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Wende D, Karmann A, Weinhold I. Deprivation as a fundamental cause of morbidity and reduced life expectancy: an observational study using German statutory health insurance data. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2024; 24:257-277. [PMID: 38580883 DOI: 10.1007/s10754-024-09374-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/11/2024] [Indexed: 04/07/2024]
Abstract
Across all developed countries, there is a steep life expectancy gradient with respect to deprivation. This paper provides a theoretical underpinning for this gradient in line with the Grossman model, indicating that deprivation affects morbidity and, consequently, life expectancy in three ways: directly from deprivation to morbidity, and indirectly through lower income and a trade-off between investments in health and social status. Using rich German claims data covering 6.3 million insured people over four years, this paper illustrates that deprivation increases morbidity and reduces life expectancy. It was estimated that highly deprived individuals had approximately two more chronic diseases and a life expectancy reduced by 15 years compared to the least deprived individuals. This mechanism of deprivation is identified as fundamental, as deprived people remain trapped in their social status, and this status results in health investment decisions that affect long-term morbidity. However, in the German setting, the income and investment paths of the effects of deprivation were of minor relevance due to the broad national coverage of its SHI system. The most important aspects of deprivation were direct effects on morbidity, which accumulate over the lifespan. In this respect, personal aspects, such as social status, were found to be three times more important than spatial aspects, such as area deprivation.
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Affiliation(s)
- Danny Wende
- BARMER Institute for Health Systems Research, Berlin, Germany.
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Raspe H, Lill C. [Inflammatory Bowel Diseases: Regional Deprivation, Disease Characteristics and Relevant Health Care]. DAS GESUNDHEITSWESEN 2023; 85:149-157. [PMID: 34560799 DOI: 10.1055/a-1530-5529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
HINTERGRUND Regionale Deprivation ist als ökologischer Parameter eine Komponente der sozialen Determinanten von Gesundheit. Zu ihrer Messung stehen in Deutschland der "German Index of Multiple Deprivation" (GIMD) und der "German Index of Socioeconomic Deprivation" (GISD) zur Verfügung. Chronisch entzündliche Darmerkrankungen (CED) sind keine häufigen, aber ernste körperliche Erkrankungen unklarer Ätiologie, mit vergleichsweise frühem Auftreten im Erwachsenenalter, oft chronisch-behandlungsbedürftigem Verlauf und unsicherer Prognose. Daten einer kontrollierten Versorgungsstudie erlauben es, Assoziationen zwischen regio-naler Deprivation und Merkmalen der Krankheit und ihrer Versorgung zu untersuchen. Wir erwarteten ungünstigere Krankheitsverhältnisse bei höherer Deprivation. METHODIK Vorgestellt werden deskriptive Zusatzauswertungen (n=530) der 2016 bis 2019 durchgeführten MERCED-Studie zu Wirksamkeit und Nutzen einer stationären medizinischen Rehabilitation bei Sozialversicherten mit einer CED. Analysiert wurden Daten aus der Basisbefragung zu selbstberichteten Krankheitsmerkmalen, Krankheitsfolgen und Versorgungsleistungen in ihrem Zusammenhang mit dem Ausmaß regionaler Deprivation der Wohnregion (Kreisebene). ERGEBNISSE Die Zuordnung der Wohnregion der Kranken zu den Quintilen von GIMD und GISD korrelieren unter rho=0,76 miteinander (gewichtetes kappa=0,74). Regionale Deprivation zeigt, gemessen mit dem GIMD, überzufällige Unterschiede allein in den sozialen Teilhabeeinschränkungen (IMET) und der Zahl der "Einschränkungstage". Dabei schildern sich Personen aus dem niedrigsten Deprivationsquintil als am stärksten eingeschränkt. Für die Einschränkungstage findet sich ein irre-guläres Muster. Beim GISD wird eine unsystematische Variation der gesundheitsbezogenen Lebensqualität (EQ-VAS) statistisch auffällig. Auch hier berichten Personen mit der geringsten regionalen Deprivation von einer besonders schlechten Lebensqualität. In einem Extremgruppenvergleich weisen Personen, die in nach GIMD und GISD stark deprivierten Regionen leben, günstigere Werte im Krankheitsverlauf beim IMET und EQ-VAS auf. Auch für Parameter der medizinischen Versorgung lassen sich keine systematischen Zusammenhänge mit den Deprivationsindizes darstellen. SCHLUSSFOLGERUNG Krankheitsmerkmale, Krankheitsfolgen und die medizinische Versorgung von CED-Kranken zeigen sich weitgehend unabhängig vom Ausmaß der mit zwei Indizes bestimmten regionalen Deprivation. Die wenigen auffälligen Unterschiede weisen in eine überraschende Richtung: Personen aus deprivierten Regionen berichten günstigere Krankheitsverhältnisse. BACKGROUND As an ecological parameter, area deprivation is one component of the social determinants of health. For Germany two indices to measure area deprivation are currently available: The German Index of Multiple Deprivation (GIMD) and the German Index of Socioeconomic Deprivation (GISD). Inflammatory bowel diseases (IBD) are not frequent but severe diseases of so far unknown etiology, comparatively early manifestation in adulthood, often chronic course requiring long-lasting medical attention, and uncertain prognosis. Data of a controlled health care trial enable us to study associations between area deprivation and disease and treatment variables. We expected more unfavourable conditions with increasing level of deprivation. METHODS We present secondary descriptive analyses of an RCT on effectiveness and benefit of medical inpatient rehab of 530 socially insured IBD patients. We used data from the initial assessment of numerous self-reported disease characteristics, consequences of disease, and health care items in relation to the extent of area deprivation at patients' county ("Kreis") level. RESULTS Grouped into quintiles, patients' results from GIMD and GISD are closely correlated (rho=0.76; weighted kappa=0.74). Regional deprivation, as assessed by GIMD, shows noticeable associations only with participation restriction (IMET scale) and number of disability days. However, subjects from least deprived areas report highest restrictions whereas the distribution of disability days exhibits an irregular pattern. GISD data are weakly and unsystematically related to quality of life measurements. Again, patients from least deprived areas show a considerably low quality of life. A comparison of two extreme groups (very low vs. very high deprivation in GIMD and GISD combined) corroborates the finding: Subjects from highly deprived areas report in general more favourable disease characteristics. We found no association between deprivation and any health care item. CONCLUSION Disease characteristics, psychosocial consequences, and health care of IBD seem to be mainly independent of the extent of area deprivation. The few statistically noticeable associations are unexpected: Patients from more deprived counties give more favourable reports.
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Affiliation(s)
- Heiner Raspe
- Zentrum für Bevölkerungsmedizin und Versorgungsforschung, Universität zu Lübeck, Lübeck, Deutschland
| | - Cassandra Lill
- Institut für Sozialmedizin und Epidemiologie, Universität zu Lübeck, Lübeck, Deutschland
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Nübler L, Busse R, Siegel M. The role of consumer choice in out-of-pocket spending on health. Int J Equity Health 2023; 22:24. [PMID: 36721164 PMCID: PMC9890873 DOI: 10.1186/s12939-023-01838-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 01/21/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Analyses of out-of-pocket healthcare spending often suffer from an inability to distinguish necessary from optional spending in the data without making further assumptions. We propose a two-dimensional rating of the spending categories often available in household budget survey data where we consider the requirement to pay for necessary healthcare as one dimension and the incentive to pay extra for additional services, higher quality options or more convenience as a second dimension to assess the distortionary potential of higher spending for additional healthcare or higher quality options. METHODS We use three waves of a large German Household Budget Survey and decompose the Kakwani-index of total out-of-pocket healthcare spending into contributions of the eleven spending categories available in our data, across which user charge regulations vary considerably. We compute and decompose Kakwani-indexes for the different spending categories to compare the degrees of regressiveness across them. RESULTS The results suggest that categories with higher incentives for additional spending exhibit smaller contributions to the overall regressive effect of total out-of-pocket spending than categories where spending is presumably mostly on necessary and effective care. CONCLUSIONS Assessing the consumer choice potential of different spending categories is important because extra spending among the better-off may outweigh necessary spending in aggregate expenditure data, and may also hint at potential inequalities in the quality of provided healthcare.
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Affiliation(s)
- Laura Nübler
- grid.6734.60000 0001 2292 8254Department of Empirical Health Economics, Technische Universität Berlin, H51, Straße des 17. Juni 135, 10623 Berlin, Germany
| | - Reinhard Busse
- grid.6734.60000 0001 2292 8254Department of Healthcare Management, Technische Universität Berlin, Berlin, Germany ,Berlin Centre of Health Economics Research (BerlinHECOR), Berlin, Germany
| | - Martin Siegel
- grid.6734.60000 0001 2292 8254Department of Empirical Health Economics, Technische Universität Berlin, H51, Straße des 17. Juni 135, 10623 Berlin, Germany ,Berlin Centre of Health Economics Research (BerlinHECOR), Berlin, Germany
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Contoyannis P, Hurley J, Walli-Attaei M. When the technical is also normative: a critical assessment of measuring health inequalities using the concentration index-based indices. Popul Health Metr 2022; 20:21. [PMID: 36456956 PMCID: PMC9713974 DOI: 10.1186/s12963-022-00299-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 09/25/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Concentration index-based measures are one of the most popular tools for estimating socioeconomic-status-related health inequalities. In recent years, several variants of the concentration index have been developed that are designed to correct for deficiencies of the standard concentration index and which are increasingly being used. These variants, which include the Wagstaff index and the Erreygers index, have important technical and normative differences. MAIN BODY In this study, we provide a non-technical review and critical assessment of these indices. We (i) discuss the difficulties that arise when measurement tools intended for income are applied in a health context, (ii) describe and illustrate the interrelationship between the technical and normative properties of these indices, (iii) discuss challenges that arise when determining whether index estimates are large or of policy significance, and (iv) evaluate the alignment of research practice with the properties of the indices used. Issues discussed in parts (i) and (ii) include the different conceptions of inequality that underpin the indices, the types of changes to a distribution which leave inequality unchanged and the importance of the measurement scale and range of the outcome variable. These concepts are illustrated using hypothetical examples. For parts (iii) and (iv), we reviewed 44 empirical studies published between 2015 and 2017 and find that researchers often fail to provide meaningful interpretations of the index estimates. CONCLUSION We propose a series of questions to facilitate further sensitivity analyses and provide a better understanding of the index estimates. We also provide a guide for researchers and policy analysts to facilitate the critical assessment of studies using these indices, while helping applied researchers to choose inequality measures that have the normative properties they seek.
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Affiliation(s)
- Paul Contoyannis
- grid.25073.330000 0004 1936 8227Department of Economics and the Center for Health Economics and Policy Analysis, McMaster University, Hamilton, ON Canada
| | - Jeremiah Hurley
- grid.25073.330000 0004 1936 8227Department of Economics and the Center for Health Economics and Policy Analysis, McMaster University, Hamilton, ON Canada
| | - Marjan Walli-Attaei
- grid.413615.40000 0004 0408 1354Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON L8L 2X2 Canada
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Impact of subjective and objective neighbourhood characteristics and individual socioeconomic position on allostatic load: A cross-sectional analysis of an all-age UK household panel study. Health Place 2022; 78:102930. [DOI: 10.1016/j.healthplace.2022.102930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 10/14/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022]
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Chen X, Woo J, Yu R, Chung GKK, Yao W, Yeoh EK. Subjective Social Status, Area Deprivation, and Gender Differences in Health among Chinese Older People. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9857. [PMID: 36011511 PMCID: PMC9408352 DOI: 10.3390/ijerph19169857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
This study examined the gender differences in the main and interactive effects of subjective social status and area deprivation on health among older adults in Hong Kong. Data for this study came from the baseline of MrOs and MsOs studies, including 4000 Chinese men and women ≥ 65 in Hong Kong. Subjective social status was assessed using the MacArthur Scale of subjective social status scale. Our results reaffirm that subjective social status is an independent indicator of health after adjusting for objective SES measures (e.g., education and income). Perceived rank on the community ladder was more closely related to health among older people than was the society ladder, particularly for women. Although area-level social deprivation was not significantly associated with the health of older people, it may moderate the effect of subjective social status on health. Women with a lower perceived status in the community were more likely to experience depressive symptoms but better grip strength when living in more deprived neighborhoods. The findings suggested that subjective social status provides important information for the physical and mental health of the older population. Policymakers may implement interventions to enhance the subjective social status of older adults. Given the greater contribution of relative status in the community to the health of women, these policies and interventions should target to improve women's perceived status in the community.
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Affiliation(s)
- Xi Chen
- Department of Sociology and Social Policy, Lingnan University, Hong Kong SAR, China
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jean Woo
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ruby Yu
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gary Ka-Ki Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wei Yao
- Department of Sociology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Eng-Kiong Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
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Pointon L, Howe AS, Hobbs M, Paynter J, Gauld N, Turner N, Willing E. Evidence of suboptimal maternal vaccination coverage in pregnant New Zealand women and increasing inequity over time: A nationwide retrospective cohort study. Vaccine 2022; 40:2150-2160. [PMID: 35248420 PMCID: PMC9352189 DOI: 10.1016/j.vaccine.2022.02.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/12/2022] [Accepted: 02/23/2022] [Indexed: 11/24/2022]
Abstract
Background Adequate maternal vaccination coverage is critical for the prevention and control of infectious disease outbreaks such as pertussis, influenza, and more recently COVID-19. To guide efforts to increase vaccination coverage this study examined the extent of vaccination coverage in pregnant New Zealand women over time by area-level deprivation and ethnicity. Methods A retrospective cohort study was used consisting of all pregnant women who delivered between 01 January 2013 and 31 December 2018, using administrative health datasets. Outcomes were defined as receipt of influenza or pertussis vaccination in any one of the relevant data sources (National Immunisation Register, Proclaims, or Pharmaceutical collection) during their eligible pregnancy. Ethnicity was prioritised as Māori (NZ indigenous), Pacific, Asian, and Other or NZ European and deprivation was defined using New Zealand Index of Multiple Deprivation (IMD). Results Between 2013 and 2018, Asian women had the highest maternal vaccination coverage (36%) for pertussis, while Māori and Pacific women had the lowest, 13% and 15% respectively. Coverage of pertussis vaccination during pregnancy in low deprivation Māori women was 24% and 28% in Pacific women. This is in comparison to 30% and 25% in high deprivation Asian and European/Other women, respectively. Similar trends were seen for influenza. Conclusion Between 2013 and 2018 maternal vaccination coverage increased for pertussis and influenza. Despite this coverage remains suboptimal, and existing ethnic and deprivation inequities increased. There is an urgent need to focus on equity, to engage and support ethic communities by creating genuinely accessible, culturally appropriate health services.
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Affiliation(s)
- Leah Pointon
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Anna S Howe
- School of Health Sciences, University of Canterbury, Christchurch, Canterbury, New Zealand; Immunisation Advisory Centre, University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child and Youth Health, University of Auckland, New Zealand.
| | - Matthew Hobbs
- School of Health Sciences, University of Canterbury, Christchurch, Canterbury, New Zealand; GeoHealth Laboratory, University of Canterbury, Christchurch, Canterbury, New Zealand
| | - Janine Paynter
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Natalie Gauld
- Department of Paediatrics: Child and Youth Health, University of Auckland, New Zealand; School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Nikki Turner
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, Auckland, New Zealand; Immunisation Advisory Centre, University of Auckland, Auckland, New Zealand
| | - Esther Willing
- Kōhatu - Centre for Hauora Māori, Division of Health Sciences, University of Otago, New Zealand
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Liu H, Wang M. Socioeconomic status and ADL disability of the older adults: Cumulative health effects, social outcomes and impact mechanisms. PLoS One 2022; 17:e0262808. [PMID: 35143499 PMCID: PMC8830695 DOI: 10.1371/journal.pone.0262808] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/06/2022] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Socioeconomic status (SES) is one of the important indicators affecting individual's social participation and resource allocation, and it also plays an important role in the health shock of individuals. Faced by the trend of aging society, more and more nations across the world began to pay attention to prevent the risk of health shock of old adults. METHODS Based on the data of China Health and Retirement Longitudinal Study (CHARLS) in 2013, 2015 and 2018, this study uses path analysis and ologit model to empirically estimate the effects of SES and health shock on the activities of daily living (ADL) disability of old adults. RESULTS As a result, first, it was found that SES has significant impact on the disability of old adults. Specifically, economic conditions (income) plays dominant role. Economic status affects the risk of individual disability mainly through life security and health behavior. Secondly, SES significantly affecting health shock, with education and economic status showing remarkable impact, and there is an apparent group inequality. Furthermore, taking high education group as reference, the probability of good sight or hearing ability of the low education group was only 49.76% and 63.29% of the high education group, respectively, while the rates of no pain and severe illness were 155.50% and 54.69% of the high education group. At last, the estimation of path effect of SES on ADL disability indicates evident group inequality, with health shock plays critical mediating role. CONCLUSIONS SES is an important factor influencing residents' health shock, and health shocks like cerebral thrombosis and cerebral hemorrhage will indirectly lead to the risk of individual ADL disability. Furthermore, among the multi-dimensional indicators of SES, individual income and education are predominant factors affecting health shock and ADL disability, while occupation of pre-retirement have little impact.
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Affiliation(s)
- Huan Liu
- School of Public Administration, Zhejiang University of Finance & Economics, Hang Zhou, Zhejiang Province, China
| | - Meng Wang
- School of Public Administration, Zhejiang University of Finance & Economics, Hang Zhou, Zhejiang Province, China
- * E-mail:
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Grau AJ, Dienlin S, Bartig D, Maier W, Buggle F, Becher H. Regional Deprivation, Stroke Incidence, and Stroke Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:397-402. [PMID: 34304754 DOI: 10.3238/arztebl.m2021.0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/07/2020] [Accepted: 02/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes. METHODS We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses. RESULTS The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile. CONCLUSION These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.
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Affiliation(s)
- Armin J Grau
- Department of Neurology, Ludwigshafen Hospital, Ludwigshafen; Quality Assurance Agency of Rhineland-Palatinate, Mainz; DRG Market, Osnabrück; Helmholtz Center Munich - German Research Center for Health and the Environment (Ltd), Institute for Health Economics and Management in Healthcare, Neuherberg; Oberwallis Hospital Center, Visp, Switzerland; Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg
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Horizontal inequity in the utilisation of healthcare services in Australia. Health Policy 2020; 124:1263-1271. [PMID: 32950284 DOI: 10.1016/j.healthpol.2020.08.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/03/2020] [Accepted: 08/26/2020] [Indexed: 11/22/2022]
Abstract
The Australian universal healthcare system aims to ensure affordable and equitable use of healthcare services based on individual health needs. This paper presents empirical evidence on the extent of horizontal inequity (HI) in healthcare services (unequal utilisation by income for equal need) in Australia during the period of promoting reliance on private healthcare financing. Using data from the most recent Australian National Health Survey of 2011-12 and 2014-15, we examined and measured the extent of HI in eight indicators of out-of-hospital services and hospital-related care. Contrary to earlier studies, our results show a small but pro-rich inequity in the probability of general practitioner visits. Inequity in the distribution of specialist and dentist visits was in favour of richer people, a result that is commonly found in other developed countries and is also consistent with existing Australian evidence. Hospital-related care was equitably distributed compared to the pro-poor pattern found in earlier studies. Despite the universal health insurance system in Australia, there was inequity in the utilisation of needed healthcare services. Our evidence is relevant to similar health systems as governments move to higher out-of-pocket payments and other private sources to reduce pressure on public healthcare expenditure.
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Pulok MH, van Gool K, Hajizadeh M, Allin S, Hall J. Measuring horizontal inequity in healthcare utilisation: a review of methodological developments and debates. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:171-180. [PMID: 31542840 DOI: 10.1007/s10198-019-01118-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/12/2019] [Indexed: 06/10/2023]
Abstract
Equity in healthcare is an overarching goal of many healthcare systems around the world. Empirical studies of equity in healthcare utilisation primarily rely on the horizontal inequity (HI) approach which measures unequal utilisation of healthcare services by socioeconomic status (SES) for equal medical need. The HI method examines, quantifies, and explains inequity which is based on regression analysis, the concentration index, and the decomposition technique. However, this method is not beyond limitations and criticisms, and it has been subject to several methodological challenges in the past decade. This review presents a summary of the recent developments and debates on various methodological issues and their implications on the assessment of HI in healthcare utilisation. We discuss the key disputes centred on measurement scale of healthcare variables as well as the evolution of the decomposition technique. We also highlight the issues about the choice of variables as the indicator of SES in measuring inequity. This follows a discussion on the application of the longitudinal method and use of administrative data to quantify inequity. Future research could exploit the potential for health administrative data linked to social data to generate more comprehensive estimates of inequity across the healthcare continuum. This review would be helpful to guide future applied research to examine inequity in healthcare utilisation.
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Affiliation(s)
- Mohammad Habibullah Pulok
- School of Health Administration, Dalhousie University, Halifax, NS, Canada.
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, NS, Canada.
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Sydney, NSW, Australia.
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Mohammad Hajizadeh
- School of Health Administration, Dalhousie University, Halifax, NS, Canada
| | - Sara Allin
- Institute of Health Policy, Management and Evaluation, The University of Toronto, Toronto, ON, Canada
| | - Jane Hall
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Sydney, NSW, Australia
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Silbersdorff A, Schneider KS. Distributional Regression Techniques in Socioeconomic Research on the Inequality of Health with an Application on the Relationship between Mental Health and Income. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4009. [PMID: 31635091 PMCID: PMC6843976 DOI: 10.3390/ijerph16204009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/07/2019] [Accepted: 10/15/2019] [Indexed: 12/02/2022]
Abstract
This study addresses the much-discussed issue of the relationship between health and income. In particular, it focuses on the relation between mental health and household income by using generalized additive models of location, scale and shape and thus employing a distributional perspective. Furthermore, this study aims to give guidelines to applied researchers interested in taking a distributional perspective on health inequalities. In our analysis we use cross-sectional data of the German socioeconomic Panel (SOEP). We find that when not only looking at the expected mental health score of an individual but also at other distributional aspects, like the risk of moderate and severe mental illness, that the relationship between income and mental health is much more pronounced. We thus show that taking a distributional perspective, can add to and indeed enrich the mostly mean-based assessment of existent health inequalities.
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Affiliation(s)
| | - Kai Sebastian Schneider
- Department of Clinical Psychology, PFH Private University of Applied Sciences, 37073 Göttingen, Germany.
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Wende D. Spatial risk adjustment between health insurances: using GWR in risk adjustment models to conserve incentives for service optimisation and reduce MAUP. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:1079-1091. [PMID: 31197612 DOI: 10.1007/s10198-019-01079-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 06/04/2019] [Indexed: 06/09/2023]
Abstract
This paper presents a new approach to deal with spatial inequalities in risk adjustment between health insurances. The shortcomings of non-spatial and spatial fixed effects in risk adjustment models are analysed and opposed against spatial kernel estimators. Theoretical and empirical evidence suggests that a reasonable choice of the spatial kernel could limit the spatial uncertainty of the modifiable area unit problem under heavy-tailed claims data, leading to more precise predictions and economically positive incentives on the healthcare market. A case study of the German risk adjustment shows a spatial risk spread of 86 Euro p.c., leading to incentives for spatial risk selection. The proposed estimator eliminates this issue and conserves incentives for services optimisation.
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Affiliation(s)
- Danny Wende
- Wissenschaftliches Institut für Gesundheitsökonomie und Gesundheitssystemforschung (WIG2 GmbH), Markt 8, 04109, Leipzig, Germany.
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Schederecker F, Kurz C, Fairburn J, Maier W. Do alternative weighting approaches for an Index of Multiple Deprivation change the association with mortality? A sensitivity analysis from Germany. BMJ Open 2019; 9:e028553. [PMID: 31455703 PMCID: PMC6719755 DOI: 10.1136/bmjopen-2018-028553] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES This study aimed to assess the impact of using different weighting procedures for the German Index of Multiple Deprivation (GIMD) investigating their link to mortality rates. DESIGN AND SETTING In addition to the original (normative) weighting of the GIMD domains, four alternative weighting approaches were applied: equal weighting, linear regression, maximization algorithm and factor analysis. Correlation analyses to quantify the association between the differently weighted GIMD versions and mortality based on district-level official data from Germany in 2010 were applied (n=412 districts). OUTCOME MEASURES Total mortality (all age groups) and premature mortality (<65 years). RESULTS All correlations of the GIMD versions with both total and premature mortality were highly significant (p<0.001). The comparison of these associations using Williams's t-test for paired correlations showed significant differences, which proved to be small in respect to absolute values of Spearman's rho (total mortality: between 0.535 and 0.615; premature mortality: between 0.699 and 0.832). CONCLUSIONS The association between area deprivation and mortality proved to be stable, regardless of different weighting of the GIMD domains. The theory-based weighting of the GIMD should be maintained, due to the stability of the GIMD scores and the relationship to mortality.
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Affiliation(s)
- Florian Schederecker
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
- IBE - Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Germany
| | - Christoph Kurz
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
| | - Jon Fairburn
- Business School, Staffordshire University, Stoke-on-Trent, UK
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), Neuherberg, Germany
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[Indices of Multiple Deprivation for the analysis of regional health disparities in Germany : Experiences from epidemiology and healthcare research]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 60:1403-1412. [PMID: 29119206 DOI: 10.1007/s00103-017-2646-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Deprivation indices allow material and social differences at the regional level to be described in a statistically efficient and concise manner and to use these in health analyses. Following the British example, Indices of Multiple Deprivation (IMDs) are now available for Germany, the German Index of Multiple Deprivation (GIMD) as well as its regional versions. In this study, empirical experiences based on the use of these indices in health studies will be presented. METHOD The German IMDs consist of seven deprivation domains, which represent single aspects of deprivation (income, employment, and educational deprivation, municipal revenue deprivation, social capital deprivation, environment and security deprivation). Specific indicators were generated from data of official statistics and assigned to the deprivation domains. The weighted single domains were finally combined to an overall index. The German IMDs are available at a municipal level and at a district level. RESULTS Analyses using the IMDs showed significant associations between regional deprivation and mortality, morbidity and aspects of health services research. Multilevel analyses showed significant associations with regional deprivation, independent of individual factors. CONCLUSIONS The German IMDs are valid and efficient tools for the use in epidemiology and health services research, but also for health policy. When constructing deprivation indices, several methodological challenges have to be considered.
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McCann A, McNulty H, Rigby J, Hughes CF, Hoey L, Molloy AM, Cunningham CJ, Casey MC, Tracey F, O’Kane MJ, McCarroll K, Ward M, Moore K, Strain J, Moore A. Effect of Area‐Level Socioeconomic Deprivation on Risk of Cognitive Dysfunction in Older Adults. J Am Geriatr Soc 2018; 66:1269-1275. [DOI: 10.1111/jgs.15258] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Adrian McCann
- Nutrition Innovation Centre for Food and HealthUlster UniversityColeraineNorthern IrelandUnited Kingdom
| | - Helene McNulty
- Nutrition Innovation Centre for Food and HealthUlster UniversityColeraineNorthern IrelandUnited Kingdom
| | - Jan Rigby
- National Centre for GeoComputationMaynooth UniversityMaynoothIreland
| | - Catherine F. Hughes
- Nutrition Innovation Centre for Food and HealthUlster UniversityColeraineNorthern IrelandUnited Kingdom
| | - Leane Hoey
- Nutrition Innovation Centre for Food and HealthUlster UniversityColeraineNorthern IrelandUnited Kingdom
| | - Anne M. Molloy
- Institute of Molecular Medicine, School of Medicine, Trinity College DublinDublinIreland
| | | | - Miriam C. Casey
- Mercer's Institute for Research on Ageing, St James's HospitalDublinIreland
| | - Fergal Tracey
- Causeway Hospital, Northern Health and Social Care TrustColeraineNorthern IrelandUnited Kingdom
| | - Maurice J. O’Kane
- Clinical Chemistry LaboratoryAltnagelvin Hospital, Western Health and Social Care TrustLondonderryNorthern IrelandUnited Kingdom
| | - Kevin McCarroll
- Mercer's Institute for Research on Ageing, St James's HospitalDublinIreland
| | - Mary Ward
- Nutrition Innovation Centre for Food and HealthUlster UniversityColeraineNorthern IrelandUnited Kingdom
| | - Katie Moore
- Nutrition Innovation Centre for Food and HealthUlster UniversityColeraineNorthern IrelandUnited Kingdom
| | - J.J. Strain
- Nutrition Innovation Centre for Food and HealthUlster UniversityColeraineNorthern IrelandUnited Kingdom
| | - Adrian Moore
- School of Environmental SciencesUlster UniversityColeraineNorthern IrelandUnited Kingdom
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Lago S, Cantarero D, Rivera B, Pascual M, Blázquez-Fernández C, Casal B, Reyes F. Socioeconomic status, health inequalities and non-communicable diseases: a systematic review. ZEITSCHRIFT FUR GESUNDHEITSWISSENSCHAFTEN = JOURNAL OF PUBLIC HEALTH 2017; 26:1-14. [PMID: 29416959 PMCID: PMC5794817 DOI: 10.1007/s10389-017-0850-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/25/2017] [Indexed: 11/07/2022]
Abstract
AIM A comprehensive approach to health highlights its close relationship with the social and economic conditions, physical environment and individual lifestyles. However, this relationship is not exempt from methodological problems that may bias the establishment of direct effects between the variables studied. Thus, further research is necessary to investigate the role of socioeconomic variables, their composition and distribution according to health status, particularly on non-communicable diseases. SUBJECTS AND METHODS To shed light on this field, here a systematic review is performed using PubMed, the Cochrane Library and Web of Science. A 7-year retrospective horizon was considered until 21 July 2017. RESULTS Twenty-six papers were obtained from the database search. Additionally, results from "hand searching" were also included, where a wider horizon was considered. Five of the 26 studies analyzed used aggregated data compared to 21 using individual data. Eleven considered income as a study variable, while 17 analyzed the effect of income inequality on health status (2 of the studies considered both the absolute level and distribution of income). The most used indicator of inequality in the literature was the Gini index. CONCLUSION Although different types of analysis produce very different results concerning the role of health determinants, the general conclusion is that income distribution is related to health where it represents a measure of the differences in social class in the society. The effect of income inequality is to increase the gap between social classes or to widen differences in status.
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Affiliation(s)
- Santiago Lago
- GEN Governance and Economics Network-Spain, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
- Department of Applied Economics, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
| | - David Cantarero
- GEN Governance and Economics Network-Spain, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
- Department of Economics, Faculty of Business and Economics University of Cantabria, Avda. de los Castros, S/N, 39005 Santander, Spain
| | - Berta Rivera
- GEN Governance and Economics Network-Spain, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
- Department of Applied Economics, Faculty of Business and Economics University of A Coruña, Campus de Elviña, 15071 A Coruña, Spain
| | - Marta Pascual
- GEN Governance and Economics Network-Spain, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
- Department of Economics, Faculty of Business and Economics University of Cantabria, Avda. de los Castros, S/N, 39005 Santander, Spain
| | - Carla Blázquez-Fernández
- GEN Governance and Economics Network-Spain, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
- Department of Economics, Faculty of Business and Economics University of Cantabria, Avda. de los Castros, S/N, 39005 Santander, Spain
| | - Bruno Casal
- GEN Governance and Economics Network-Spain, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
- Department of Applied Economics, Faculty of Business and Economics University of A Coruña, Campus de Elviña, 15071 A Coruña, Spain
| | - Francisco Reyes
- GEN Governance and Economics Network-Spain, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
- Department of Applied Economics, Faculty of Business and Tourism University of Vigo, Campus Universitario As Lagoas s/n, 32004 Ourense, Spain
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Fairburn J, Maier W, Braubach M. Incorporating Environmental Justice into Second Generation Indices of Multiple Deprivation: Lessons from the UK and Progress Internationally. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E750. [PMID: 27472347 PMCID: PMC4997436 DOI: 10.3390/ijerph13080750] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/03/2016] [Accepted: 06/08/2016] [Indexed: 01/22/2023]
Abstract
Second generation area-based indices of multiple deprivation have been extensively used in the UK over the last 15 years. They resulted from significant developments in political, technical, and conceptual spheres for deprivation data. We review the parallel development of environmental justice research and how and when environmental data was incorporated into these indices. We explain the transfer of these methods from the UK to Germany and assess the progress internationally in developing such indices. Finally, we illustrate how billions of pounds in the UK was allocated by using these tools to tackle neighbourhood deprivation and environmental justice to address the determinants of health.
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Affiliation(s)
- Jon Fairburn
- Business School, Staffordshire University, Staffordshire ST4 2DE, UK.
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg 85764, Germany.
| | - Matthias Braubach
- European Centre for Environment and Health, World Health Organization (WHO) Regional Office for Europe, Bonn 53113, Germany.
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Siegel M, Koller D, Vogt V, Sundmacher L. Developing a composite index of spatial accessibility across different health care sectors: A German example. Health Policy 2016; 120:205-12. [PMID: 26831039 DOI: 10.1016/j.healthpol.2016.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 11/26/2015] [Accepted: 01/04/2016] [Indexed: 11/15/2022]
Abstract
The evolving lack of ambulatory care providers especially in rural areas increasingly challenges the strict separation between ambulatory and inpatient care in Germany. Some consider allowing hospitals to treat ambulatory patients to tackle potential shortages of ambulatory care in underserved areas. In this paper, we develop an integrated index of spatial accessibility covering multiple dimensions of health care. This index may contribute to the empirical evidence concerning potential risks and benefits of integrating the currently separated health care sectors. Accessibility is measured separately for each type of care based on official data at the district level. Applying an Improved Gravity Model allows us to factor in potential cross-border utilization. We combine the accessibilities for each type of care into a univariate index by adapting the concept of regional multiple deprivation measurement to allow for a limited substitutability between health care sectors. The results suggest that better health care accessibility in urban areas persists when taking a holistic view. We believe that this new index may provide an empirical basis for an inter-sectoral capacity planning.
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Affiliation(s)
- Martin Siegel
- Berlin Centre of Health Economics Research (BerlinHECOR), Department of Health Care Management, Technische Universität Berlin, H80, Straße des 17. Juni 135, 10623 Berlin, Germany..
| | - Daniela Koller
- Department of Health Services Management, Ludwig-Maximilians-Universität München, Schackstraße 4, 80539 München, Germany.
| | - Verena Vogt
- Berlin Centre of Health Economics Research (BerlinHECOR), Department of Health Care Management, Technische Universität Berlin, H80, Straße des 17. Juni 135, 10623 Berlin, Germany..
| | - Leonie Sundmacher
- Department of Health Services Management, Ludwig-Maximilians-Universität München, Schackstraße 4, 80539 München, Germany.
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Grundmann N, Mielck A, Siegel M, Maier W. Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany. BMC Public Health 2014; 14:1264. [PMID: 25495106 PMCID: PMC4301883 DOI: 10.1186/1471-2458-14-1264] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/04/2014] [Indexed: 02/06/2023] Open
Abstract
Background The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES). Methods The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity. Results We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12–1.64) as well as for obesity (OR 1.14; 95% CI 1.02–1.26). Further analyses showed that these associations were relatively similar for both men and women. Conclusions Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.
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Affiliation(s)
| | | | | | - Werner Maier
- Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany.
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