- Socioeconomic position and prediagnostic health care contacts in children with cancer in Denmark: a nationwide register study. - Hypothesized mechanisms include prediagnostic utilization of and navigation through the health care system, which may differ by socioeconomic resources of the families. - In this nationwide register-based study we investigated the association between measures of family socioeconomic position in relation to prediagnostic health care contacts and stage of disease at diagnosis in children with cancer in Denmark.. - We fitted multivariable conditional logistic regression models for the association of family socioeconomic and health-related variables with firstly, frequent health care contacts and secondly, advanced stage.. - Results: We found higher odds ratios (OR) of frequent both overall and emergency health care contacts in the last 3 months before diagnosis in children from households with short parental education and mixed affiliation to work market, when compared to children with high family socioeconomic position. - was observed in the UK, where the health care system is also characterized by GPs acting as gatekeepers to specialized health care [26]. - To our knowledge, no pre- vious study has addressed the association between SEP, prediagnostic health care contacts and stage at diagnosis in children with cancer. - In this nationwide study, we took advantage of the high-quality registry data of Denmark to examine the association between SEP and the number of health care contacts during the 24 months prior to a childhood cancer diagnosis with a particular focus on the last 3 months before diagnosis. - Moreover, in a subpopulation, we assessed the association between SEP and stage of disease at diagnosis and examined whether number of health care contacts may mediate such an association.. - Indicators of SEP included highest parental education in the household categorized into short (<. - Health care contacts. - The Danish National Health Service Register holds in- formation on all contacts and procedures/services in the primary health care sector in Denmark since while the NPR has registered all hospital admissions since 1978 and outpatient and emergency contacts since 1994 [39]. - Information on all health care contacts in- cluding date and contact type were collected for 24 months prior to the child’s diagnosis. - Based on the distribution of health care contacts throughout the full period of 24 months prior to diagnosis, we de- fined the period of primary interest as the period im- mediately up to diagnosis. - Descriptive analyses were performed to describe the number of children diagnosed with cancer at ages 0–15 years in total and by highest parental education in the household. - Logistic regression was used to estimate multivariate- adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between selected socioeconomic variables and the odds of frequent contacts to the health care system in the last 3 months before diagnosis for all contacts and emergency contacts respectively. - In the first model we adjusted for sex, period of diagnosis and age at diagnosis (as a con- tinuous variable), highest parental education in the household and household cohabitation, and in the sec- ond model we additionally adjusted for total number of contacts in the 24 months before diagnosis (as a con- tinuous variable). - Contacts with the health care system. - Frequent contacts with the health care system. - Analyzing specifically the last 3 months prior to diagno- sis, children from families with short parental education had higher ORs of frequent contacts to the health care system across diagnostic groups compared to families with long education (Table 2), although only statistically significant for CNS tumors (OR: 1.81. - Table 1 Characteristics of the study population by highest parental education in the household. - Characteristics Highest parental education in the household a Total. - 95% CI than girls Table 1 Characteristics of the study population by highest parental education in the household (Continued). - a Highest parental education in the household categorized into short (<. - Highest parental education in the household Short Medium Long. - 1 Distribution of pre-diagnostic contacts to the health care system in children diagnosed with cancer 0 – 24 months before diagnosis by highest parental education in the household, diagnostic group and time since diagnosis. - Long 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.). - Parents as couple 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.). - Fifth quintile 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.). - At work 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.). - Denmark 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.). - 1 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.). - No 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.) 1 (Ref.). - For each socioeconomic variable, the models are adjusted for sex, diagnostic group (as an interaction term in the model, where we estimate the OR for each diagnostic group), diagnosis period and age at diagnosis (continuous), highest parental education in the household and household cohabitation status. - health care contacts did not change the estimates consider- ably (Table 4), nor did excluding age from the models.. - In this unique nationwide register-based study with min- imal risk of bias, there seems to be an association be- tween several indicators of family SEP, parental health and prediagnostic health care contacts among children diagnosed with cancer in Denmark. - Further, our analyses indicate increased use of emergency health care among families with short education, mixed affiliation to work market and non-Western origin in the last 3 months before diagnosis and point towards possible differences in utilization and understanding of the health care system by socioeconomic group in Denmark. - Socioeconomic differences in the number of prediag- nostic health care contacts were also found in an earlier Danish population-based study, which showed that chil- dren with cancer had more contacts than their cancer- free peers and further that children with cancer from low- and medium-income families had higher odds of frequent contacts to their GP compared to high-income families the last 3 months prior to diagnosis [19]. - Taking together, these observations and our findings point to- wards possible differences in understanding of the health care system by SEP. - An increased contact frequency among families with low SEP may thus be due to socioeconomic differences in health liter- acy and/or a social gradient in the communication be- tween families and health care professionals [44, 45].. - Anyhow, in Denmark, all health care services for children are free in both the primary and secondary health care system and the parent ’ s social or health resources should formally not Table 3 Odds ratio (95% CI) of frequent emergency contacts to the health care system. - Long 20 270 1 (Ref.) 1 (Ref.). - Parents as couple 31 480 1 (Ref.) 1 (Ref.). - No NA 503 1 (Ref.) 1 (Ref.). - Long 19 21 1 (Ref.) 1 (Ref.). - Parents as couple 38 46 1 (Ref.) 1 (Ref.). - Long NA 30 1 (Ref.) 1 (Ref.). - Parents as couple 26 49 1 (Ref.) 1 (Ref.). - No 26 53 1 (Ref.) 1 (Ref.). - Long 34 NA 1 (Ref.) 1 (Ref.). - Parents as couple 53 26 1 (Ref.) 1 (Ref.). - No 57 27 1 (Ref.) 1 (Ref.). - be a barrier for bringing the child to health care services.. - To our knowledge, this is the first as- sessment of SEP in relation to prediagnostic health care contacts and stage of disease at diagnosis in chil- dren with cancer. - Parents as couple 20 50 1 (Ref.) 1 (Ref.). - No 20 53 1 (Ref.) 1 (Ref.). - Long NA 19 1 (Ref.) 1 (Ref.). - Parents as couple 11 39 1 (Ref.) 1 (Ref.). - No NA 38 1 (Ref.) 1 (Ref.). - Long NA NA 1 (Ref.) 1 (Ref.). - a Model 1 is adjusted for sex, diagnosis period and diagnosis age (as a continuous variable), highest parental education in the household and household cohabitation status.. - Our findings indicate that family circumstances like parental education, affiliation to the work market, and depression are associated with increased overall utilization of the health care system before diagnosis of childhood cancer while additionally to these SEP indicators also being of non-Western origin was asso- ciated with increased utilization of acute health care.. - There may be a potential for redu- cing the number of contacts and the time to diagnosis by ensuring support for families who struggle to navigate through the health care system when their child is sick.. - org/10.1186/s x.. - Additional file 1: Supplementary Table 1 Number of all contacts and emergency contacts to the health care system in children diagnosed with cancer 0 – 24 months before diagnosis by time before diagnosis and diagnostic group.. - 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