fruit and vegetables more frequently. 75% and 81% stated that they avoided or included several foodstuffs for the sake of their health. The foodstuffs which were most frequently avoided were fat meat while wholemeal bread or vegetables and fruit were the foodstuffs which the majority included. 17% of the men and 29% of the women consumed more than three foodstuffs which were good for the heart daily. In particular, married persons, persons from the higher social classes and non-smokers had dietary habits beneficial to the heart. More than 90% knew that it was of significance in the avoidance of cardiovascular disease to eat less butter and fat and more vegetables and fish. The results show that the population in the County of Vejle are aware of the significance of diet for the risk of cardiovascular disease. A great proportion of the population, therefore, attempt to alter their diets in a healthier direction. A number still exist who have unsuitable diets as regards prevention of cardiovascular disease. In the County of Vejle, continued efforts will be made in the campaign against cardiovascular disease.

[The dietary awareness of Danish adults]

By means of an interview investigation of a representative sample comprizing 4,753 adult Danes over the age of 15 years, the attempted dietary principles of the population are illustrated. 60% of the population try to avoid certain foodstuffs from the point of view of health and 75% include certain foodstuffs in their diets for the same reason. The persons who particularly follow the dietary recommendations made in recent years, which consist of avoiding fat and including coarse bread, vegetables and fruit in the diet are women, aged 25-44 years, individuals with high net incomes and persons living in the suburbs of the capital and in the three largest Danish provincial towns. The efforts to achieve healthy dietary habits are, in addition, associated with non-smoking and moderate alcohol consumption. During the past five years, the proportion of Danes who try to alter dietary habits has increased by approximately 10%. During the same period, the actual average diet has, however, not altered in the same positive direction. The dietary principles aimed at and which are reported here are, therefore, expression of Danes' awareness of dietary principles rather than the actual behaviour. Thus, despite optimal knowledge, barriers exist which prevent alteration of dietary behaviour.

Family planning services delivery. Danish experience

The purpose of this article is to give an overview of the Danish family planning services delivery based on a description of the country, the people, and their opinions. All laws and regulations about contraceptive services, including abortion and sterilization, are described in historical perspectives. It is concluded that the system has been developed on the basis of the health care system of the country to such a degree that it broadly covers the prevailing general attitudes of the population and that the expectations of the population to the system are reasonably met. What remains unsatisfactory is a relatively high proportion of induced abortions. Future possibilities for solving this problem could be: to improve the education of physicians, health nurses, midwives, teachers, and social workers with regard to family planning and sexuality; to revise teacher's guidelines on sex education and intensified sex education in the schools; to intensify information to risk groups such as teenagers and single women; and to accomplish general organisation of school class visits to family planning clinics.

United States and Denmark: different approaches to health care and family planning

The findings of this study suggest that, compared to the United States, Danish health care policies and family planning services delivery systems are, in the aggregate, more conducive to the promotion of effective contraceptive practice, more instrumental in conveying information to high-risk groups, and more successful in reducing the incidence of unintended pregnancies and induced abortions. One of the major reasons for this difference may stem from the positive and nonambivalent climate of public opinion about sexuality in Denmark and the manner in which health care and family planning services are delivered to all segments of the population regardless of age, income, or location of residence. Research in reproductive behavior is greatly facilitated by the existence of automated population registers.

Psychiatric admissions and choice of abortion

A statistical analysis is presented of the intensities of admissions to psychiatric hospitals among women in Denmark who either gave birth to a child in the year 1975 or had an induced abortion in the same year. The models used are time-continuous Markov and semi-Markov processes, and the methods employed include non-parametric and semi-parametric analysis of counting processes. The influence of prior psychiatric admissions on the choice of terminating the pregnancy with an induced abortion is also studied.