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Stress is a widespread phenomenon and young people especially are experiencing high levels of stress. School-related factors are the most frequently self-reported stressors among adolescents, but few interventions have targeted the school environment. This study evaluated the effectiveness of the Healthy High School (HHS) intervention on stress at a 9-month follow-up. The study included 5201 first-year high school students (~16 years) in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (N = 15). Baseline measurements were conducted in August 2016 and the follow-up was conducted in May 2017. The intervention was designed to promote well-being (primary outcome) by focusing on physical activity, meals, sleep, sense of security, and stress (secondary outcomes). The intervention comprised: structural initiatives at the school level; a teaching material; peer-led innovation workshops; and a smartphone app. The 10-item Perceived Stress Scale was used to measure stress. Intervention effects on perceived stress were estimated using an intention-to-treat approach with multiple imputations of missing data and multilevel general linear regression modelling. A total of 4577 students answered the baseline questionnaire. No statistically significant difference was found in stress between students at intervention and control schools at the follow-up (mean score: 16.7 versus 16.7, adjusted b = 0.42, 95% CI: −0.16;1.00). The HHS Study is one of the first large randomized controlled trials targeting school environmental stressors. Potential implementation failures and the failures of the program theory are discussed.

Ensomhed er prævalent i ungdommen. Langvarig ensomhed har alvorlige konsekvenser for unges hverdag, sundhed og trivsel både på kort og lang sigt. Flere studier tyder på, at unges etniske baggrund har betydning for om og hvor meget de føler sig ensomme. Formålet med disse interview var at undersøge unges oplevelser og erfaringer med ensomhed.

Loneliness has previously been linked to cognitive and attentional bias, and such biases may have a detrimental impact on perceived scholastic self-beliefs. Little is known about the relationship in school-aged adolescents. The current study examined the association between loneliness and scholastic self-beliefs in a nationally representative Danish sample of adolescents (aged 11-, 13- and 15 years, n = 3815, collected in 2014 by the Health Behaviour in School-aged Children study (HBSC)). Through binary logistic regressions, results demonstrated that higher levels of loneliness, measured by a single item and a composite score, were associated with poorer self-reported achievement perception, higher feelings of school dissatisfaction, and greater feelings of school pressure. Results also suggested gender played a moderating role. The current study highlights the importance of loneliness for scholastic self-beliefs, and provides a novel insight by utilising distinct loneliness measures. The implications, in relation to research and practise, are discussed.

Chronic backpain among adolescents is important because the prevalence is high, above 10%, and more than 10% of all adolescents experience impacts on important day-to-day activities. Chronic backpain tracks into adulthood and is associated with several health problems. The objective was to study trends in the prevalence of chronic backpain among adolescents 1991-2018, to examine the association with socioeconomic status (SES), and whether this association changed over time. The study used data from eight comparable cross-sectional school surveys of nationally representative samples of 11-15-year-olds in 1991, 1994, 1998, 2002, 2006, 2010, 2014, and 2018, which constitute the Danish arm of the international Health Behaviour in School-aged Children (HBSC) study. The participation rate was 74.6% of the eligible study population, n = 29,952. Chronic backpain was defined as self-reported backpain daily or several days a week during the last 6 months. The prevalence of chronic backpain was 11.1%, significantly increasing from 8.9% in 1991 to 11.7% in 2018. The OR for chronic backpain was 1.20 (95% CI: 1.10-1.31) in middle, and 1.56 (95% CI: 1.41-1.73) in low compared to high SES. Sensitivity analyses with two other cut-points for backpain frequency showed similar associations.Conclusion: Chronic backpain is common among adolescents and the prevalence increased from 1991 to 2018. The prevalence was highest in lower SES families. We recommend increased efforts to prevent chronic backpain. What is Known: • Chronic backpain among adolescents is common, has a high burden of disability, is associated with several health problems, and tracks into adulthood. What is New: • The prevalence of chronic backpain among adolescents in Denmark increased from 8.9% in 1991 to 11.7% in 2018. • The prevalence was highest among adolescents from lower SES families.

Purpose Workplace and study environments generally provide opportunities for social connectedness, however, not all individuals in such settings are equally well connected. It is possible that potential mental health benefits of participation in social leisure activities may be greater for individuals that lack social connectedness through a workplace or study environment. This study aims to examine if the association between social leisure activities and mental health is moderated by the degree of social connectedness at work/school. Design/methodology/approach Data stem from 2,406 adults (age range 16-64 years old) from The Danish Mental Health and Well-Being Survey 2016. Validated scales were used to measure mental well-being and depression/anxiety symptoms. Multivariable linear regression analyses were conducted. Findings Participation in social leisure activities (i.e. participation in community/social groups such as a sports association, art club, book club, running group, card game club, cultural or political group) was positively associated with mental well-being and negatively associated with depression/anxiety symptoms. The associations were stronger among individuals feeling less socially connected at work/school and strongest among individuals that were unemployed or not enrolled in education. Originality/value Mental health promotion strategies may focus on promoting social leisure activities especially among unemployed or otherwise socially isolated groups, as well as among individuals that are not well connected at their workplace or school. Workplaces and schools may also monitor employee/student social connectedness and potentially intervene accordingly.

Background Previous literature has examined the societal costs of mental illness, but few studies have estimated the costs associated with mental well-being. In this study, a prospective analysis was conducted on Danish data to determine 1) the association between mental well-being (measured in 2016) and government expenditure in 2017, specifially healthcare costs and sickness benefit transfers. Methods Data stem from a Danish population-based survey of 3,508 adults (aged 16 + years) in 2016, which was linked to Danish registry data. A validated scale (WEMWBS) was used for the assessment of mental well-being. Costs are expressed in USD PPP. A two-part model was applied to predict costs in 2017, adjusting for sociodemographics, health status (including psychiatric morbidity and health behaviour), as well as costs in the previous year (2016). Results Each point increase in mental well-being (measured in 2016) was associated with lower healthcare costs ($− 42.5, 95% CI = $− 78.7, $− 6.3) and lower costs in terms of sickness benefit transfers ($− 23.1, 95% CI = $− 41.9, $− 4.3) per person in 2017. Conclusions Estimated reductions in costs related to mental well-being add to what is already known about potential savings related to the prevention of mental illness. It does so by illustrating the savings that could be made by moving from lower to higher levels of mental well-being both within and beyond the clinical range. Our estimates pertain to costs associated with those health-related outcomes that were included in the study, but excluding other social and economic outcomes and benefits. They cover immediate cost estimates (costs generated the year following mental well-being measurement) and not those that could follow improved mental well-being over the longer term. They may therefore be considered conservative from a societal perspective. Population approaches to mental health promotion are necessary, not only to potentiate disease prevention strategies, but also to reduce costs related to lower levels of mental well-being in the non-mental illness population. Our results suggest that useful reductions in both health care resource use and costs, as well as in costs due to sick leave from the workplace, could be achieved from investment in mental well-being promotion within a year.

Process evaluation of public health interventions is important for understanding intervention results and can help explain why interventions succeed or fail. This study evaluated implementation of a school-based intervention combining educational and environmental strategies to prevent stress among Danish high school students. We investigated dose delivered, dose received, fidelity, appreciation, barriers and facilitators at the 15 intervention schools using mixed methods and multiple data sources: questionnaires among students, teachers and school coordinators; semi-structured interviews with school coordinators; telephone interviews with student counsellors; and focus group interviews with students and teachers. Implementation varied by schools and classes. Half of the intervention schools delivered the environmental strategies. For the educational strategies, dose delivered differed according to intervention provider. Students reported a lower dose received compared with dose delivered reported by school staff. Overall, student counsellors, school coordinators and students—especially those with low perceived stress—were satisfied with the stress preventive initiatives while teacher satisfaction varied. Five main barriers and three facilitators for implementation were identified. The use of multiple data sources and data methods created new knowledge of the implementation process which is important for the interpretation of effect evaluation and development of future interventions.

Aims: We examined the relationship between loneliness and health among young adolescents. We also investigated the validity of a single-item measure of loneliness by comparing this to a composite score. Methods: The current data come from a nationally representative sample of 11- to 15-year-old adolescents ( N=3305; F=52%) from Denmark collected in 2014 as part of the Health Behaviour in School-aged Children (HBSC) collaborative cross-national survey. Results: A series of binary logistic regressions showed that higher loneliness among adolescents, whether measured using the single- or multi-item measurement, was associated with poorer self-rated health, higher frequency of headache, stomach ache, backache, difficulties sleeping, greater sleep disturbance and more instances of feeling tired in the morning. Those associations were relatively consistent across sex and age groups. Conclusions: Loneliness is associated with poorer self-reported health and sleep problems among young adolescents. Those findings are similar across two measures of loneliness, suggesting robust findings. The development of interventions and health-education efforts to fight loneliness in adolescence is important.

Background The prevalence of low well-being, perceived stress and unhealthy behaviours is high among high school students, but few interventions have addressed these problems. The aim of this paper is to present a study protocol of a cluster randomised controlled trial evaluating the Healthy High School (HHS) intervention programme. The intervention programme is designed to improve well-being (primary outcome) by preventing 1) stress and promoting 2) sleep, 3) sense of community, 4) physical activity (PA) and 5) regular and healthy meals among high school students in Denmark. Methods The development of the HHS study was guided by the Intervention Mapping protocol. The intervention comprises four components: 1) a teaching material, 2) a smartphone app, 3) a catalogue focusing on environmental changes, and 4) a peer-led innovation workshop aiming at inspiring students to initiate and participate in various movement activities. The HHS study employs a cluster-randomised controlled trial design. Thirty-one high schools across Denmark were randomly allocated to intervention (16 schools) or control (15 schools) groups. The study included all first-year students (~ 16 years of age) (n = 5976 students). Timeline: Intervention: August 2016 – June 2017. Collection of questionnaire data: Baseline (August 2016), 1st follow-up (May 2017) and 2nd follow-up (April 2018). All students were invited to participate in a monthly sub-study about perceived stress using text messages for data collection (September 2016 – June 2017). PA was objectively assessed among a sub-sample of students using accelerometers (Axivity, AX3) in August 2016 and May 2017. Primary outcome measures: Student well-being measured by the Cantril Ladder and the five item World Health Organisation Well-being Index (individual level outcomes). Secondary outcome measures: Stress (10-item Perceived Stress Scale), sleep (quantity and quality), PA (hours of moderate-to-vigorous PA per week, hours of daily sedentary time and average daily PA), meal habits (daily intake of breakfast, lunch, snacks and water), and strong sense of community in class and at school, respectively (individual level outcomes). The study encompasses process and effect evaluation as well as health economic analyses. Trial registration ISRCTN ISRCTN43284296, 28 April 2017, retrospectively registered.

Many young adolescents experiment with substance use which can have substantial health implications later in life. This study examined trends in substance use among Danish adolescents from 2002 to 2018, including exclusive and dual current use of alcohol and cigarettes. Data on 13- and 15-year-olds (N = 15,295) from five comparable cross-sectional Health Behavior in School-aged Children (HBSC) surveys were used. Cochran-Armitage test for trend assessed the development in substance use patterns over time. Overall, a decreasing trend in current use of alcohol and cigarettes was found among Danish adolescents during the 16-year study period: from 71.7% in 2002 to 51.6% in 2018. In 2018, most adolescents (41.8%) currently used alcohol exclusively, 8.6% had a dual current use of cigarettes and alcohol, and 1.3% smoked cigarettes exclusively. Trends in alcohol use differed according to age groups, while no gender-specific trends in substance use were found. Findings suggest that a significant prevention potential in adolescent substance use remains, and future initiatives may focus on dual use of substances as well as tailored efforts to specific subgroups in high risk of using substances.

An amendment to this paper has been published and can be accessed via the original article.

Purpose The purpose of this paper is to investigate the overall campaign reach and impact of the ABCs of Mental Health in Denmark; a secondary objective is to investigate how mental health-promoting beliefs and actions are associated with good mental health. Design/methodology/approach A questionnaire was administered to two representative cross-sectional samples of the Danish population (1,508 respondents in 2019; 1,507 respondents in 2021) via an online survey. The data were subsequently pooled together into one sample consisting of 3,015 respondents. In addition to questions pertaining to campaign reach and impact, the questionnaire also included a validated scale for mental well-being and questions about beliefs and actions in regard to enhancing mental health. Findings About 7.6% had been reached by the campaign (familiar with ABC name or messages), or 11.9% when also counting familiarity with campaign slogans. Among these, respondents reported (proportions in parentheses) that the campaign had 1) made them reflect on their mental health (74.2%), talk to friends and family about mental health (35.5%), given them new knowledge about what they can do to enhance mental health (78.4%), or take action to enhance their own mental health (16.2%). An internal well-being locus of control and proactive behaviours towards enhancing mental health are shown to be associated with higher mean scores on mental well-being, lower odds of low mental well-being and higher odds of higher mental well-being. Originality/value An internal well-being locus of control and proactive behaviours towards enhancing mental health are suggested to both prevent low levels of mental well-being and promoting high levels of mental well-being. The results indicate that the ABCs of Mental Health campaign may be implemented to promote such beliefs and actions universally throughout the population.

Peer-led interventions are highlighted as promising strategies to promote health among adolescents, but little is known about the mechanisms underlying this approach. To better understand the role of peer mentors (PMs) as implementers in school-based health promotion, we combined participant observations, focus group interviews and video recordings to explore high school students' reception of a peer-led intervention component (YoungActive). YoungActive aimed to increase well-being among first-year high school students (∼16 years of age) through the promotion of movement and sense of community and was implemented during the school year 2016-2017 in a larger school-based intervention study, the Healthy High School study in Denmark. The Healthy High School study was designed as a cluster-randomized controlled trial with 15 intervention schools and 15 control schools. At each intervention school, university students in Sports Science and Health (members of the research group) facilitated an innovation workshop aiming at inspiring all first-year students to initiate movement activities at schools. The findings illustrate potentials and challenges implied in the PM role. The peer mentors' profound commitment, as well as their response and sensibility to situational contingencies, were found to be significant for the students' reception and experience of the intervention. In conclusion, the specific job of PMs as implementers seems to consist of simultaneously following a manual and situationally adjusting in an emerging context balancing commitment and identification to the target group and the intervention project.Peer-delivery of health promotion is highlighted as a promising strategy to reach adolescents, but little is known about the mechanisms underlying this approach. To better understand the role of peer mentors (PMs) as implementers, we used qualitative methods to explore high school students’ reception of a peer-led workshop (YoungActive) in a school-based intervention in Denmark. YoungActive aimed to increase well-being among first-year high school students (∼16 years of age) through the promotion of movement and sense of community and was implemented during the school year 2016–2017. At each intervention school, university students in Sports Science and Health facilitated an innovation workshop to inspire all first-year students to initiate movement activities at schools. We found different potentials and challenges implied in the PM approach. Balancing peer mentors’ commitment and identification to the recipients and the intervention seems central.

Underweight among adolescents is an important clinical and public health issue. It is associated with adverse health outcomes throughout the life-span and may reflect food poverty, unhealthy eating habits, or some underlying health conditions.To study prevalence and trends in underweight among adolescents 1998-2018, to examine social inequality in underweight, and whether social inequality changed over time.Data were derived from 6 cross-sectional school surveys from The Health Behaviour in School-aged Children study in Denmark. The study included 11-, 13-, and 15-year-old schoolchildren in random samples of schools in 1998, 2002, 2006, 2010, 2014, and 2018 (n = 22,177). Underweight was determined by body mass index-for-age thinness grade 2-3 (the Cole and Lobstein method). Socioeconomic status was determined using occupational social class (the Danish OSC Measurement).The overall prevalence of underweight was 3.1% among boys and 5.3% among girls (P0.0001) and decreased by age (P0.0001) among both boys and girls. The prevalence of underweight was almost stable from 1998 to 2018. There was no observed absolute or relative social inequality in the prevalence of underweight among boys or girls.The prevalence of underweight in 11- to 15-year-olds was significantly higher among girls than boys. The prevalence remained stable from 1998 to 2018. There was no significant association between SES and prevalence of underweight. It is important to elucidate the underlying causes of underweight such as malnutrition, eating disorders, eating problems, loss of appetite, chronic diseases, insufficient knowledge of nutrients effects on bodily functions, and persistent pain.Underweight among adolescents is an important clinical and public health issue as it may reflect food poverty, unhealthy eating habits, or some underlying health problem. The aim was to study prevalence and trends in underweight among adolescents 1998–2018 and to examine social inequality in underweight. We used data from 6 cross-sectional school surveys from Denmark. Across all surveys, the number of participants was 22,177 11-, 13-, and 15-year-old students. The prevalence of thinness grades 2 and 3 were taken as indicators of underweight and were 3.1% among boys and 5.3% among girls. This prevalence was almost stable from 1998 to 2018. Contrary to overweight, which is usually more prevalent in lower socioeconomic groups, underweight was not associated with socioeconomic status. There were 2 exceptions: the prevalence of underweight among girls was highest in those from high socioeconomic groups in1998, while the prevalence among boys was highest in those from low socioeconomic groups in 2018. Underweight conditions in adolescents need careful medical examinations to elucidate the underlying causes of underweight, for example, malnutrition, eating disorders, eating problems, loss of appetite, voluntary uptake of fad diets, chronic disease, insufficient knowledge of nutrients that impact their bodily functions, mental health problems, and persistent pain.

The Healthy High School (HHS) intervention was developed to promote well-being among first-year high school students (~16 years of age) in Denmark by targeting stress, physical activity, meal habits, sleep, and sense of community. Thirty-one schools were randomly allocated to intervention (16 schools) or control (15 schools) groups in a cluster-randomized controlled trial. The purpose of this short communication was to compare characteristics of students and schools between 1) schools accepting to participate in the HHS study and non-participating schools using national survey data and 2) intervention and control schools using HHS baseline data. We included cross-sectional data from the Danish National Youth Study 2014 on 119 schools and 22,935 first-year students to characterize participating schools and students. At baseline (August 2016), students (n = 4577; 88.0%) and principals (n = 29; 96.7%) completed online questionnaires. Compared to non-participating schools, fewer HHS schools perceived their school as being popular and offered weekly sport activities outside school hours. More HHS schools had teachers engaged in health promotion activities and focused on stress prevention. The characteristics of HHS students did not differ markedly from non-participating high school students. There were no socio-demographic, outcome or contextual differences between the study arms. To ensure successful recruitment of schools it is important that the intervention meets the need of the schools and that the advantages of participation are explicit. This underlines the need for a thorough needs assessment prior to intervention development, co-creation of intervention activities with school staff, and a well-planned recruitment strategy.

This paper explores loneliness as it is understood and experienced by adolescents, with a special focus on the importance of their migration status. We recruited students from five schools following a maximum variation sampling scheme, and we conducted 15 semi-structured, individual interviews with eighth-grade adolescents (aged 14–15 years) that were immigrants, descendants, and with a Danish majority background. A thematic analysis was applied with a special focus on differences and similarities in understanding and experiencing loneliness between adolescents with diverse migration status. The results showed more similarities than differences in loneliness. Generally, loneliness was described as an adverse feeling, varying in intensity and duration, and participants referenced distressing emotions. Feeling lonely was distinguished from being alone and characterized as an invisible social stigma. A variety of perceived social deficiencies were emphasized as causing loneliness, emerging in the interrelation between characteristics of the individual and their social context. The results add to the current literature by highlighting that it is not the presence of specific individual characteristics that causes loneliness, instead, loneliness is dependent on the social contexts the individual is embedded in. Differences across migration status were few and related to variations in the adolescents’ individual characteristics. The findings highlight the importance of (1) studying the characteristics of both the individual and the social context in research on the antecedents to adolescents’ loneliness, and (2) applying this perspective in other studies on the importance of migration status.

Background Previous studies have shown that multicomponent interventions may improve meal frequency and eating habits in children, but evidence among young people is limited. This study evaluated the effect of the Healthy High School (HHS) intervention on daily intake of breakfast, lunch, water, fruit, and vegetables at 9-month follow-up. Methods The study included first-year students (≈16 years) attending high school in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (operating as usual) (N = 15). The intervention was designed to promote well-being (primary outcome) by focusing on healthy habits including meals, stress prevention, and strong peer relations. It included a curriculum, structural and organisational initiatives, a workshop, and a smartphone application. Students completed self-administered online questionnaires at the beginning of the school year and nine months later. To account for clustering of data, we used multilevel logistic regression analyses to estimate odds ratios (OR). We applied an intention-to-treat approach with multiple imputations of missing data. Results At baseline 4577 of 5201 students answered the questionnaire and 4512 at follow-up. In both groups the proportion of students eating breakfast decreased from approximately 50% to 40% from baseline to follow-up, and lunch frequency decreased from approximately 50% to 47%. Daily water intake, intake of fresh fruit and intake of vegetables remained unchanged from baseline to follow-up. There were no significant between group differences on any of the outcomes at first follow-up: breakfast: OR = 0.85 (95% CI: 0.65;1.10), lunch: OR = 0.96 (95% CI: 0.75;1.22), water intake: OR = 1.14 (95% CI: 0.92;1.40), intake of fresh fruit: (OR = 1.07, 95% CI: 0.84;1.37), vegetables: (OR = 1.01, 95% CI: 0.77;1.33). Conclusion No evidence of an effect of the HHS intervention was found for any of the outcomes. Future studies are warranted to explore how health promoting interventions can be integrated in further education to support educational goals. Moreover, how to fit interventions to the lives and wishes of young people, by also including systems outside of the school setting. Trial registration ISRCTN, ISRCTN43284296. Registered 28 April 2017 - retrospectively registered.

Background Mental disorder in childhood is an important public health issue. We aimed to examine the prospective association between parental education at childbirth and diagnosed mental disorders in young children and explore whether this association was mediated or modified by parent–child relations in infancy. Methods Prospective cohort study of all newborn was from 2002 to 2010 from 16 municipalities in the capital region of Copenhagen, Denmark, with follow-up until their 8th birthday, N = 40 762. Baseline data included information from national population registers and from health visitors’ records at child aged 0 to 10 months. Outcome variable: any mental disorder diagnosed at hospital from age 11 months to 8 years. Results Low parental education was predictive of diagnosed child mental disorder, adjusted odds ratio (AOR) = 1.83 (95% CI 1.49–2.23). Problematic parent–child relation at age 8–10 months was also predictive of mental disorder, AOR = 2.06 (1.57–2.70) but did not mediate the association between parental education and mental disorder. AOR for mental disorders was 3.24 (2.03–5.16 for the combination vocational training and problematic parent–child relation and 2.49 (1.42–4.38) for the combination primary school and problematic parent–child relation. Conclusions Low parental education and problematic parent–child relation were independent risk factors for diagnosed mental disorders in the age span of 11 months to 8 years.

Chronic backpain among adolescents is important because the prevalence and the burden of disability is high. Chronic backpain tracks into adulthood and is associated with several health problems. The objective was to study trends in the prevalence of chronic backpain among adolescents 1991-2018, to examine the association with socioeconomic status (SES) and whether this association changed over time. The study used data from eight comparable cross-sectional school-surveys of nationally representative samples of 11-15-year-olds in 1991, 1994, 1998, 2002, 2006, 2010, 2014 and 2018, the Danish arm of the international Health Behaviour in School-aged Children (HBSC) study. The participation rate was 88.0%, n=29,952. Chronic backpain was defined as self-reported backpain daily or several days a week during the last six months. The prevalence of chronic backpain was 11.1%, significantly increasing from 8.9% in 1991 to 11.7% in 2018. The OR for chronic backpain was 1.20 (1.10-1.31) in middle and 1.56 (1.41-1.73) in low compared to high OSC. Sensitivity analyses with two other cut-points for backpain frequency showed similar associations. Conclusion: Chronic backpain is common among adolescents and the prevalence increased from 1991 to 2918. The prevalence was highest in lower SES families. We recommend increased efforts to prevent chronic backpain.

Introduction Previous studies have shown that engaging in formal social participation may protect against declining mental health, but social network size (the number of close social ties a person has) may moderate the relationship. We assessed the potential moderating role of social network size using longitudinal data. Methods Nationally representative data from two consecutive waves (2011, 2013) of the SHARE survey were analyzed. The data consisted of 38,300 adults from 13 European countries aged 50 years and older in 2011. Measures pertaining to formal social participation, social network size, quality of life, and depression symptoms were used. Multivariable linear regression models were conducted. Results The majority of participants (over 70% of the sample) had a social network size of four or less close social ties. We identified significant moderations in both models. Individuals with relatively few close social ties may have benefitted from formal social participation both in terms of reductions in depression symptoms and increases in quality of life, while formal social participation among those with many social ties did not appear to be beneficial, and may even to some extent have been detrimental. Conclusions Declines in mental health specifically among those with relatively few close social ties could potentially be prevented through the promotion of formal social participation. It is possible that such strategies could have a greater impact by specifically targeting individuals that are otherwise socially isolated. High levels of formal participation among those with relatively many close social ties may not be pragmatically beneficial.

Objectives The association between socioeconomic status and recurrent abdominal pain (RAP) among adolescents is an understudied issue. No study has examined whether such an association changes over time. The aim was to examine trends in RAP among adolescents in Denmark from 1991 to 2018, to examine whether there was social inequality in RAP and whether this inequality varied over time. Methods The study used data from the Danish part of the international Health Behaviour in School-aged Children (HBSC) study of nationally representative samples of 11-, 13- and 15-year-olds. This study pooled data from eight comparable surveys from 1991 to 2018, overall participation rate 88.0%, n=30,048. The definition of RAP was self-reported stomach-ache daily or several days per week during the past six months. We reported absolute inequality as prevalence difference in RAP between low and high socioeconomic status and relative inequality as odds ratio for RAP by socioeconomic status. Results In the entire study population, 5.6% reported RAP, 3.1% among boys and 7.8% among girls. There was a significant increase in RAP from 1991 to 2018 among boys and girls, test for trend, p Conclusions The prevalence of RAP increased from 1991 to 2018. The prevalence was significantly higher among girls than among boys, and significantly higher in low socioeconomic status families. Professionals should be aware of RAP as common and potentially serious health problems among children and adolescents. In addition to clinical examination it is important to focus on improving the child’s quality of life, reduce parents’ and children’s concerns about the seriousness of the condition, and consider supplements to medicine use.

Background: Previous research has suggested that leisure activity may benefit mental health and protect against substance use among adolescents, but more research is needed to asses associations with a wide range of outcomes. The aim of this study was to assess associations between multiple leisure activities and (1) mental health outcomes and (2) substance use outcomes in a sample of Danish adolescents.Methods: Using data from the Danish part of the European School Survey Project on Alcohol and Other Drugs (ESPAD) collected in 2019, nation-wide cross-sectional data from 2,488 participants aged 15 or 16 in Denmark were analyzed to assess associations between number of leisure activity types and outcomes pertaining to mental health and substance use.Results: Our results show that engaging in multiple activity types at least once a week—as compared to one single type of activity—is associated with increased odds for high mental well-being, and reduced odds for mental health problems. Engaging in multiple activity types is also associated with reduced odds for overall substance use and for using substances as a coping method. Among those using substances, engaging in multiple activity types is associated with reduced odds of above average substance use.Conclusion: Increasing opportunities for adolescents to engage in leisure activities is suggested to be useful in enhancing mental health and preventing substance use and promoting mental health. Promoting and increasing access to leisure activities among adolescents could be a promising avenue for policy and practice.

Background The Mental Health Continuum–Short Form (MHC-SF) is a measure of positive mental health and flourishing, which is widely used in several countries but has not yet been validated in Denmark. This study aimed to examine its qualitative and quantitative properties in a Danish population sample and compare scores with Canada and the Netherlands. Methods Three thousand five hundred eight participants aged 16–95 filled out an electronic survey. Both the unidimensional and multidimensional aspects of the Danish MHC-SF were studied through bifactor modelling. Cognitive interviews examined face validity and usability. Results The general score of the Danish MHC-SF was reliable for computing unit-weighted composite scores, as well as using a bifactor model to compute general factor scores or measurement models in an SEM context. Nonetheless, subscale scores were unreliable, explaining very low variance beyond that explained by the general factor. The participants of the qualitative interviews observed problems with wording and content of the items, especially from the social subscale. The general score correlated with other scales as expected. We found substantial variation in flourishing prevalence rates between the three cultural settings. Conclusions The Danish MHC-SF produced reliable general scores of well-being. Most of the issues observed regarding the subscale scores have been shown in previous research in other contexts. The further analysis of indices of the bifactor model and the inclusion of qualitative interviews allowed for a better understanding of the possible sources of problems with the questionnaire’s subscales. The use of subscales, the substantive understanding of the general score, as well as the operationalization of the state of flourishing, require further study.

At present there are different positions regarding trends in adolescent mental health. Can we trust trend data on the mental health among adolescents in the Nordic countries? Some question the trustworthiness of adolescent self-reports, which describe ordinary daily hassles as health complaints, which cannot be interpreted as signs of mental disorders. In addition, today there is a more open climate for talking about mental issues, which can lead to an overestimation of the prevalence of mental disorders. Statistics on mental health services statistics report increased psychopharmaceutic prescriptions as well as consumption of professional care. Such data argues for increased governmental investment in adolescent mental health services. Is this pattern due to increased availability of mental health services and/or increased prevalence of mental health problems in the adolescent population? A concern is that data availability influences policymaking and allocation of resources. If there is an emphasis on self-reported data from adolescents that may an increased risk of medicalization of young people's dealing with their daily lives. If on the other hand the reported problems among young people is disregarded, this would be against the UN Child Convention. The survey data has important qualities especially if the data is analysed and reported properly. The validation of survey measure has been done both regarding psychometric quality and content validity. Advanced analysis of the data can draw a more nuanced picture. Moreover, some screening instruments have been developed as a first step towards making diagnosis. Instead the HBSC surveys ask boys and girls about their health and well-being, social environment and health behaviours. HBSC uses findings at national and international levels to gain new insights into young people's health and wellbeing, understand the social determinants of health, and inform policy and practice to improve young people's lives.

Long-term trends in mental health of school-aged children can be analysed in the HBSC study. In Sweden the proportion of the children that report at least two weekly health complaints during the last six months has increased from the first data collection 1985/1985 to the latest 2017/2018 among all age groups for both girls and boys. Among the 11-year-old it reached 41 % among girls and 30 % boys, and among 15-year-old girls 62 % and boys 35 %. Can we trust this? The prevalence of two or more weekly health complaints showed large differences by country over time and especially in 2014, when Iceland and Sweden showed an almost 10%-point larger prevalence of multiple weekly symptoms (about 35%) than Denmark, Finland and Norway (about 25%). Norway was the only country to show a decline during 2002-2014. The prevalence of sleep difficulties has increased over the 12-year period in Denmark, Iceland, and Finland. In Sweden the prevalence fell from 26% to 21% from 2002 to 2006 but rose by 10% points from 2010 to 2014. Only Norway showed a positive development over the 12-year period; the prevalence declined in 2014 to 17% the lowest prevalence of sleep difficulties in any of the five Nordic countries. The trend of excellent self-rated health for Nordic adolescents indicates a small overall improvement between 2002 and 2006 but a stable trend in the following periods up until 2014. Finland and especially Sweden shows a decline in the prevalence of students having an excellent self-rated health. The only country to show a positive development in the prevalence of students having excellent self-rated health from 2002 to 2014, is Norway. The overall prevalence of adolescents having high life satisfaction has declined in most of the Nordic countries examined.

The aim is to discuss methodological challenges for research on adolescent positive mental health. A first consideration is which questions should the measurement instrument answer. In the clinical context it should have the properties of giving enough information for making a diagnosis of high quality. In the public health context, its objective may be to give information that enables the researcher to describe trends at the population level and provide guidance on areas of intervention. The HBSC study is monitoring the health and health behaviour of school-aged children in a public health context. It is a population survey, defined by the form of data collection and the method of analysis. The data is collected by questionnaire from a representative sample of school-aged children. It tries to answer descriptive questions (What, who, when?), but also tries to explore causal associations (Why?), given the limitations of the cross-sectional design. Surveys have advantages: Good for gathering descriptive data; Can cover a wide range of topics. Are relatively inexpensive to use; Can include large number of respondents; and Can be analysed using a variety of existing software. Among the disadvantages can be mentioned: Self-report may lead to biased reporting; Data may provide a general picture but lack depth; Difficult to obtain adequate information on context; and Differences in understanding: it is difficult to formulate questions in such a way that it will mean exactly same thing to each respondent. The choice of measurement tools or indicators involves both theoretical and practical issues. Multidisciplinary research teams may include different theoretical traditions, which is an asset but also make it necessary to be explicit regarding overall aims of the study. Most often the theoretical issues focus one of three topics: the value of the types of data; the relative scientific rigor of the data; or basic, underlying philosophies of evaluation.

Treatment and prevention alone are unlikely to make a significant difference in reducing the burden of poor mental health and mental illness. Therefore, mental health promotion (MHP) initiatives are advocated. In 2014, the ABCs of mental health (ABCs) partnership was established in Denmark, in the partnership, partner organisations, e.g., municipalities and NGOs, use a research-based framework for MHP, the ABC-framework, to develop and implement MHP initiatives. This paper has two aims: (1) to outline the overall characteristics of these MHP initiatives, and (2) to explore local coordinator and stakeholder perceptions of the implementation processes and the impact of the MHP initiatives. Questionnaire surveys, individual interviews and group interviews were conducted during 2017&ndash, 2020. The MHP initiatives were grouped according to three strategies: building MHP capacity, campaign activities to promote mental health awareness and knowledge and establishing and promoting opportunities to engage in mentally healthy activities. The ABC-framework was positively received and viewed as providing relevant knowledge for working with MHP as well as fostering intersectoral and interprofessional collaborations. However, using a bottom-up approach to develop and implement MHP initiatives can be time-consuming and resource demanding, and it requires a deliberate balancing of local adaptability and concrete guidance when engaging stakeholders and implementers. Overall, using the ABC-framework to develop and implement MHP initiatives holds great promise for advancing and promoting MHP practice.

Background Mental well-being is fundamental for a good life. Previous literature has examined the predictors of mental disorders and continuous measures of positive mental health. Very few studies have specifically focused on the predictors of different levels of mental well-being, but those that have suggest a different picture. This study aimed to compare socioeconomic and relational/recreational behaviour predictors of different levels of mental well-being as well as common mental disorders (CMDs). Methods Data from 3508 adults aged 16+ years old from the Danish Mental Health and Well-Being Survey 2016 were linked to Danish national register-based data. Mental well-being was assessed using the Warwick-Edinburgh Mental Well-being Scale, and information on CMDs was assessed using the Patient Health Questionnaire (PHQ-4). Regression analyses were conducted to estimate the predictors of low and high mental well-being compared to moderate mental well-being and also of CMDs. Results Lower socioeconomic position (education, income and employment status) was associated with increased odds of low mental well-being and the presence of CMDs, but did not significantly predict high mental well-being. Relational/recreational behaviours (informal and formal social participation, social support and recreational activity) were associated with reduced odds of low mental well-being and CMDs, and also with increased odds of high mental well-being. Conclusions Socioeconomic predictors of high mental well-being do not mirror those of low mental well-being and CMDs, whereas relational/recreational predictors of high mental well-being do mirror those of low mental well-being and CMDs. These findings have important implications for public mental health strategies.

Summary: Background: Research indicates that social isolation and loneliness increase the risk of mental disorders, but less is known about the distinct contributions of different aspects of isolation. We aimed to distinguish the pathways through which social disconnectedness (eg, small social network, infrequent social interaction) and perceptions of social isolation (eg, loneliness, perceived lack of support) contribute to anxiety and depression symptom severity in community-residing older adults aged 57–85 years at baseline. Methods: We did a longitudinal mediation analysis with data from the National Social Life, Health, and Aging Project (NSHAP). The study included individuals from the USA born between 1920 and 1947. Validated measures on social disconnectedness, perceived isolation, and depression and anxiety symptoms were used. Structural equation modelling was used to construct complete longitudinal path models. Findings: Using data from 3005 adults aged 57–85 years, we identified two significant longitudinal mediation patterns with symptoms of depression, and two with anxiety symptoms. Overall, social disconnectedness predicted higher subsequent perceived isolation (β=0·09; p

Purpose: The aims were to examine social inequality in low life satisfaction among Danish adolescents and whether the social inequality changes over time. Methods: The study population was 20,328 11-, 13- and 15-year-olds from the Danish Health Behaviour in School-aged Children (HBSC) study 2002, 2006, 2010, 2014 and 2018 with data about life satisfaction and occupational social class (OSC). Low life satisfaction was defined as values under 6 on the Cantril Ladder. Results: The proportion with low life satisfaction was 10.5% in high, 11.7% in medium and 14.7% in low OSC (chi2-test, p < 0.0001). The OR (95% CI) for low life satisfaction was 1.25 (1.13–1.39) in medium and 1.62 (1.43–1.83) in low compared to high OSC. There was no upwards or downwards trend in low life satisfaction over time and the absolute and relative social inequality in low life satisfaction did not change from 2002 to 2018. Conclusion: The study shows that the political ambition on reducing social inequality in health and wellbeing has not been met in relation to low life satisfaction among Danish adolescents.

Introduction Previous studies have shown that formal social participation may reduce the risk of developing chronic conditions. Yet, the underlying mechanisms are largely unknown. In this study, we assessed the potential mediating roles of quality of life and depressive symptoms using longitudinal data. Method We analyzed nationally representative data from three consecutive waves (2011, 2013, 2015) of the SHARE survey, including 28,982 adults from 12 European countries aged 50 years and above at baseline. Measures were self-reported and included formal social participation (i.e. active participation within volunteer organizations, educational institutions, clubs, religious organizations, or political/civic groups), quality of life (CASP-12), depressive symptoms (EURO-D), and chronic conditions. Structural equation modeling was used to construct a focused longitudinal path model. Results Formal social participation at baseline was inversely associated with the number of chronic conditions at 4-year follow-up. We identified two significant longitudinal mediation patterns: 1) formal social participation predicted higher levels of quality of life, which in turn, predicted lower levels of chronic conditions; and 2) formal social participation predicted lower levels of depressive symptoms, which, in turn, also predicted lower levels of chronic conditions. Conclusions Formal social participation functions as a protective factor against the onset or development of chronic conditions. This association is partially explained by enhanced quality of life and diminished depressive symptoms.

Aims: The aims of this study were: (a) to examine trends in daily emotional symptoms among 11- to 15-year-olds from 1991 to 2014 in Denmark, and (b) to examine trends in social inequality in daily emotional symptoms, that is, whether the differences in prevalence between adolescents with parents of varying occupational social class changed over time. Methods: We combined seven comparable cross-sectional Health Behaviour in School-aged Children surveys ( N=31,169). Daily emotional symptoms were measured by the HBSC Symptom Check List and occupational social class (OSC) by students’ reports about parents’ occupation. We calculated absolute (per cent) differences in emotional symptoms between high and low OSC and relative differences by odds ratio for emotional symptoms by parents’ OSC. Results: Eight per cent reported at least one daily emotional symptoms, with an increasing trend from 1991 to 2014 ( p

Background Loneliness and social inequality in health are important public health concerns. We examined (i) trends in loneliness among adolescents from 1991 to 2014 in Denmark and (ii) trends in social inequality in loneliness. Methods Study population: 11–15-year olds in random samples of schools in 1991, 1994, 1998, 2006 and 2014, n = 19 096. Loneliness was measured by a single item and social background by parents’ occupational social class (OSC). We calculated absolute (%) differences in loneliness between high and low OSC and relative differences by odds ratio for loneliness. Results Across all surveys, 6.3% reported feeling lonely. The prevalence increased from 4.4% in 1991 to 7.2% in 2014. The prevalence of loneliness in high, middle and low OSC was 5.8, 5.9 and 8.0%. The increase in loneliness was more pronounced in higher than lower OSC, resulting in a decreasing absolute social inequality in loneliness. The statistical interaction between OSC and survey year was significant, P = 0.0176, i.e. the relative social inequality in loneliness also decreased from 1991 to 2014. Conclusion The prevalence of loneliness increased from 1991 to 2014. The social inequality in loneliness decreased in both absolute and relative terms because of a rising prevalence of loneliness among children from high OSC.

Fatigue is frequent in cancer patients undergoing chemotherapy. Erythropoietins (EPO) have shown well-documented effects on these patients, and administered in pharmacological doses, may reduce the need for transfusion of blood cells and improve quality of life (QoL). An explorative, descriptive, non-randomised intervention study using semi-structured interviews was conducted with the aim to gain an insight into the effects and experiences associated with EPO treatment in combination with a structured 6-week physical exercise intervention. Sixteen cancer patients with evidence of disease, who had received at least one cycle chemotherapy, participated. Participants received 500 μg Darbepoetin Alfa (DA) every 3 weeks during the intervention. Four typologies of patients were identified with regard to DA effects. The interviews revealed that eleven patients experienced some kind of immediate improvement in cognitive and emotional functioning, and subjective daily well-being. Furthermore physical improvement and changes in QoL outcomes showed no significant differences between the study group and a reference group. A significant increase in the hemoglobin concentration (7.14-7.87 mmol/L, P

Increasing numbers of migrant youth around the world mean growing numbers of heterogeneous school environments in many countries. Contradictory findings regarding the relationship between immigrant school composition (the percentage of immigrant versus non-immigrant students in a school) and adolescent peer violence necessitate further consideration. The current study examined the relationship between immigrant school composition and peer violence, considering classmate support as a potential moderator among 51,636 adolescents (50.1 % female) from 11 countries. The findings showed that a higher percentage of immigrant adolescents in a school was related to higher levels of physical fighting and bullying perpetration for both immigrant and non-immigrant adolescents and lower levels of victimization for immigrants. In environments of low classmate support, the positive relationship between immigrant school composition and fighting was stronger for non-immigrants than in environments with high classmate support. In environments of low classmate support, the negative relationship between immigrant school composition and fighting and bullying victimization was stronger for immigrant adolescents than in environments with high classmate support. In general, the contribution of immigrant school composition was modest in comparison to the contribution of classmate support. The findings emphasize that it is not just the number of immigrants in a class per se, but rather the environment in the classroom which influences levels of peer violence. The results highlight a need for school intervention programs encouraging positive relations in schools with immigrant populations.

Aims: This comparative study examines absolute and relative socioeconomic differences in emotional symptoms among adolescents using standardised data from five Nordic countries and gives recommendations on how to present socioeconomic inequality. Methods: The Health Behaviour in School-aged Children (HBSC) international cross-sectional study from 2005/2006 provided data on 29,642 11–15-year-old adolescents from nationally random samples in Denmark, Finland, Iceland, Norway and Sweden. The outcome was daily emotional symptoms. Family Affluence Scale (FAS) was used as indicator of socioeconomic position. We applied four summary measures of inequality: Prevalence Difference, Odds Ratio, Slope Index of Inequality and Relative Index of Inequality, and presented the socioeconomic inequality by a graphical illustration of the prevalence of emotional symptoms, the size of the FAS groups and the summary indices of inequality in each country. Results: The prevalence of emotional symptoms ranged from 8.1% in Denmark to 13.2% in Iceland. There were large country variations in the size of the low FAS-group ranging from 2% in Iceland to 12% in Finland. The largest absolute and relative socioeconomic inequalities were found in Iceland and the smallest in Finland for girls and in Denmark for boys. Conclusions: Emotional symptoms were more common among Nordic adolescents from low affluence families. This association appeared in the study of both absolute and relative inequality. A comprehensive presentation of socioeconomic inequality should include the prevalence of the health outcome, the size of the socioeconomic groups, and the regression line representing the summary indices of inequality.

OBJECTIVES: Young people's engagement in electronic gaming and Internet communication have caused concerns about potential harmful effects on their social relations, but the literature is inconclusive. The aim of this paper was to examine whether perceived problems with computer gaming and Internet communication are associated with young people's social relations.METHODS: Cross-sectional questionnaire survey in 13 schools in the city of Aarhus, Denmark, in 2009. Response rate 89 %, n = 2,100 students in grades 5, 7, and 9. Independent variables were perceived problems related to computer gaming and Internet use, respectively. Outcomes were measures of structural (number of days/week with friends, number of friends) and functional (confidence in others, being bullied, bullying others) dimensions of student's social relations.RESULTS: Perception of problems related to computer gaming were associated with almost all aspects of poor social relations among boys. Among girls, an association was only seen for bullying. For both boys and girls, perceived problems related to Internet use were associated with bullying only.CONCLUSIONS: Although the study is cross-sectional, the findings suggest that computer gaming and Internet use may be harmful to young people's social relations.

OBJECTIVES: This study examined the relationship between trustful communication with parents and frequency of emotional symptoms in schoolchildren and whether this relationship was modified by the family's socio-economic position.METHODS: Pooled data (n = 15,646) from the Danish Health Behaviour in School-aged Children surveys 2002, 2006 and 2010 were analysed by multilevel multivariable logistic regression.RESULTS: 8 % of all schoolchildren reported emotional symptoms almost daily. Odds ratio for daily symptoms was 2.1 (1.8-2.4) for children without trustful communication with parents compared to children with trustful communication. This association appears unaffected by family occupational class. A substantial socio-economic gradient in emotional symptoms persisted, independent of parent-child communication.CONCLUSIONS: Trustful communication with parents might have a fundamental importance, regardless of socio-economic position.