Margit Kriegbaum

The Prevalence of Severe Asthma and Low Asthma Control Among Danish Adults

BACKGROUND The prevalence of severe asthma is unknown. However, international expert statements estimate that severe asthma represents 5% to 10 % of the entire asthma population. OBJECTIVE Based on register data from a nationwide population, we wanted to investigate the prevalence of severe asthma, the extent of asthma control, and contact with specialist care. METHODS A descriptive cross-sectional register study was performed. By using a nationwide prescription database, we identified current patients with asthma (age, 18-44 years) in 2010. Severity was classified as severe versus mild-moderate asthma according to the level of antiasthma treatment. We investigated prescription drug use, hospitalizations, emergency department visits, and outpatient clinic visits according to severity. RESULTS Among a nationwide population, we identified 61,583 current patients with asthma. Based on the level of antiasthma treatment, 8.1% of identified patients was classified as having severe asthma. Low asthma control (dispensed prescriptions of prednisolone, emergency department visits, hospitalization, or excessive short-acting β₂-agonist use) was more frequent in subjects with severe asthma (36.4% vs 25.2%, P < .0001); 63.8% with severe asthma and low asthma control were not managed by specialist care. Patients with severe asthma with specialist contact more frequently had impaired asthma control compared with subjects not treated by a specialist (44.4% vs 33.1%, P < .0001). CONCLUSION Based on the level of treatment, 8.1% of a nationwide population of current patients with asthma was classified as having severe asthma. Low asthma control was more frequent among subjects with severe asthma, and only a minority had access to specialist care. There is room for optimizing asthma management, particularly among patients with severe disease.

Socioeconomic position and variations in coping strategies in musculoskeletal pain: a cross-sectional study of 1,287 40- and 50-year-old men and women.

OBJECTIVE To examine the association between socioeconomic position and coping strategies in musculoskeletal pain. DESIGN AND SUBJECTS Cross-sectional study of a random sample of 40- and 50-year-old Danes, participation rate 69%, n=7,125. The study included 1,287 persons who reported functional limitations due to musculoskeletal pain. METHODS Data was collected by postal questionnaires and scales were developed on problem-solving coping and avoidant coping, based on a range of preliminary studies. Multivariate logistic regression analyses was used to study the correlation with socioeconomic position, measured by occupational social class. RESULTS Among women, there was no correlation between social class and avoidant coping, but a significant decrease in the use of problem-solving coping by decreasing social class, adjusted odds ratio (OR) = 2.64 (95% confidence interval (CI) 1.31-5.32) in social class V vs social classes I + II. Among men, there was no correlation between social class and problem-solving coping, but a significant increase in the use of avoidant coping with decreasing social class, adjusted OR = 3.31 (95% CI 1.75-6.25) in V vs I + II. CONCLUSION It is important for clinicians who advise and support patients in their response to musculoskeletal pain to be aware of socioeconomic differences in coping strategies. Gender differences in the association between socioeconomic factors and coping should be further investigated.

Coping with unemployment: Does educational attainment make any difference?

Aims: The aim of this study was to examine the cross-sectional association between educational attainment and coping strategies with unemployment in a random sample of 37- to 56-year-old Danish men and women in long-term unemployment. Methods: Data were based on a survey among 575 men and 1,064 women who had been unemployed at least 70% of the time during a three-year period (October 1996 to October 1999). The outcome measures were two scales for coping with unemployment, one for problem-solving coping, and one for avoidant coping. Educational attainment was measured by years of vocational training. Results: A significant association was found between low educational attainment and low use of problem-solving coping among both men, OR=1.81 (95% CI 1.19—2.75), and women, OR=1.57 (1.13— 2.18). Adjustment for cohabitation status, self rated health, economic strain, and unemployment status did not change this association substantially. High use of avoidant coping was associated with low educational attainment among men, OR=1.57 (0.98—2.51). For women, medium educational attainment was significantly associated with low use of avoidant coping, OR=0.60 (0.42—0.85). This result was not affected by adjustment for the covariates. Conclusions: Coping strategies are considered a potential modifier of the impact of unemployment on health and well-being. In this study, differences in coping strategies with unemployment were associated with educational attainment.

Rapid Report on Methodology: Does Loss to Follow-up in a Cohort Study Bias Associations Between Early Life Factors and Lifestyle-Related Health Outcomes?

PURPOSE To examine the consequences of non-response in a follow-up survey for associations between early-life factors and lifestyle-related health outcomes in adulthood. METHODS In a cohort of 11532 Danish men born in 1953 we had nearly complete follow-up in the National Patient Register, but only 66% of 9507 eligible cohort members participated in a follow-up survey, in 2004. We examined whether characteristics measured early in life and discharge from hospital for alcohol abuse or tobacco-related lung diseases, were associated with survey response. Associations between the early-life characteristics and these two health outcomes were calculated in the entire cohort and among responders, and the effect of non-response was described by a Relative Odd Ratio (ROR=OR(responders)/OR(entire cohort)). RESULTS A low response rate at age 50 years was related to having a single mother at birth, low educational attainment at age 18, and low cognitive function at ages 12 and 18. The risk of alcohol overuse and tobacco-related diseases was also highest among non-responders. However, the associations between early-life characteristics and the outcomes were nearly the same in responders as in the entire cohort. CONCLUSIONS Although non-responders differed from responders in terms of early-life exposures and incidence of the lifestyle-related outcomes, we found no overt effects of this on the exposure-risk associations.

Loss to follow up did not bias associations between early life factors and adult depression

OBJECTIVE This study examines the consequences of nonresponse in a follow-up survey for the associations of early life factors with adult depression. STUDY DESIGN AND SETTING A cohort of 11,532 Danish men born in 1953 had nearly complete follow up for outcomes retrieved from the Danish Psychiatric Register and the National Prescription Register, but only 66% of 9,507 eligible cohort members participated in a follow-up survey in 2004. We examined whether characteristics measured at birth and at ages 12 and 18 years, were associated with survey response. Associations between early life characteristics and four measures of depression were described by odd ratios (OR), estimated by logistic regression. For the register-based measures the effect of nonresponse was described by a relative OR(OR(responders)/OR(entire cohort)=ROR). RESULTS Nonresponse at 50 years of age was related to having a single mother at birth, low educational attainment at age 18, and low cognitive function at ages 12 and 18. Hospitalizations for depression and having claimed a prescription for an antidepressive drug were also most frequent among men who did not respond in the follow up. However, the effect of this nonresponse on the estimated ORs was small, and all ROR were nonsignificant. CONCLUSION Although early life characteristics were related to response in a follow-up survey, the ORs for the exposure-risk associations were not biased by nonresponse.

Reduced probability of smoking cessation in men with increasing number of job losses and partnership breakdowns

Background Unemployment and partnership breakdowns are common stressful life events, but their association with smoking cessation has been investigated in only a few studies. Objective To investigate how history of employment and cohabitation affects the probability of smoking cessation and to study joint exposure to both. Methods Birth cohort study of smoking cessation of 6232 Danish men born in 1953 with a follow-up at age 51 (response rate 66.2%). History of unemployment and cohabitation was measured annually using register data. Information on smoking cessation was obtained by a questionnaire. Results The probability of smoking cessation decreased with the number of job losses (ranging from 1 OR 0.54 (95% CI 0.46 to 0.64) to 3+ OR 0.41 (95% CI 0.30 to 0.55)) and of broken partnerships (ranging from 1 OR 0.74 (95% CI 0.63 to 0.85) to 3+ OR 0.50 (95% CI 0.39 to 0.63)). Furthermore, smoking cessation was associated with the duration of the periods of unemployment (ranging from 1–5 years (OR 0.75, 95% CI 0.65 to 0.85) to 10–23 years (OR 0.29, 95% CI 0.22 to 0.38)) and with living without a partner for >5 years (ranging from 6–9 years to 10–23 years (OR 0.80, 95% CI 0.66 to 0.97) to 10–23 years (OR 0.44, 95% CI 0.37 to 0.52)). Those who never cohabited and experienced one or more job losses had a particular low chance of smoking cessation (OR 0.19, 95% CI 0.12 to 0.30). Conclusion The numbers of job losses and of broken partnerships were both inversely associated with probability of smoking cessation.

Excessive drinking and history of unemployment and cohabitation in Danish men born in 1953

BACKGROUND Few studies exist on social inequality of excessive drinking in Denmark and differences seem to be less pronounced than in other European countries. The aims of this study were to investigate how history of employment and cohabitation is associated with excessive drinking and to study interaction between both. METHODS Birth-cohort study of 6112 Danish men born in 1953 with follow-up in 2004 on excessive drinking at age 51 years. RESULTS Excessive drinking (between 22 and 35 units of alcohol per week) differed little depending on history of unemployment and cohabitation. Risk of very excessive drinking (drinking >35 units of alcohol per week) increased with number of job losses-ranging from one job-loss [odds ratio (OR) 1.72, 95% confidence interval (CI) 1.39-2.14] to three or more job-losses (OR 2.48, 95% CI 1.75-3.52)--and duration of unemployment--ranging from 1 to 5 years (OR 1.34, 95% CI 1.11-1.63) to ≥10 years (OR 4.16, CI 3.13-5-53). Very excessive drinking was also associated with number of broken partnerships-ranging from one broken partnership (OR 1.43, 95% CI 1.16-1.77) to three or more broken partnerships (OR 2.69, 95% CI 2.03-3.55)--and with living alone for >5 years--ranging from 6 to 9 years (OR 1.73, 95% CI 1.30-2.29) to ≥10 years (OR 2.55, 95% CI 2.04-3.55). We found an interaction between the number of job-losses and of broken partnerships in relation to very excessive drinking. CONCLUSIONS Very excessive drinking is related to number of job-losses, broken partnerships, living alone and duration of unemployment.

Job Loss and Broken Partnerships: Do the Number of Stressful Life Events Influence the Risk of Ischemic Heart Disease in Men?

PURPOSE The aim of this study was to investigate the effects of the accumulated number of job losses and broken partnerships (defined as the end of cohabitation) on the risk of fatal and nonfatal events of ischemic heart disease (IHD). METHODS Prospective birth cohort study with follow-up of events of IHD from 1993 to 2004. Participants were 8365 men born in the metropolitan area of Copenhagen, Denmark, in 1953. Events of IHD were retrieved from the Danish National Patient Register and the Cause of Death Registry. Job losses and broken partnerships were identified in the Social Registers. We included mothers marital status and fathers occupation at birth, body mass index at 18 years, and own educational attainment as covariates. RESULTS We found that only broken partnerships were associated with IHD (1.28 95% confidence interval 1.02-1.58) and the subdiagnoses of other IHD (1.37 95% confidence interval 1.02-1.85). We found no indication of dose-response relationship between number of events and risk of IHD. CONCLUSION In this study of middle-aged men, we found only weak support for the effect of psychosocial stress on IHD measured with register based life events; we found that IHD was associated with broken partnerships but not with job loss. We did not find that the risk of incident IHD varied with the number of these stressful life events.

Contextual factors and social consequences of incident disease

BACKGROUND Large geographical variations in the incidence of disability benefits have been reported, but it is unclear to what extent that is confounded by variations in disability rates and disease pattern in the population and whether local variations in rehabilitation and health insurance practice modify the employment effect of disease. We have studied risk of labour market exclusion following incident hospitalization for ischaemic heart disease (IHD), and whether this risk may be modified by contextual factors on the municipal level. METHODS A cohort design on a 10% random sample of the whole Danish population including individuals aged 43-60 years, (n = 516.454 person-years including 840 cases of IHD). The independent variable was incident hospitalization for IHD and outcome variable was defined as job loss 2 years after the event. Regional-level data included all the 275 Danish municipalities in 1996. RESULTS There was a strong association between incident IHD and labour market exclusion 2 years later, odds ratio (OR) = 2.8 (95% confidence intervals (CI) 2.4-3.4). Men had less risk of being excluded than women and immigrant status, low-educational attainment and co-morbidity were significantly associated with job loss. Also, regional characteristics did independently effect labour market exclusion. However, the individual relative risk of exclusion following incident IHD was not modified substantially when neither the fixed effects of the regional-level variables nor the random effect of municipality was included in the analyses. CONCLUSION Geographical variation in incidence of labour market exclusion following incident disease is not primarily an effect of differential social consequences across municipal variations in labour market and socio-economic conditions.

Stressful social relations and mortality: a prospective cohort study

Background Few studies have examined the relationship between stressful social relations in private life and all-cause mortality. Objective To evaluate the association between stressful social relations (with partner, children, other family, friends and neighbours, respectively) and all-cause mortality in a large population-based study of middle-aged men and women. Further, to investigate the possible modification of this association by labour force participation and gender. Methods We used baseline data (2000) from The Danish Longitudinal Study on Work, Unemployment and Health, including 9875 men and women aged 36–52 years, linked to the Danish Cause of Death Registry for information on all-cause mortality until 31 December 2011. Associations between stressful social relations with partner, children, other family, friends and neighbours, respectively, and all-cause mortality were examined using Cox proportional hazards models adjusted for age, gender, cohabitation status, occupational social class, hospitalisation with chronic disorder 1980–baseline, depressive symptoms and perceived emotional support. Modification by gender and labour force participation was investigated by an additive hazards model. Results Frequent worries/demands from partner or children were associated with 50–100% increased mortality risk. Frequent conflicts with any type of social relation were associated with 2–3 times increased mortality risk. Interaction between labour force participation and worries/demands (462 additional cases per 100 000 person-years, p=0.05) and conflicts with partner (830 additional cases per 100 000 person-years, p<0.01) was suggested. Being male and experiencing frequent worries/demands from partner produced 135 extra cases per 100 000 person-years, p=0.05 due to interaction. Conclusions Stressful social relations are associated with increased mortality risk among middle-aged men and women for a variety of different social roles. Those outside the labour force and men seem especially vulnerable to exposure.