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

The Joint Effect of Education and Alcohol Use on 100% Alcohol-attributable Hospitalization or Death in Canada

BACKGROUND

Individuals with low socioeconomic position (SEP) experience disproportionately greater alcohol-attributable harm than individuals with high SEP despite similar or less alcohol use (i.e., the alcohol harm paradox). We examined the sex/gender- specific independent and joint effects of education and heavy drinking or volume of alcohol use on 100% alcohol-attributable hospitalization or death.

METHODS

We conducted a cohort study among 199,125 current and former alcohol users aged 15-64 years from population-representative Canadian Community Health Surveys (2000-2008) linked to hospitalization and mortality records through 2017. We estimated the sex/gender-specific associations between education and heavy drinking or volume of alcohol use and incident 100% alcohol-attributable hospitalization or death using multivariable Fine and Gray subdistribution hazard models with competing risk (non-100% alcohol-attributable deaths), assessing additive interactions using the Synergy Index (S).

RESULTS

Overall, heavy drinking prevalence and volume of alcohol use were similar or lower in individuals with lower education compared with higher education. Lower education levels compared with a bachelor's degree or above were associated with increased 100% alcohol-attributable hospitalization or death [e.g., less than high school, men: hazard ratio (HR) = 2.78; 95% CI = 2.17, 3.56; women: HR = 2.98; 95% CI = 2.00, 4.44]. We found superadditive joint effects between low education and heavy drinking (men: S = 1.22; 95% CI = 1.14, 1.30; women: S = 1.34; 95% CI = 0.88, 2.04) and low education and higher volume of alcohol use (e.g., excess volume, men: S = 1.30; 95% CI = 1.05, 1.62; women: S = 1.41; 95% CI = 0.77, 2.58), with larger inequities in women than men with similar alcohol use.

CONCLUSIONS

Our study is consistent with the hypothesis that increased vulnerability to alcohol use among individuals with lower education partially explains the alcohol harm paradox in Canada.

Arts and culture engagement for health: a Danish population-based study

OBJECTIVES

Global health challenges are complex and new approaches are pivotal. Engagement in arts and cultural activities is commonplace across different cultures, and research shows associations with benefits for health and wellbeing. Using the arts for health promotion and prevention of illness has increased worldwide.

STUDY DESIGN

A population-based study.

METHODS

Data were obtained from the Danish Health and Wellbeing Survey in 2019. A self-administered questionnaire was sent to 14,000 randomly selected adults (aged ≥15 years). The questionnaire included items on self-rated health and frequency of participation in various cultural activities (concerts or musical events; participation in a choir, band, or orchestra; theatre show or other performing arts; cinema; art museum or exhibition; library). A cultural participation index was calculated based on the six questions on cultural activities. Logistic regression models were fitted to examine the associations between the index and good self-rated health, adjusting for relevant covariates.

RESULTS

In total, 6629 individuals completed the questionnaire (47.4%). The most frequent activity, used at least once a month, was visiting a library. A strong association between the cultural participation index and self-reported health was observed. A one-point-higher index score was associated with a 10% higher likelihood of having good self-reported health (adjusted odds ratio: 1.10; 95% confidence interval: 1.08-1.12).

CONCLUSIONS

This study supports the understanding that engagement in arts and cultural activities is beneficial for self-rated good health. Individuals with higher frequency of arts and culture engagement were more likely to report good health than those with lower engagement.

Association between cannabis use and risk of diabetes mellitus type 2: A systematic review and meta-analysis

BACKGROUND

Cannabis consumption exerts multiple effects on metabolism via various pathways, including glucose regulation and insulin secretion. Studies concerning the association between cannabis use and diabetes mellitus type 2 are discrepant.

OBJECTIVE

This study was conducted to evaluate the association between cannabis use and type 2 diabetes mellitus (T2DM).

SEARCH METHODS

We searched PubMed, Scopus, Embase, Proquest, Web of Science, and Cochrane Library with no time, language or study types restriction until July 1, 2022, using various forms of "cannabis" and "diabetes mellitus" search terms.

SELECTION CRITERIA

Randomized control trials, cohort, and case-control studies investigating the relationship between cannabis consumption and diabetes mellitus type 2 were included.

DATA COLLECTION AND ANALYSIS

The Newcastle-Ottawa scale was used to assess the quality of studies. We pooled odds ratio (OR) with 95% confidence interval (CI) using the random-effects model, generic inverse variance method, DerSimonian and Laird approach.

MAIN RESULTS

A meta-analysis of seven studies, containing 11 surveys and 4 cohorts, revealed that the odds of developing T2DM in individuals exposed to cannabis was 0.48 times (95% CI: 0.39 to 0.59) lower than in those without cannabis exposure.

CONCLUSIONS

A protective effect of cannabis consumption on the odds of diabetes mellitus type 2 development has been suggested. Yet given the considerable interstudy heterogeneity, the upward trend of cannabis consumption and cannabis legalization is recommended to conduct studies with higher levels of evidence.

Patterns of cigarette and e-cigarette use among UK adolescents: a latent class analysis of the Millennium Cohort Study

BACKGROUND

Patterning of cigarette and e-cigarette use among young people remains poorly characterized. We aimed to describe these patterns in the UK Millennium Cohort Study at age 14 and 17 years.

METHODS

Data on cigarette and e-cigarette use come from 9731 adolescents. Latent class analysis assigned participants to membership of classes of product use and multinomial logistic regression analyses assessed differences in the likelihood of belonging to classes by sociodemographic (age, gender, ethnicity, household income, maternal education and country of residence) and smoking-related social factors (caregiver tobacco use, caregiver e-cigarette use and peer smoking).

RESULTS

We identified four classes of use: 45.8% of adolescents 'continued to abstain' from cigarettes or e-cigarettes; 21.3% 'experimented' (used once or in the past but not currently) with cigarettes and/or e-cigarettes by age 17 but were not current users; 19.0% were 'late adopters', characterized by low levels of use at age 14 but high levels of experimentation and current use at age 17; and 13.9% were 'early adopters', characterized by high levels of experimentation and current use at ages 14 and 17. At age 17, 70.4% of 'early adopters' smoked cigarettes regularly plus an additional 27.3% experimented with cigarettes. Corresponding percentages for e-cigarettes were 37.9% and 58.9%. Tobacco and e-cigarette use by caregivers, and cigarette use by peers, were associated with being both 'late adopters' and 'early adopters'.

CONCLUSIONS

Approximately one in seven adolescents in the UK are 'early adopters' of nicotine products. This highlights the need to develop and implement effective policies to prevent nicotine use uptake.

Gender-based harassment in Swedish workplaces and alcohol-related morbidity and mortality: A prospective cohort study

OBJECTIVE

The study investigated experiences of different types of work-related gender-based harassment (GBH), specifically sexual and gender harassment, as risk factors for alcohol-related morbidity and mortality (ARMM).

METHODS

Information about experiences of (i) sexual harassment (SH-I) and (ii) gender harassment (GH-I) from inside the organization and (iii) sexual harassment from a person external to the organization (SH-E) were obtained from the Swedish Work Environment Survey 1995-2013, a biannual cross-sectional survey, administered to a representative sample of the Swedish working population. The survey responses from 86 033 individuals were connected to multiple registers containing information about alcohol-related diagnoses, treatment, or cause of death. Cox proportional hazard models were fitted to assess hazard ratios (HR) of incident ARMM during a mean follow-up of eight (SH-I and GH-I) and ten (SH-E) years.

RESULTS

A higher prospective risk estimate of ARMM was found among participants who reported experiences of SH-E [HR 2.01, 95% confidence interval (CI) 1.61-2.52], GH-I (HR 1.33, CI 1.03-1.70), or SH-I (HR 2.37, CI 1.42-3.00). Additional analyses, distinguishing one-time from reoccurring harassment experiences, indicated a dose-response relationship for all three harassment types. Gender did not modify the associations. Under the assumption of causality, 9.3% (95% CI 5.4-13.1) of the risk of ARMM among Swedish women and 2.1% (95% CI 0.6-3.6) among Swedish men would be attributable to any of the three types of GBH included in this study.

CONCLUSIONS

Experiences of GBH in the work context may be a highly relevant factor in the etiology of ARMM.

Asking informed consent may lead to significant participation bias and suboptimal cardiovascular risk management in learning healthcare systems

BACKGROUND

The Utrecht Cardiovascular Cohort - CardioVascular Risk Management (UCC-CVRM) was set up as a learning healthcare system (LHS), aiming at guideline based cardiovascular risk factor measurement in all patients in routine clinical care. However, not all patients provided informed consent, which may lead to participation bias. We aimed to study participation bias in a LHS by assessing differences in and completeness of cardiovascular risk management (CVRM) indicators in electronic health records (EHRs) of consenting, non-consenting, and non-responding patients, using the UCC-CVRM as an example.

METHODS

All patients visiting the University Medical Center Utrecht for first time evaluation of a(n) (a)symptomatic vascular disease or condition were invited to participate. Routine care data was collected in the EHR and an informed consent was asked. Differences in patient characteristics were compared between consent groups. We performed multivariable logistic regression to identify determinants of non-consent. We used multinomial regression for an exploratory analysis for the determinants of non-response. Presence of CVRM indicators were compared between consent groups. A waiver (19/641) was obtained from our ethics committee.

RESULTS

Out of 5730 patients invited, 2378 were consenting, 1907 non-consenting, and 1445 non-responding. Non-consent was related to young and old age, lower education level, lower BMI, physical activity and haemoglobin levels, higher heartrate, cardiovascular disease history and absence of proteinuria. Non-response increased with young and old age, higher education level, physical activity, HbA1c and decreased with lower levels of haemoglobin, BMI, and systolic blood pressure. Presence of CVRM indicators was 5-30% lower in non-consenting patients and even lower in non-responding patients, compared to consenting patients. Non-consent and non-response varied across specialisms.

CONCLUSIONS

A traditional informed consent procedure in a LHS may lead to participation bias and potentially to suboptimal CVRM, which is detrimental for feedback on findings in a LHS. This underlines the importance of reassessing the informed consent procedure in a LHS.

Assessing targeted invitation and response modes to improve survey participation in a diverse New York City panel: Healthy NYC

BACKGROUND

Healthy NYC is an innovative survey panel created by the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) that offers a cost-effective mechanism for collecting priority and timely health information. Between November 2020 and June 2021, invitations for six different surveys were sent to Healthy NYC panelists by postal mail, email, and text messages. Panelists had the option to complete surveys online or via paper survey.

METHODS

We analyzed whether panelists varied by sociodemographic characteristics based on the contact mode they provided and the type of invitation that led to their response using logistic regression models. Poisson regression models were used to determine whether the number of invitations received before participating in a survey was associated with sociodemographic characteristics.

RESULTS

Younger age and higher education were positively associated with providing an email or text contact. Furthermore, age, race, and income were significant predictors for invitation modes that led to a survey response. Black panelists had 72% greater odds (OR 1.72 95% CI: 1.11-2.68) of responding to a mail invite and 33% lesser odds (OR 0.67, 95% CI: 0.54-0.83) of responding to an email invite compared with White panelists. Additionally, in five of the six surveys, more than half of the respondents completed surveys after two invites. Email invitations garnered the highest participation rates.

CONCLUSIONS

We recommend using targeted invitation modes as an additional strategy to improve participation in panels. For lower-income panelists who do not provide an email address, it may be reasonable to offer additional response options that do not require internet access. Our study's findings provide insight into how panels can tailor outreach to panelists, especially among underrepresented groups, in the most economical and efficient ways.

Refusal to participate in research among hard-to-reach populations: The case of detained persons

Providing insights on refusal to participate in research is critical to achieve a better understanding of the non-response bias. Little is known on people who refused to participate, especially in hard-to-reach populations such as detained persons. This study investigated the potential non-response bias among detained persons, comparing participants who accepted or refused to sign a one-time general informed consent. We used data collected in a cross-sectional study primary designed to evaluate a one-time general informed consent for research. A total of 190 participants were included in the study (response rate = 84.7%). The main outcome was the acceptance to sign the informed consent, used as a proxy to evaluate non-response. We collected sociodemographic variables, health literacy, and self-reported clinical information. A total of 83.2% of the participants signed the informed consent. In the multivariable model after lasso selection and according to the relative bias, the most important predictors were the level of education (OR = 2.13, bias = 20.7%), health insurance status (OR = 2.04, bias = 7.8%), need of another study language (OR = 0.21, bias = 39.4%), health literacy (OR = 2.20, bias = 10.0%), and region of origin (not included in the lasso regression model, bias = 9.2%). Clinical characteristics were not significantly associated with the main outcome and had low relative biases (≤ 2.7%). Refusers were more likely to have social vulnerabilities than consenters, but clinical vulnerabilities were similar in both groups. The non-response bias probably occurred in this prison population. Therefore, efforts should be made to reach this vulnerable population, improve participation in research, and ensure a fair and equitable distribution of research benefits.

Disparities in Tobacco Use by Disability and Type: Findings From the 2019 National Health Interview Survey

INTRODUCTION

People with disabilities report a higher prevalence of cigarette use than people without disabilities. However, evidence is limited on the relationships between disability type, degree of functional difficulty, and other tobacco product use.

METHODS

Data from the 2019 U.S. National Health Interview Survey were used to estimate the prevalence and odds of tobacco product use for 6 disability types and degree of functional difficulty. Bivariate and multivariable analyses conducted in 2021 examined the associations between tobacco product use and disability type.

RESULTS

Compared to adults who reported no difficulty, current cigarette use prevalence was higher for adults who reported a lot of difficulty/cannot do at all to vision (21.5% vs 13.1%), hearing (19.6% vs 13.6%), mobility (20.0% vs 12.9%), and cognitive (25.4% vs 12.9%) disability questions. The odds of current cigarette (AOR=1.32), pipe (AOR=1.85), and smokeless tobacco (AOR=1.57) use were significantly higher for adults who reported a lot of difficulty/cannot do at all to any disability question and significantly higher for current cigarette (AOR=1.24), e-cigarette (AOR=1.33), pipe (AOR=1.45), and smokeless tobacco (AOR=1.29) use for adults who reported some difficulty to any disability question than those who reported no difficulty. Pipe use was correlated with mobility difficulty (AOR=1.68), and smokeless tobacco use was correlated with hearing difficulty (AOR=1.95).

CONCLUSIONS

People who reported difficulty with vision, hearing, mobility, or cognition had a higher cigarette use prevalence than people without disabilities. Other tobacco use differed by disability type. Future research should tailor tobacco interventions to reduce these disparities.

Stable Gender Gap and Similar Gender Trend in Chronic Morbidities between 1997-2015 in Adult Canary Population

There is little information about the trend of the gender gap in chronic morbidities and whether the trend of expansion occurs equally in the age and gender groups. The objectives were to examine the consistency and stability of the gender gap in the main self-reported chronic morbidities in the general population, and, likewise, to analyze the trend of major chronic morbidities between 1997 and 2015 in men and women across age groups. The data were extracted from the Canary Health Survey, which uses a probabilistic sampling in the population >16 years of age, for the years 1997 (n = 2167), 2004 (n = 4304), 2009 (n = 4542), and 2015 (n = 4560). The data for the twelve most frequent chronic morbidities were analyzed using logistic regression, estimating the annual change ratio between 1997 and 2015, adjusting for age and educational level. The interaction of age with the period (1997−2015) was examined to analyze the rate of change for each morbidity in the age groups. Musculoskeletal diseases, headaches, anxiety and depression, and peripheral vascular diseases showed a stable gender gap across observed years. High cholesterol and high blood pressure tended to a gap reduction, while heart disease, diabetes, and respiratory disease did not show a significant gender gap along the period. The trend of the main chronic morbidities increased similarly in men and women in all age groups, but significantly in women older than 60 years and in men older than 45 years. Aging explained a substantial part of the trend of increasing prevalence of the main chronic morbidities, but not totally. Factors other than age and education are driving the increase in chronic morbidity in older age groups.

A study of high neuroticism in long-term survivors of childhood, adolescence, and young adult cancers

Neuroticism is a basic personality trait concerning negative feelings under stressful conditions. Our purpose was to examine the rate of high neuroticism and factors associated with high neuroticism in long-term (≥ 5 years) survivors of childhood, adolescent, and young adult cancer (CAYACSs). Norwegian CAYACSs aged 0–39 years when diagnosed and treated between 1985 and 2009 for cancer in childhood/adolescence (0–18 years), or as young adults (19–39 years) and alive in 2015 were mailed a questionnaire. Data from 1629 CAYACSs (481 children/adolescents and 1148 young adults) were analyzed. High neuroticism was found in 44% of survivors of childhood/adolescent cancers versus 34% in survivors of young adult cancer (p < 0.001). The rate of high neuroticism in female CAYACSs was 40% and in males 30% (p < 0.001). The corresponding difference between male survivor group was non-significant. In multivariable analysis, young age at survey, more adverse effects, poor self-rated health, female sex, chronic fatigue, and increased depression remained significantly associated with high neuroticism. Cancer treatment, comorbidity, and lifestyle were significant in bivariate analyses. Cancer at earlier age could increase the risk of high neuroticism among adult survivors. Screening for neuroticism could identify CAYACSs at risk for experiencing multiple health concerns and needing special follow-up attention.

Predictors of non-response to successive waves of surveys in the Japan Environment and Children's Study during the 3-year postpartum period: a longitudinal cohort study

OBJECTIVES

We examined changes in factors related to non-response to successive waves of the nationwide birth cohort study, the Japan Environment and Children's Study (JECS), during the first 3 years after childbirth.

DESIGN

Longitudinal cohort study.

SETTING

As the baseline survey, mothers completed self-administered questionnaires distributed by hand during pregnancy or 1 month after delivery. The self-administered questionnaires that we used in this study were then distributed by mail every 6 months until the children were 3 years old, for a total of six times.

PARTICIPANTS

Of 103 060 mothers who consented to participate in the JECS during pregnancy, 88 489 mothers were included in the study after excluding those with multiple births, miscarriages or stillbirths and those who withdrew from the study within 3 years after providing informed consent.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were collected at the baseline survey on participants' socioeconomic status, medical history, health status, health-related behaviours and their children's health conditions and living situations. The strength of the impact of related factors and the prediction of response status were examined and compared using binominal logistic regression analysis.

RESULTS

For all six follow-up questionnaire surveys, higher maternal age was strongly associated with providing a response. Factors that were strongly associated with mothers not providing a response were smoking after childbirth and having more children. The concordance rate of response status based on the presented model was about 70%, suggesting that the response status for the first 3 years after birth can be predicted from the information collected in the baseline survey.

CONCLUSION

By identifying predictors of non-response from information obtained in baseline surveys, researchers may be able to reduce non-response to successive survey waves by issuing reminders, reviewing data collection methods and providing appropriate financial and/or non-financial incentives.

Motivation to Reduce Drinking and Engagement in Alcohol Misuse Treatment in Alcohol-Related Liver Disease: A National Health Survey

INTRODUCTION

The study aim was to identify predictors of motivation to reduce alcohol consumption and whether motivation predicts engagement in alcohol misuse treatment in alcohol-related liver disease (ALD).

METHODS

Data from health surveys and health-care registries were combined.

RESULTS

Of 674 patients with ALD, 65% consumed alcohol. Recent hospital admission and severe alcohol problems were associated with motivation to reduce alcohol consumption. Two-year probability for engagement in misuse treatment was 29% for patients with motivation to reduce alcohol consumption versus 6.5% for patients without motivation.

DISCUSSION

ALD patients with recent hospital admission were more motivated to cut down alcohol consumption, and motivation predicted engagement in alcohol misuse treatment. This insight can help us target brief interventions.

Prevalence of at-risk drinking recognition: A systematic review and meta-analysis

BACKGROUND

There is a prominent "treatment gap" in relation to at-risk drinking (ARD), whereby a minority of at-risk drinkers ever access treatment. Research suggests that recognition of problem drinking is a necessary precursor for help-seeking and treatment.

OBJECTIVE

This systematic review and meta-analysis aimed to estimate the prevalence of ARD recognition within those meeting criteria for ARD.

METHOD

PsycINFO, Web of Science, Scopus, and MEDLINE were searched using the terms: problem* AND (recogni* OR perceive* OR perception OR self-identif*) AND alcohol - to identify studies published in English between 2000 and 2022. Studies reported the frequency (weighted or unweighted) of participants meeting ARD criteria that also directly identified ARD, perceived a need for help, or endorsed a readiness to change. The prevalence of ARD recognition was estimated using a random-effects meta-analysis with 95% confidence intervals (CIs).

RESULTS

17 studies were included which provided data for 33,349 participants with ARD. Most (n = 14) were US studies. ARD was self-identified via a single indicator in 7 studies, whereas recognition was assessed via stages of change in 4 studies and need for help in 6 studies. The pooled prevalence of ARD recognition was 31% (95% CI: 25%-36%), and subgroup analyses indicated alcohol use severity, measure of recognition, and population type to be significant sources of heterogeneity.

CONCLUSIONS

Most individuals with ARD fail to recognise their drinking problem so preventive approaches that promote recognition may be helpful. However, we must be cautious of how inconsistency in question framing affects self-reported problem recognition.

Acute symptoms in SARS-CoV-2 positive adolescents aged 15-18 years - Results from a Danish national cross-sectional survey study

BACKGROUND

The purpose of this study was to investigate prevalence of self-reported symptom burden during the acute phase of SARS-CoV-2 infection and associated factors including sex differences.

METHODS

All Danish adolescents aged 15-18 years with laboratory confirmed SARS-CoV-2 infection between January 2020 and July 2021 were invited to participate. A survey covered the initial four weeks of SARS-CoV-2 infection and included questions regarding 17 symptoms associated with acute COVID-19, symptom burden and medical history. Statistical analyses included descriptive statistics and logistic regression.

FINDINGS

A total of 24,315 adolescents with SARS-CoV-2 infection were invited and 6630 (27.3%) completed the questionnaire. The median age was 17.6 years, and 58.4% (n = 3873) were female. No symptoms were reported by 33.8% (n = 2241), mild perceived symptom burden by 57.2%(n = 3775), and severe symptom burden by 9.0 % (n = 594). Two thirds (n = 2999) of the symptomatic participants reported a symptom duration of 1-10 days. The most prevalent symptoms included headaches 39.2% (n = 2597), a reduced sense of smell 36.2% (n = 2398), cough 31.6% (n = 2093), sore throat 31.1% (n = 2063), and a reduced sense of taste 31.1% (n = 2062). Adolescents at the age of 18 years had higher odds of reporting ≥6 symptoms OR1.47 (95%CI, 1.23-1.76), p < 0.0001 and adolescents 18+ years old had higher odds of reporting a severe symptom burden OR1.98 (95%CI, 1.43-2.73) compared to the 15years old adolescents. A history of OCD/anxiety/depression was associated with reporting ≥6 symptoms OR 1.67 (95%CI, 1.34-2.09), p < 0.0001 and a history of allergy and OCD/anxiety/depression reporting severe symptom burden OR 1.64 (95%CI, 1.35-1.99), p < 0.0001 and OR 1.75 (95%CI, 1.28-2.36), p = 0.0004. Females reported more symptoms than males; median of three (IQR 0-6) vs. a median of two (IQR 0-4) symptoms, p < 0.0001.

INTERPRETATION

Two in three experienced symptoms and the majority reported mild symptom burden. Headache, a reduced sense of smell and taste, cough and sore throat were most common. Female sex, asthma and previous Epstein-Barr virus were associated with more symptoms and higher symptom burden.

FUNDING

The study was funded by the AP Møller Foundation. The research was investigator initiated. The study funder played no role in the study.

Smoking and labour market participation: a 5-year prospective cohort study of transitions between work, unemployment and sickness absence

AIM

To examine whether smokers are at higher risk of unemployment and sickness absence and have a lower chance of getting employed compared to never smokers.

METHODS

The study sample in this prospective register-based cohort study consisted of 87,830 men and women between 18 and 60 years of age from the Danish National Health Survey 2010. Assessment of smoking status was obtained at baseline and the participants were followed in the Danish register-based evaluation of marginalisation database from 2010 to 2015. Data were analysed by Cox proportional hazards.

RESULTS

The median age was 44.5 years and 47.3% were men. At baseline, 88.8% were categorised as working, 7.7% as unemployed and 3.5% as being on sickness absence. At the 5-year follow-up, hazard ratios for transitions from work to unemployment were 1.31 (95% confidence interval (CI) 1.22-1.40; P<0.001) for current smokers (<15/day) and 1.52 (95% CI 1.43-1.62; P<0.001) for current heavy smokers (⩾15/day), compared to never smokers. Hazard ratios for transitions from work to sickness absence were 1.31 (95% CI 1.24-1.38; P<0.001) for current smokers (<15/day) and 1.64 (95% CI 1.56-1.71; P<0.001) for current heavy smokers (⩾15/day). Current heavy smokers (⩾15/day) also had a lower chance of becoming re-employed with a hazard ratio of 0.81 (95% CI 0.75-0.88; P<0.001) compared to never smokers.

Smoking was associated with a higher risk of unemployment and sickness absence, and a lower chance of becoming employed. More focus on smoking prevention and smoking cessation could therefore be implemented in relation to job seeking and sickness absence.

Educational Gradients in Drinking Amount and Heavy Episodic Drinking among Working-Age Men and Women in Spain

Alcohol-related harm decreases as socioeconomic position increases, although sometimes the opposite happens with alcohol intake. The objective was to know the educational gradient in monthly measures of drinking amount and heavy episodic drinking (HED) among people aged 25−64 years in Spain from 1997−2017. Such gradient was characterized with the relative percent change (PC) in drinking measures per year of education from generalized linear regression models after adjusting for age, year, region, marital status and immigration status. Among men, the PCs were significantly positive (p < 0.05) for prevalence of <21 g alcohol/day (2.9%) and 1−3 HED days (1.4%), and they were negative for prevalences of 21−40 g/day (−1.1%), >40 g/day (−6.0%) and ≥4 HED days (−3.2%), while among women they ranged from 3.6% to 5.7%. The gradient in prevalences of >40 g/day (men) and >20 g/day (women) was greatly attenuated after additionally adjusting for HED, while that of ≥4 HED days was only slightly attenuated after additionally adjusting for drinking amount. Among women, the gradients, especially in HED measures, seem steeper in 2009−2017 than in 1997−2007. Educational inequality remained after additional adjustment for income and occupation, although it decreased among women. These results can guide preventive interventions and help explain socioeconomic inequalities in alcohol-related harm.

The impact of non-response weighting in health surveys for estimates on primary health care utilization

Background

Low response rates in health surveys may affect the representativeness and generalizability of results if non-response is systematically related to the indicator of interest. To account for such potential bias, weighting procedures are widely used with an overall aim to obtain less biased estimates. The aim of this study was to assess the impact of applying calibrated weights on prevalence estimates of primary health care utilization among respondents compared to the entire sample of a representative Danish survey of adults aged ≥16 years.

Methods

Registry-based 1-year prevalence data on health care utilization of chiropractor/physiotherapist, dentist and psychologist in 2016 were linked to the entire sample (n = 312 349), including respondents (n = 183 372), from the Danish National Health Survey in 2017. Calibrated weights, which applied information on e.g. sex, age, ethnic background, education and overall health service use were used to assess their impact on prevalence estimates among respondents.

Results

Across all included types of health care, weighting for non-response decreased prevalence estimates among respondents, which resulted in less biased estimates. For example, the overall 1-year prevalence of chiropractor/physiotherapist, dentist and psychologist utilization decreased from 19.1% to 16.9%, 68.4% to 62.5% and 1.9% to 1.8%, respectively. The corresponding prevalence in the entire sample was 16.5%, 59.4% and 1.7%.

Conclusions

Applying calibrated weights to survey data to account for non-response reduces bias in primary health care utilization estimates. Future studies are needed to explore the possible impact of weighting on other health estimates.

The impact of parental substance use disorder and other family-related problems on school related outcomes

Aims

To identify young people with different levels of family-related problems, including parental substance use disorder (PSUD), and investigate differences in grades at graduation from compulsory school and further enrollment in education.

Methods

Participants included 6784 emerging adults (aged 15-25 years) from samples drawn for two national surveys in Denmark 2014-2015. Latent classes were constructed using the following parental variables: PSUD, offspring not living with both parents, and parental criminality, mental disorders, chronic diseases and long-term unemployment. The characteristics were analyzed using an independent one-way ANOVA. Differences in grade point average and further enrollment were analyzed using linear regression and logistic regression, respectively.

Results

Four classes of families were identified: 1. "Low adverse childhood experiences (ACE) families", 2. "Families with PSUD", 3. "Families with unemployment" and 4. "High ACE families". There were significant differences in grades, with the highest average among youth from "Low ACE families" (males = 6.83; females = 7.40) and significant lower averages among both males and females from the other types of families, but lowest among young people from "High ACE families" (Males = 5.58; females = 5.79). Youth from "Families with PSUD" (Males: OR = 1.51; 95% CI: 1.01-2.26; females: OR = 2.16; 95% CI: 1.22-3.85) and "High ACE families" (Males: OR = 1.78; 95% CI: 1.11-2.26) were significantly more likely not to be enrolled in further education compared with "Low ACE families".

Conclusions

Young people who experience PSUD, both as the primary family-related problem as well as among multiple family-related problems, are at increased risk for negative school-related outcomes.

Improving Estimates of Alcohol-Attributable Deaths in the United States: Impact of Adjusting for the Underreporting of Alcohol Consumption

OBJECTIVE

Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths.

METHOD

Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach.

RESULTS

Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6).

CONCLUSIONS

Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates.

Improving Estimates of Alcohol-Attributable Deaths in the United States: Impact of Adjusting for the Underreporting of Alcohol Consumption

OBJECTIVE

Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths.

METHOD

Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach.

RESULTS

Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6).

CONCLUSIONS

Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates.

A Controlled Study of Major Depressive Episodes in Long-Term Childhood, Adolescence, and Young Adult Cancer Survivors (The NOR-CAYACS Study)

Simple Summary

A major depressive episode (MDE) is a common mental disorder with profound consequences concerning work ability, comorbidity, and health-related quality of life. Therefore, screening for probable MDE (pMDE) in survivors of childhood and adolescence (CACSs) and young adult cancer (YACSs) survivors is clinically important. This study shows that pMDE is more common among CACSs and YACSs than found in a normative sample using two different definitions of pMDE based on the PHQ-9 screener. pMDE based on a total PHQ-9 score of 10 or more gave higher rates of pMDE than those based on an algorithmic definition. Statistical analyses showed that pMDE according to both definitions was significantly associated with psychosocial factors and self-rated health, while survivor groups, cancer types, and adverse events were not. Screening for pMDE is meaningful in CACSs and YACSs since we have effective treatment methods for pMDE if the condition is identified rather than overlooked.

Abstract

Background: A major depressive episode (MDE) is typically self-rated by screening forms identifying probable MDE (pMDE). This population-based cross-sectional questionnaire study examined the prevalence rates of pMDE identified by the PHQ-9 screener in long-term survivors of childhood and adolescence (CACSs) and young adult cancer (YACSs) and a normative sample (NORMs). Methods: Data from 488 CACSs, 1202 YACSs, and 1453 NORMs were analyzed, and pMDE was defined both by cut-off ≥10 on the total PHQ-9 score and by an algorithm. Results: The prevalence rates of pMDE among CACSs were 21.5%, 16.6% in YACSs, and 9.2% among NORMs using the cut-off definition. With the algorithm, the prevalence rates of pMDE were 8.0% among CACSs, 8.1% among YACSs, and 3.9% among NORMs. Independent of definition, CACSs and YACSs had significantly increased prevalence rates of pMDE compared to NORMs. Psychosocial factors and self-rated health were significantly associated with both definitions of pMDE in multivariable analyses, while survivor groups, cancer types, and adverse events were not. Conclusion: Since pMDE has negative health consequences and is amenable to treatment, healthcare providers should be attentive and screen for pMDE in young cancer survivors. For PHQ-9, the preferred type of definition of pMDE should be determined.

Socioeconomic inequalities in the incidence of alcohol-related liver disease: A nationwide Danish study

Background

There is socio-economic inequality in total alcohol-related harm, but knowledge of inequality in the incidence of specific alcohol-related diseases would be beneficial for prevention. Registry-based studies with nationwide coverage may reveal the full burden of socioeconomic inequality compared to what can be captured in questionnaire-based studies. We examined the incidence of alcohol-related liver disease (ALD) according to socioeconomic status and age.

Methods

We used national registries to identify patients with an incident diagnosis of ALD and their socioeconomic status in 2009-2018 in Denmark. We computed ALD incidence rates by socioeconomic status (education and employment status) and age-group (30-39, 40-49, 50-59, 60-69 years) and quantified the inequalities as the absolute and relative difference in incidence rates between low and high socioeconomic status.

Findings

Of 17,473 patients with newly diagnosed ALD, 78% of whom had cirrhosis, 86% had a low or medium-low educational level and only 20% were employed. ALD patients were less likely to be employed in the 10 years prior to diagnosis than controls. The incidence rate of ALD correlated inversely with educational level, from 181 (95% CI, 167-197) to 910 (95% CI, 764-1086) per million person-years from the highest to the lowest educational level. By employment status, the incidence rate per million person-years was 211 (95% CI, 189-236) for employed and 3449 (95% CI, 2785-4271) for unemployed. Incidence rates increased gradually with age leading to larger inequalities in absolute numbers for older age-groups. Although ALD was rare in the younger age-groups, the relative differences in incidence rates between high and low socioeconomic status were large for these ages. The pattern of socioeconomic inequality in ALD incidence was similar for men and women.

Interpretation

This study showed substantial socioeconomic inequalities in ALD incidence for people aged 30-69 years.

Funding

The study was supported by grants from the Novo Nordisk Foundation (NNF18OC0054612) and the Research Fund of Bispebjerg Hospital.

Estimating perceived parental substance use disorder: Using register data to adjust for non-participation in survey research

AIMS

To estimate the prevalence of parental substance use disorder (PSUD) in the general population based on young adults' reports adjusted for non-participation using register-based indicators of PSUD.

DESIGN

A national sample survey study combined with a retrospective register-based study. Setting Denmark. Participants 10,414 young people (aged 15-25 years) invited to two national sample surveys in 2014 and 2015 (5,755 participants and 4,659 non-participants).

MEASUREMENTS

A crude prevalence of PSUD was calculated based on participants' reports. Parental data from medical, mortality, prescription, and treatment registers (from the young adults' birth until the time of the surveys) were used to estimate a register-based prevalence of PSUD for both participants and non-participants. Differences between participants and non-participants were analysed using bivariate comparisons. Inverse probability weighting was used to adjust for bias due to non-participation. The crude prevalence of PSUD based on survey data was adjusted using the ratio of incidence proportion of the register-based PSUD compared with the survey-based PSUD.

FINDINGS

A total of 731 (12.7%) of the 5,755 survey participants reported PSUD. Register-based PSUD was more common among non-participants (856/4,659; 18.4%) compared with participants (738/5,755; 12.8%, OR = 1.53, 95% CI 1.38-1.70). The adjusted estimate of the survey-based PSUD increased by 2.5 percentage points, from 12.7% to 15.2%.

CONCLUSIONS

In the absence of register data, youth-reported PSUD is likely to underestimate the number of young people experiencing PSUD.

Elucidating causal effects of type 2 diabetes on ischemic heart disease from observational data on middle-aged Swedish women: a triangular analytical approach

The association between type 2 diabetes (T2D) and ischemic heart disease (IHD) is well established but the potential causal association needs further studying. In an attempt to elucidate the causal effect of T2D on IHD, we used three different analytical approaches in two different datasets. A well-defined cohort of 6047 women aged 50–59 years were included at baseline (1995 to 2000) and followed until 2015 for IHD. The median follow-up was 16.3 years. We used a Marginal Structural Cox model (MSM Cox) to account for time-varying exposure (time at onset of T2D) and for ten confounders (using inverse probability weighting, IPW). We also compared the MSM-Cox models with traditional Cox regression modelling in the cohort. Finally, we analyzed information on individuals from Swedish population-based registers with national coverage in a comprehensive co-relative design and extrapolated the results to MZ twins. The Hazard Ratio (HR) for IHD in relation to T2D at baseline and T2D occurring during the follow-up in the MSM Cox model weighted by IPW (based on the ten included confounders) was 1.43 (95% confidence interval [CI] 1.07–1.92). The corresponding HR from the traditional Cox regression model was of similar effect size. The average extrapolated MZ twin estimate from our co-relative model was 1.61 (95% CI 1.48–1.86). Our findings, based on a triangular approach, support the existence of a causal association between T2D and IHD and that preventive long-term measures in order to avoid or postpone IHD should include monitoring and treatment of both the T2D itself as well as other cardiovascular risk factors.

History of healthcare use and disease burden in older adults with different levels of alcohol use. A register-based cohort study

BACKGROUND

Only a minority of individuals with problematic alcohol use ever seek alcohol treatment. Knowledge of general help-seeking behavior in the healthcare system can identify possibilities for prevention and intervention.

METHOD

The current study describes healthcare use, burden of disease, and prior morbidities over a 15-year period by current alcohol use behavior among Danish adults aged 60-70. The Danish National Health Survey 2013 and the baseline assessment of the Elderly Study (2014-2016) were linked to Danish national registers to collect annual information on healthcare use and morbidity for the 15 years prior to inclusion. Participants from the 3 largest Danish municipalities were divided into 4 groups with varying drinking patterns and no recent treatment [12-month abstinent (n = 691), low-risk drinkers (n = 1978), moderate-risk drinkers (n = 602), and high-risk drinkers (n = 467)], and a group of treatment-seeking individuals with a 12-month DSM-5 alcohol use disorder (AUD; n=262). Negative binomial regression models were utilized to compare rates of healthcare use and logistic regressions were used to compare odds of diagnoses.

RESULTS

Low-, moderate-, and high-risk drinkers had similar rates of past healthcare utilization (low-risk mean yearly number of contacts for primary care 7.50 (yearly range 6.25-8.45), outpatient care 0.80 (0.41-1.32) and inpatient care 0.13 (0.10-0.21)). Higher rates were observed for both the 12-month abstinent group (adjusted RR = 1.16-1.26) and the group with AUD (ARR = 1.40-1.60) compared to the group with low-risk alcohol consumption. Individuals with AUD had higher odds of previous liver disease (adjusted OR = 6.30), ulcer disease (AOR = 2.83), and peripheral vascular disease (AOR 2.71). Twelve-month abstinence was associated with higher odds of diabetes (AOR = 1.97) and ulcer disease (AOR = 2.10).

CONCLUSIONS

Looking back in time, we found that older adults had regular healthcare contacts, with those who received treatment for AUD having had the highest contact frequency and prevalence of alcohol-related diseases. Thus, healthcare settings are suitable locations for efforts at AUD prevention and intervention.

Revisiting the continuum of resistance model in the digital age: a comparison of early and delayed respondents to the Norwegian counties public health survey

Background

The continuum of resistance model’s premise is that delayed respondents to a survey are more similar to non-respondents than early respondents are. For decades, survey researchers have applied this model in attempts to evaluate and adjust for non-response bias. Despite a recent resurgence in the model’s popularity, its value has only been assessed in one large online population health survey.

Methods

Respondents to the Norwegian Counties Public Health Survey in Hordaland, Norway, were divided into three groups: those who responded within 7 days of the initial email/SMS invitation (wave 1, n = 6950); those who responded after 8 to 14 days and 1 reminder (wave 2, n = 4950); and those who responded after 15 or more days and 2 reminders (wave 3, n = 4045). Logistic regression analyses were used to compare respondents’ age, sex and educational level between waves, as well as the prevalence of poor general health, life dissatisfaction, mental distress, chronic health problems, weekly alcohol consumption, monthly binge drinking, daily smoking, physical activity, low social support and receipt of a disability pension.

Results

The overall response to the survey was 41.5%. Respondents in wave 1 were more likely to be older, female and more highly educated than those in waves 2 and 3. However, there were no substantial differences between waves for any health outcomes, with a maximal prevalence difference of 2.6% for weekly alcohol consumption (wave 1: 21.3%, wave 3: 18.7%).

Conclusions

There appeared to be a mild continuum of resistance for demographic variables. However, this was not reflected in health and related outcomes, which were uniformly similar across waves. The continuum of resistance model is unlikely to be useful to adjust for nonresponse bias in large online surveys of population health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10764-2.

Total cholesterol/HDL-C ratio versus non-HDL-C as predictors for ischemic heart disease: a 17-year follow-up study of women in southern Sweden

BACKGROUND

A distorted blood lipid profile is an important risk factor for ischemic heart disease (IHD) but the predictive ability of the different lipid measures has rarely been studied. Our aim was to examine and compare, in a large sample of women, the predictive ability of total cholesterol/HDL cholesterol ratio (TC/HDL-C) and non-HDL-C in relation to IHD, adjusted for age, exercise, smoking, waist-hip ratio, blood pressure, and diabetes mellitus.

METHODS

Between 1995 and 2000, a total of 6537 women aged 50-59 years from the Women's Health in Lund area (WHILA) study in southern Sweden were included and underwent a baseline examination. The women were followed through national registers for incidence of IHD during a mean follow-up of 17 years. The prediction accuracy was estimated through Harrell's C and Akaike Information Criterion (AIC).

RESULTS

Increasing TC/HDL-C as well as non-HDL-C showed strong associations with IHD, with the highest risk in the 5th quintile, where the HR was 2.30 (95% CI: 1.70-3.11) for TC/HDL-C and 1.67 (95% CI: 1.25-2.24) for non-HDL-C, after adjustments. Comparisons using Harrell's C and AIC indicated that TC/HDL-C has a slightly higher predictive ability than that of non-HDL-C (Harrell's C 0.62 and 0.59 respectively, p = 0.003 for difference, age-adjusted model; AIC for TC/HDL-C < AIC for non-HDL-C).

CONCLUSIONS

TC/HDL-C ratio and non-HDL-C are both clinical predictors for IHD in middle-aged women. The results indicate that the predictive ability of TC/HDL-C was higher than that of non-HDL-C; however, non-HDL-C was linearly related to IHD (p = 0.58) and may be easier to calculate and interpret in clinical practice, for early identification of future IHD in women.

Big data, observational research and P-value: a recipe for false-positive findings? A study of simulated and real prospective cohorts

BACKGROUND

An increasing number of observational studies combine large sample sizes with low participation rates, which could lead to standard inference failing to control the false-discovery rate. We investigated if the 'empirical calibration of P-value' method (EPCV), reliant on negative controls, can preserve type I error in the context of survival analysis.

METHODS

We used simulated cohort studies with 50% participation rate and two different selection bias mechanisms, and a real-life application on predictors of cancer mortality using data from four population-based cohorts in Northern Italy (n = 6976 men and women aged 25-74 years at baseline and 17 years of median follow-up).

RESULTS

Type I error for the standard Cox model was above the 5% nominal level in 15 out of 16 simulated settings; for n = 10 000, the chances of a null association with hazard ratio = 1.05 having a P-value < 0.05 were 42.5%. Conversely, EPCV with 10 negative controls preserved the 5% nominal level in all the simulation settings, reducing bias in the point estimate by 80-90% when its main assumption was verified. In the real case, 15 out of 21 (71%) blood markers with no association with cancer mortality according to literature had a P-value < 0.05 in age- and gender-adjusted Cox models. After calibration, only 1 (4.8%) remained statistically significant.

CONCLUSIONS

In the analyses of large observational studies prone to selection bias, the use of empirical distribution to calibrate P-values can substantially reduce the number of trivial results needing further screening for relevance and external validity.

Alcohol-related Outcomes and All-cause Mortality in the Health 2000 Survey by Participation Status and Compared with the Finnish Population

BACKGROUND

In the context of declining levels of participation, understanding differences between participants and non-participants in health surveys is increasingly important for reliable measurement of health-related behaviors and their social differentials. This study compared participants and non-participants of the Finnish Health 2000 survey, and participants and a representative sample of the target population, in terms of alcohol-related harms (hospitalizations and deaths) and all-cause mortality.

METHODS

We individually linked 6,127 survey participants and 1,040 non-participants, aged 30-79, and a register-based population sample (n = 496,079) to 12 years of subsequent administrative hospital discharge and mortality data. We estimated age-standardized rates and rate ratios for each outcome for non-participants and the population sample relative to participants with and without sampling weights by sex and educational attainment.

RESULTS

Harms and mortality were higher in non-participants, relative to participants for both men (rate ratios = 1.5 [95% confidence interval = 1.2, 1.9] for harms; 1.6 [1.3, 2.0] for mortality) and women (2.7 [1.6, 4.4] harms; 1.7 [1.4, 2.0] mortality). Non-participation bias in harms estimates in women increased with education and in all-cause mortality overall. Age-adjusted comparisons between the population sample and sampling weighted participants were inconclusive for differences by sex; however, there were some large differences by educational attainment level.

CONCLUSIONS

Rates of harms and mortality in non-participants exceed those in participants. Weighted participants' rates reflected those in the population well by age and sex, but insufficiently by educational attainment. Despite relatively high participation levels (85%), social differentiating factors and levels of harm and mortality were underestimated in the participants.

Causal inference with observational data: the need for triangulation of evidence

The goal of much observational research is to identify risk factors that have a causal effect on health and social outcomes. However, observational data are subject to biases from confounding, selection and measurement, which can result in an underestimate or overestimate of the effect of interest. Various advanced statistical approaches exist that offer certain advantages in terms of addressing these potential biases. However, although these statistical approaches have different underlying statistical assumptions, in practice they cannot always completely remove key sources of bias; therefore, using design-based approaches to improve causal inference is also important. Here it is the design of the study that addresses the problem of potential bias - either by ensuring it is not present (under certain assumptions) or by comparing results across methods with different sources and direction of potential bias. The distinction between statistical and design-based approaches is not an absolute one, but it provides a framework for triangulation - the thoughtful application of multiple approaches (e.g. statistical and design based), each with their own strengths and weaknesses, and in particular sources and directions of bias. It is unlikely that any single method can provide a definite answer to a causal question, but the triangulation of evidence provided by different approaches can provide a stronger basis for causal inference. Triangulation can be considered part of wider efforts to improve the transparency and robustness of scientific research, and the wider scientific infrastructure and system of incentives.

Reliability of a Rapid Screener for an Intercept Survey about Drug Use

Intercept surveys are a relatively inexpensive method to rapidly collect data on drug use. However, querying use of dozens of drugs can be time-consuming. We determined whether using a rapid screener is efficacious in detecting which participants use drugs and should be offered a full survey which asks more extensively about use. We surveyed 103 adults (age 18-29) on streets of Manhattan, NY in 2019 to test the reliability of a screener which queried past-year use of six drugs. Those reporting any drug use on the screener (and a third of those not reporting drug use) were offered the full survey which queried use of 97 drugs. We compared self-reported use on the screener to the full survey. Self-reported use of ecstasy, cocaine, and LSD had high test-retest reliability (Kappa = 0.90-1.00), and the screener had high sensitivity (1.00) and specificity (0.97-1.00) in detecting use of these drugs. Reliability for marijuana (Kappa = 0.62) and nonmedical opioid use (Kappa = 0.75) was lower. The screener had higher sensitivity (0.94) and lower specificity (0.64) in detecting marijuana use, and lower sensitivity (0.71) and higher specificity (0.98) in detecting nonmedical opioid use. Within the full survey, all participants reporting use of amphetamine (nonmedical use), shrooms, poppers, synthetic cannabinoids, synthetic cathinones, novel psychedelics, ketamine, or GHB reported use of at least one drug queried on the screener. Self-reported use of common drugs on a screener can reliably be used as an inclusion criterion for more extensive intercept surveys about drug use behavior.

The Danish National Health Survey: Study design, response rate and respondent characteristics in 2010, 2013 and 2017

Aim: This article aims to describe the study design, including descriptive statistics on changes in response rates, characteristics associated with response and response mode distribution, in the Danish National Health Survey (DNHS) in 2010, 2013 and 2017. Methods: Each survey was based on five regional stratified random samples and one national random sample drawn from the Danish Civil Registration System. The subsamples were mutually exclusive. Around 300,000 individuals (aged ⩾16 years) were invited to participate in each survey using a mixed-mode approach (paper/web). A questionnaire with a minimum of 52 questions was used in all subsamples. In 2010 and 2013, invitations were sent via the regular postal service, whereas a secure electronical mail service was used to invite the majority (around 90%) in 2017. Weights accounted for survey design and non-response. Results: Participation decreased from 59.5% in 2010 to 54.0% in 2013 after which it increased to 58.7% in 2017. The proportion answering the web questionnaire increased from 31.0% to 77.4% between 2013 and 2017 and varied from 73.8% to 79.7% between the subsamples in 2017. Overall, the response rate was low among young men and old women and among individuals who were unmarried, had low sociodemographic status, were from ethnic minority backgrounds or were living in the eastern part of Denmark. Conclusions: The survey mode, response mode distribution as well as response rate have changed over time. Weights to handle non-response can be applied to accommodate possible problems in generalising the results. However, efforts should continuously be made to ensure that response is missing at random.

Decomposing the educational gradient in allostatic load across European populations. What matters the most: differentials in exposure or in susceptibility?

Background

We investigate whether socially disadvantaged individuals are more susceptible to the detrimental effects of smoking and alcohol intake on allostatic load (AL), a marker of physiological ‘wear and tear’, resulting from adaptation to chronic stress.

Methods

In a cross-sectional analysis, 27 019 men and 26 738 women aged 35–74 years were identified from 21 European cohorts in the BiomarCaRE consortium. We defined three educational classes (EDs) according to years of schooling and an AL score as the sum of z-scores of eight selected biomarkers from the cardiovascular, metabolic and inflammatory systems. We used the Oaxaca-Blinder decomposition to disentangle the ED gradient in AL score into the differential exposure (DE, attributable to different distribution of smoking and alcohol intake across EDs) and the differential susceptibility (DS, attributable to a different effect of risk factors on AL across EDs) components.

Results

Less-educated men (mean AL difference: 0.68, 95% CI 0.57 to 0.79) and women (1.52, 95% CI 1.40 to 1.64) had higher AL scores. DE accounted for 7% and 6% of the gradient in men and women, respectively. In men, combining smoking and alcohol intake, DS accounted for 42% of the gradient (smoking DS coefficient=0.177, 26% of the gradient; alcohol DS coefficient=0.109; 16%, not statistically significant). DS contribution increased to 69% in metabolic markers. DS estimates were consistent across age groups, irrespective of comorbidities and robust to unmeasured confounding. No DS was observed in women.

Conclusions

In men, a DS mechanism substantially contributes to the educational class gradient in allostatic load.

Mental health and the risk of negative social life events: A prospective cohort study among the adult Danish population

Background: The consequences of poor mental health on morbidity and mortality are well established. However, studies prospectively examining the consequences on social life events are lacking. This study prospectively examines the risk of various social life events (educational attainment, employment status, marital status and parenthood) defined in administrative registers by mental health status at baseline defined by the MCS-12 in the Danish adult population. Methods: The analysis is based on data from the Danish National Health Survey 2010. A total of 177,639 individuals completed the questionnaire (59.5% of the sample). MCS-12 was used to categorise participants according to mental health status (poor, moderate and good). Survey data were linked to administrative registers at the individual level and followed for a minimum of 4 years. Cox proportional hazards models were used to prospectively examine the risk of various social life events according to mental health status at baseline. Results: Individuals with poor mental health and, to a certain degree, individuals with moderate mental health were less likely to experience positive life events such as progression in educational level, getting married, being employed and becoming a parent and were more likely to experience negative life events such as becoming unemployed and divorced/widowed. Conclusions: Mental health status is associated with educational attainment, employment status, marital status and parenthood. These results add to a growing body of evidence indicating that poor mental health is associated with substantial societal-level impairments that should be taken into consideration when making decisions regarding allocation of treatment and research resources.

Cannabis use, subsequent other illicit drug use and drug use disorders: A 16-year follow-up study among Swedish adults

AIMS

To examine the association between cannabis use and subsequent other illicit drug use and drug use disorders (harmful use and dependence).

DESIGN, SETTING, PARTICIPANTS

We used survey data from a population-based cohort in Stockholm County (collected 1998-2000), with linkage to the National Patient Register. The study base comprised participants aged 20-64 years (N = 10 345), followed-up until 2014. Cox and logistic regression analyses were conducted to test associations between self-reported cannabis use and risk of subsequent other illicit drug use (three-year follow-up) and drug use disorders (16-year follow-up).

FINDINGS

The odds ratio (OR) for other illicit drug use onset at three-year follow-up for lifetime cannabis users was 7.00 (4.47-10.35, 95% CI) and for recent cannabis users 34.41 (19.14-61.88, 95% CI). Adjusting for age and AUDIT score attenuated the association, for lifetime users: OR = 5.48 (3.69-8.13, 95% CI) and OR = 5.65 (3.80-8.41, 95% CI), and for recent users: OR = 18.32 (9.88-33.99, 95% CI) and OR = 20.88 (11.19-38.95, 95% CI). For cannabis users only, the hazard ratio (HR) for drug use disorders at 16-year follow-up was 0.89 (0.31-2.61, 95%CI). For cannabis and other illicit drug users, the corresponding HR was 7.27 (3.85-13.75, 95% CI).

CONCLUSIONS

There was no independent association between cannabis use and subsequent drug use disorders. The association with subsequent drug use disorders was rather explained by other illicit drug use, which cannabis users were at higher risk of at the three-year follow-up.

Unconditional and conditional monetary incentives to increase response to mailed questionnaires: A randomized controlled study within a trial (SWAT)

RATIONALE, AIMS, AND OBJECTIVES

High response rates to research questionnaires can help to ensure results are more representative of the population studied and provide increased statistical power, on which the study may have been predicated. Improving speed and quality of response can reduce costs.

METHOD

We conducted a randomized study within a trial (SWAT) to assess questionnaire response rates, reminders sent, and data completeness with unconditional compared with conditional monetary incentives. Eligible individuals were mailed a series of psychological questionnaires as a follow-up to a baseline host trial questionnaire. Half received a £5 gift voucher with questionnaires (unconditional), and half were promised the voucher after returning questionnaires (conditional).

RESULTS

Of 1079 individuals, response rates to the first follow-up questionnaire were 94.2% and 91.7% in the unconditional and conditional monetary incentive groups, respectively (OR 1.78; 95% CI, 0.85-3.72). There were significantly greater odds of returning repeat questionnaires in the unconditional group at 6 months (OR 2.97; 95% CI, 1.01-8.71; .047) but not at 12 months (OR 1.12; 95% CI, 0.44-2.85). Incentive condition had no impact at any time point on the proportion of sent questionnaires that needed reminders. Odds of incomplete questionnaires were significantly greater at 3 months in the unconditional compared with the conditional incentive group (OR 2.45; 95% CI, 1.32-4.55; .004).

CONCLUSIONS

Unconditional monetary incentives can produce a transitory greater likelihood of mailed questionnaire response in a clinical trial participant group, consistent with the direction of effect in other settings. However, this could have been a chance finding. The use of multiple strategies to promote response may have created a ceiling effect. This strategy has potential to reduce administrative and postage costs, weighed against the cost of incentives used, but could risk compromising the completeness of data.

Validation of the Yale Food Addiction Scale 2.0 and estimation of the population prevalence of food addiction

BACKGROUND & AIMS

Food addiction (FA) is likely to contribute to the global obesity epidemic. Most studies of FA have been conducted within clinical and/or highly selected populations, suggesting that prevalence estimates of FA may be biased. This is problematic as valid estimates of the population prevalence of FA is a requirement for informing and designing public health initiatives focusing on this phenotype. Therefore, we aimed to estimate the weighted prevalence of food addiction in the adult general population of Denmark.

METHODS

A random sample of 5000 individuals aged 18 to 62 from the Danish population was invited to participate in a survey, which included the Yale Food Addiction Scale (YFAS 2.0) and several rating scales measuring eating pathology and other psychopathology. Health, demographic and socioeconomic data from the Danish registers were linked to all invitees to allow for attrition analysis. The analysis had three steps: I) Psychometric validation of the Danish version of YFAS 2.0 II) Attrition analysis to examine selection bias, and III) Estimation of the weighted prevalence of FA taking attrition into account.

RESULTS

The confirmatory factor analysis of the YFAS 2.0 supported a one-factor model, and the scale had good internal consistency. The YFAS 2.0 score correlated with eating pathology including binge eating frequency, impulsivity and body mass index (BMI). The survey response rate was 34.0% (n = 1699) with a slight overrepresentation of respondents with higher socioeconomic status. The crude prevalence of FA was 9.0%. When taking attrition into account, the weighted prevalence of FA was 9.4% CI 95% [7.9-10.9].

CONCLUSIONS

The psychometric properties of the Danish version of the YFAS 2.0 were good. The weighted prevalence of FA was very similar to the crude prevalence estimate. This suggests that attrition may not be a large problem when estimating the prevalence of FA with the YFAS 2.0.

Sociodemographic, personal, and disease-related determinants of referral to patient-reported outcome-based follow-up of remote outpatients: a prospective cohort study

Purpose

We examined the association between sociodemographic, personal, and disease-related determinants and referral to a new model of health care that uses patient-reported outcomes (PRO) measures for remote outpatient follow-up (PRO-based follow-up).

Methods

We conducted a prospective cohort study among outpatients with epilepsy at the Department of Neurology at Aarhus University Hospital, Denmark. Included were all persons aged ≥ 15 years visiting the department for the first time during the period from May 2016 to May 2018. Patients received a questionnaire containing questions about health literacy, self-efficacy, patient activation, well-being, and general health. We also collected data regarding sociodemographic status, labour market affiliation, and co-morbidity from nationwide registers. Associations were analysed as time-to-event using the pseudo-value approach. Missing data were handled using multiple imputations.

Results

A total of 802 eligible patients were included in the register-based analyses and 411 patients (51%) responded to the questionnaire. The results based on data from registers indicated that patients were less likely to be referred to PRO-based follow-up if they lived alone, had low education or household income, received temporary or permanent social benefits, or if they had a psychiatric diagnosis. The results based on data from the questionnaire indicated that patients were less likely to be referred to PRO-based follow-up if they reported low levels of health literacy, self-efficacy, patient activation, well-being, or general health.

Conclusion

Both self-reported and register-based analyses indicated that socioeconomically advantaged patients were referred more often to PRO-based follow-up than socioeconomically disadvantaged patients.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02407-2) contains supplementary material, which is available to authorised users.

The Challenges of Identifying Environmental Determinants of Type 1 Diabetes: In Search of the Holy Grail

Type 1 diabetes is the result of autoimmune-mediated destruction and inflammation of the insulin-producing β-cells of the pancreas. The excess morbidity and mortality from its complications coupled with its increasing incidence emphasize the importance to better understand the etiology of this condition. It has a strong genetic component, but a genetic predisposition is not the sole contributor to disease development as only 30% to 50% of identical twins both develop the disease. In addition, there are multiple lines of evidence to support that environmental factors contribute to the pathogenesis of type 1 diabetes. Environmental risk factors that have been proposed include infections, dietary factors, air pollution, vaccines, location of residence, childhood obesity, family environment and stress. Researchers have conducted many observational studies to identify and characterize these potential environmental factors, but findings have been inconsistent or inconclusive. Many studies have had inherent methodological issues in recruitment, participation, defining cases and exposures, and/or data analysis which may limit the interpretability of findings. Identifying and addressing these limitations may allow for greatly needed advances in our understanding of type 1 diabetes. As such, the purpose of this article is to review and discuss the limitations of observational studies that aim to determine environmental risk factors for type 1 diabetes and propose recommendations to overcome them.

Norwegian reference data on the Fatigue Questionnaire and the Patient Health Questionnaire-9 and their interrelationship

BACKGROUND

Population-based reference data on frequently used questionnaires are important for comparative purposes. Due to changes in health and lifestyles, such data should be updated every other decade. The objectives of this study were to establish Norwegian population-based reference data on the Fatigue Questionnaire (FQ) and the Patient Health Questionnaire-9 (PHQ-9) on depression, to compare the FQ-scores with our previous reference data from 1996, and to explore the relationship between the scores on these two instruments.

METHODS

In 2015, a representative sample of 6,012 Norwegians aged 18-80 years was mailed a questionnaire including the FQ and the PHQ-9, and 36% responded. Complete FQ-scores were delivered by 2,041 subjects, and complete PHQ-9 scores by 2,086 subjects. The scores are displayed according to sex and 10-year age groups.

RESULTS

Few 2015 mean scores of mental, physical, and total fatigue differed significantly from those of 1996, and the same was found for the prevalence rates of chronic fatigue. The exception was a significantly lower prevalence in 2015 of mean fatigue scores and prevalence of chronic fatigue in females ≥ 60 years. The prevalence of major depressive episode (MDE) based on the PHQ-9 sum score cut-off ≥ 10 was 5.9% for males and 9.8% for females, and 2.5% and 3.8% using a DSM-based algorithm with at least five endorsed criteria including either anhedonia or depressed mood. The correlation between the FQ and the PHQ-9 was 0.59, implying 36% shared variance.

CONCLUSIONS

This study showed considerable interrelationship between the FQ and the PHQ-9 constructs. The reference data show that scores on the FQ have only improved significantly in persons aged 60 or more years between 1996 and 2015. Our prevalence findings of MDE based on the PHQ-9 are in accordance with the findings from other countries. The FQ and the PHQ-9 should be used together in epidemiological and clinical studies.

Factors of non-responsive or lost-to-follow-up Japanese mothers during the first year post partum following the Japan Environment and Children's Study: a longitudinal cohort study

OBJECTIVES

We examined the factors related to lost-to-follow-up of a birth cohort study during the first year after delivery.

DESIGN

Longitudinal cohort study.

SETTING

Questionnaires were provided by mail. Mothers answered the questionnaires about the children twice: at 6 months and 1 year.

PARTICIPANTS

Of 103 062 pregnancies who consented to participate in the Japan Environment and Children's Study (JECS), 93 417 mothers were included in the study after excluding those with multiple births, miscarriages or stillbirths and those who withdrew from the study within 1 year after providing informed consent.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants' socioeconomic status, medical history, health status, health-related behaviours, their children's health conditions and living situations were collected by self-administered questionnaires during pregnancy or 1 month after delivery as the baseline survey. In addition, two self-administered questionnaires were distributed 6 months and 1 year after delivery. Using the response status of the two questionnaires after delivery, participants' follow-up status was divided into four groups. The related factors were examined using logistic regression analysis.

RESULTS

Factors positively correlated with lost-to-follow-up to the questionnaires were postpartum physical conditions, psychological distress during pregnancy, the child's health status at birth, the child's primary caregiver and the number of siblings of the child. Partners' active participation in JECS was associated with a lower lost-to-follow-up rate to the two questionnaires, whereas inactive participation was positively associated with a higher lost-to-follow-up rate.

CONCLUSION

The response rate to the questionnaires seems to be related to the interest and understanding of participants' partners. In addition, the response rates are related to participants' physical conditions and living conditions. To decrease lost-to-follow-up rates in consecutive questionnaire surveys within a cohort study, it may be important for investigators to recognise that participants and their motivation in research can be influenced by perceptions they may have regarding the objectives of the research.

The ratio of total cholesterol to high density lipoprotein cholesterol and myocardial infarction in Women's health in the Lund area (WHILA): a 17-year follow-up cohort study

Background

Identifying variables predictive of acute myocardial infarction (AMI) in women is important. The use of the ratio of total cholesterol-to-high density lipoprotein cholesterol (TC/HDL-C) is often overlooked. The aim was to study TC/HDL-C in relation to later AMI, in a large sample of women, adjusted for age, educational status, smoking, waist-hip ratio, blood pressure, and neighbourhood socioeconomic status. The hypothesis was that increasing TC/HDL-C is associated with an increased risk of later AMI.

Methods

From December 1995 to February 2000, 6147 women aged 50–59 years from the Womens’ Health in Lund area (WHILA) study in southern Sweden underwent a physical examination, laboratory tests and filled in a questionnaire. The women were followed through national registers for incidence of AMI during a mean follow up of 17 years.

Results

An increasing TC/HDL-C showed a strong relationship with AMI, with the lowest hazard ratio (HR = 1) in women with a ratio of ≤3.5. The HR for AMI was 1.14 (95% CI: 0.73–1.78) for those with a ratio between 3.5 and 4.0; in those with a ratio between 4.0 and 5.0 the HR for AMI was 1.46 (95% CI: 1.00–2.13) and in those with a ratio > 5.0 the HR was 1.89 (95% CI 1.26–2.82), after adjusting for potential confounding factors.

Conclusions

TC/HDL-C ratio is a powerful predictor of AMI in middle-aged women. The results indicate that this variable should be used in clinical practice and is important for early identification of individuals at risk of AMI.

Patient-reported outcomes item selection for bladder cancer patients in chemo- or immunotherapy

Background

Selection of specific patient-reported outcomes (PROs) for cancer patients requires careful consideration to the purpose and population at aim. Here we report the process of choosing which items to include in a bladder cancer population in chemo- or immunotherapy based on the Patient-Reported Outcomes Version of the Common Terminology Criteria of Adverse Events (PRO-CTCAE).

Methods

Initial PRO-CTCAE symptoms were chosen through 1) medical record audit 2) patient interviews 3) summary of product characteristics from European Medicines Agency and Food and Drug Administration for the applied chemotherapies, and 4) toxicity reporting from Phase 2 and 3 trials for immunotherapies applied in patients with urothelial cancer. The selected questions were applied in a prospective cohort of 78 bladder cancer patients receiving chemo- or immunotherapy at Rigshospitalet and Herlev Hospital, Denmark. Symptoms tested in this population were selected for the final module if they appeared in ≥3 of the following groupings a) the most prevalent PRO-CTCAE symptoms grade ≥ 2 overall during treatment b) the PRO-CTCAE symptoms reported in conjunction with hospital admissions or mentioned in focus group interviews discussing which symptoms were prevalent in this patient group with specialized c) nurses or d) physicians. The authors also included symptoms in the final module if they were present in two of the above groups and defined as actionable by clinicians.

Results

From the initial selection of PRO-CTCAE symptoms, a total of 45 PRO-CTCAE symptoms explored by 84 PRO-CTCAE questions were retrieved. Through the second selection process based on the described criteria, the study group agreed on 15 PRO-CTCAE symptoms explored by 30 PRO-CTCAE items to be appropriate and relevant for the bladder population during medical oncological treatment.

Conclusions

The selection of disease specific PROs in a bladder cancer population was feasible. The process revealed several steps of selection needed in order to reach a final module for clinical application.

Electronic supplementary material

The online version of this article (10.1186/s41687-019-0141-2) contains supplementary material, which is available to authorized users.

Recommendations for design and analysis of health examination surveys under selective non-participation

Background

The decreasing participation rates and selective non-participation peril the representativeness of health examination surveys (HESs).

Methods

Finnish HESs conducted in 1972-2012 are used to demonstrate that survey participation rates can be enhanced with well-planned recruitment procedures and auxiliary information about survey non-participants can be used to reduce selection bias.

Results

Experiments incorporated to pilot surveys and experience from previously conducted surveys lead to practical improvements. For example, SMS reminders were taken as a routine procedure to the Finnish HESs after testing their effect on a pilot study and finding them as a cost-effective way to increase participation rate especially among younger age groups. Auxiliary information about survey non-participants can be obtained from many sources: sampling frames, previous measurements in longitudinal setting, re-contacts and non-response questionnaires, and record linkage to administrative data sources. These data can be used in statistical modelling to adjust the population level estimates for the selection bias. Information on the characteristics of non-participants also helps to improve targeting the recruitment in the future.

Conclusion

All methods discussed and recommended are relatively easy to incorporate to any national HES in Europe except the record linkage of survey data from administrative data sources. This is not feasible in all European countries because of non-existence of registries, lack of an identifier needed for record linkage, or national data protection legislation which restricts the data use.

Analysis of non-respondent pregnant women who were registered in the Japan Environment and Children's Study: a longitudinal cohort study

OBJECTIVES

Non-response to questionnaires in a longitudinal study reduces the effective sample size and introduces bias. We identified the characteristics of non-respondent pregnant women, and compared them with respondents in the Japan Environment and Children's Study (JECS) during the gestational period.

DESIGN

This was a questionnaire-based, longitudinal cohort study.

SETTING

Questionnaires were provided by research coordinators to mothers at prenatal examinations (at obstetrics clinics) or by mail. Mothers were measured twice: during the first trimester and during the second/third trimester.

PARTICIPANTS

Data were collected from the 10 129 participating mothers of the 10 288 children surveyed in the 2011 baseline JECS. We excluded responses from mothers who had a miscarriage or stillbirth; therefore, we analysed data from 9649 participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data concerning demographics, medical history, health characteristics, health-related behaviour and environmental exposure were collected via self-administered questionnaires. The response status of participants' partners and contact with their obstetrician were also examined. Multivariate logistic regression analysis was used to examine factors related to non-response.

RESULTS

Response was associated with living with one's mother-in-law (ORs: 0.47, 95% CIs: 0.24 to 0.85), positive participation of participants' partner (OR: 0.25, 95% CI: 0.17 to 0.35) and multiple visits to the obstetrician (OR: 0.02, 95% CI: 0.02 to 0.03). Participants who had a medical history of allergic rhinitis, had body pain or drank alcohol had higher odds of responding (ORs: 0.68, 0.96 and 0.36, 95% CIs: 0.48 to 0.95 and 0.95 to 0.98 and 0.16 to 0.72, respectively); those exposed to secondary smoke had lower odds of responding (OR: 1.59, 95% CI: 1.12 to 2.23).

CONCLUSIONS

The non-response rate decreased when participants reported health-related behaviour or characteristics. Obtaining the understanding of people around each participant might help increase response rates.

Correcting for non-participation bias in health surveys using record-linkage, synthetic observations and pattern mixture modelling

Surveys are key means of obtaining policy-relevant information not available from routine sources. Bias arising from non-participation is typically handled by applying weights derived from limited socio-demographic characteristics. This approach neither captures nor adjusts for differences in health and related behaviours between participants and non-participants within categories. We addressed non-participation bias in alcohol consumption estimates using novel methodology applied to 2003 Scottish Health Survey responses record-linked to prospective administrative data. Differences were identified in socio-demographic characteristics, alcohol-related harm (hospitalisation or mortality) and all-cause mortality between survey participants and, from unlinked administrative sources, the contemporaneous general population of Scotland. These were used to infer the number of non-participants within each subgroup defined by socio-demographics and health outcomes. Synthetic observations for non-participants were then generated, missing only alcohol consumption. Weekly alcohol consumption values among synthetic non-participants were multiply imputed under missing at random and missing not at random assumptions. Relative to estimates adjusted using previously derived weights, the obtained mean weekly alcohol intake estimates were up to 59% higher among men and 16% higher among women, depending on the assumptions imposed. This work demonstrates the universal value of multiple imputation-based methodological advancement incorporating administrative health data over routine weighting procedures.

Alcohol’s harms to others: the self-rated health of those with a heavy drinker in their lives

Background

Studies have examined the self-rated health (SRH) of the drinker, but only few have examined the health of those affected by a heavy drinker. This Nordic study aimed to examine the association between exposure to heavy drinkers and SRH.

Methods

Data come from surveys from the five Nordic countries that participated in the Reducing Alcohol-Related Harm Standardized European Survey in 2015 (n = 7065 aged 18–64 years). Variables included a five-point Likert-scale question on one’s SRH, a question on whether the respondent knew a heavy drinker in the last 12 months, and covariates. The ‘fair’, ‘poor’ and ‘very poor’ response categories were combined and are referred to as poor SRH. Multiple logistic regression models were used to examine the relationship between knowing a heavy drinker and one’s SRH.

Results

Country-pooled adjusted analyses showed a significant relationship between knowing (and being negatively affected by) a heavy drinker and poor SRH [odds ratios (OR) = 1.39, 95% confidence intervals (CI): 1.02–1.89 for heavy drinker in household; OR = 1.23, 95% CI: 1.07–1.42 for other known heavy drinker, compared to not knowing a heavy drinker or knowing a heavy drinker, but not being negatively affected]. A graded relationship appeared such that increasing proximity of the known heavy drinker increased likelihood to report poor SRH.

Conclusion

Knowing and being negatively affected by someone close who drinks heavily increases the likelihood of reporting poor SRH. These results have implications for public health messaging regarding the well-being of relatives of heavy drinkers.

Validation of non-participation bias methodology based on record-linked Finnish register-based health survey data: a protocol paper

INTRODUCTION

Decreasing participation levels in health surveys pose a threat to the validity of estimates intended to be representative of their target population. If participants and non-participants differ systematically, the results may be biased. The application of traditional non-response adjustment methods, such as weighting, can fail to correct for such biases, as estimates are typically based on the sociodemographic information available. Therefore, a dedicated methodology to infer on non-participants offers advancement by employing survey data linked to administrative health records, with reference to data on the general population. We aim to validate such a methodology in a register-based setting, where individual-level data on participants and non-participants are available, taking alcohol consumption estimation as the exemplar focus.

METHODS AND ANALYSIS

We made use of the selected sample of the Health 2000 survey conducted in Finland and a separate register-based sample of the contemporaneous population, with follow-up until 2012. Finland has nationally representative administrative and health registers available for individual-level record linkage to the Health 2000 survey participants and invited non-participants, and the population sample. By comparing the population sample and the participants, synthetic observations representing the non-participants may be generated, as per the developed methodology. We can compare the distribution of the synthetic non-participants with the true distribution from the register data. Multiple imputation was then used to estimate alcohol consumption based on both the actual and synthetic data for non-participants, and the estimates can be compared to evaluate the methodology's performance.

ETHICS AND DISSEMINATION

Ethical approval and access to the Health 2000 survey data and data from administrative and health registers have been given by the Health 2000 Scientific Advisory Board, Statistics Finland and the National Institute for Health and Welfare. The outputs will include two publications in public health and statistical methodology journals and conference presentations.