Health inequalities in Germany and in international comparison: trends and developments over time

Temporal dynamics of socioeconomic inequalities in depressive and anxiety symptoms during the COVID-19 pandemic: a scoping review

Background

The existence of socioeconomic inequalities in the prevalence of symptoms of depression and anxiety is widely acknowledged, and individuals from lower socioeconomic backgrounds tend to exhibit higher rates of symptoms. However, the direction in which the COVID-19 pandemic has influenced these disparities remains uncertain. We therefore aimed to systematically outline the available evidence on the temporal dynamics of socioeconomic inequalities in symptoms related to depression and anxiety during the COVID-19 pandemic across high-income countries.

Methods

A scoping review was conducted by searching the databases Embase, Scopus and PsycINFO. According to pre-defined eligibility criteria, two reviewers independently screened titles and abstracts as well as full texts of the compiled records. Data from the included studies were extracted using a standardised data-extraction form and analysed numerically and narratively. The scoping review followed the PRISMA-ScR guidelines.

Results

A total of 49 studies comprising 149 analyses of socioeconomic indicators in relation to symptoms of depression and anxiety were included. Despite heterogeneous study designs and results, there was a tendency of increasing (40.9%; n = 61) or persistent (38.2%; n = 57) inequality trends to the detriment of those in socially more disadvantaged positions. Increasing inequalities were most pronounced when income was used as a socioeconomic indicator. Groups with lower socioeconomic status appeared most vulnerable in the initial phase of the COVID-19 pandemic. Throughout the pandemic, dynamics were diverse, with persistent trends most frequently reported.

Conclusion

Overall, to the detriment of those with lower socioeconomic status, mental-health inequalities persisted or increased in most analyses. Continually monitoring socioeconomic inequalities over time is crucial, since this makes it possible to adapt prevention and intervention strategies to specific pandemic phases. Interventions targeting job security, income security and educational attainment could reduce mental-health inequalities. The results can contribute to preparedness plans for future pandemics and crises.

Intersectional inequalities in somatic symptom severity in the adult population in Germany found within the SOMA.SOC study

Somatic symptoms are common in a wide range of medical conditions. In severe cases, they are associated with high individual and economic burden. To explore social inequalities in somatic symptom severity (SSS) and to identify social groups with highest SSS, we applied an intersectional research approach. Analyses are based on cross-sectional data of the adult population living in Germany (N = 2413). SSS was assessed with the Somatic Symptom Scale-8. A multiple linear regression model with three-way interaction of gender, income and history of migration and post-hoc pairwise comparison of estimated marginal means was conducted. Analyses revealed intersectional inequalities in SSS along the axis of gender, income, and history of migration. Highest SSS was found in males with low income whose parent(s) immigrated, females with low income who immigrated themselves, and females with low income and no history of migration. Intersectional approaches contribute to a more comprehensive understanding of health disparities. To reduce disparities in SSS, proportionate universal interventions combining universal screening and targeted treatment seem promising.

Aci-bench: a Novel Ambient Clinical Intelligence Dataset for Benchmarking Automatic Visit Note Generation

Recent immense breakthroughs in generative models such as in GPT4 have precipitated re-imagined ubiquitous usage of these models in all applications. One area that can benefit by improvements in artificial intelligence (AI) is healthcare. The note generation task from doctor-patient encounters, and its associated electronic medical record documentation, is one of the most arduous time-consuming tasks for physicians. It is also a natural prime potential beneficiary to advances in generative models. However with such advances, benchmarking is more critical than ever. Whether studying model weaknesses or developing new evaluation metrics, shared open datasets are an imperative part of understanding the current state-of-the-art. Unfortunately as clinic encounter conversations are not routinely recorded and are difficult to ethically share due to patient confidentiality, there are no sufficiently large clinic dialogue-note datasets to benchmark this task. Here we present the Ambient Clinical Intelligence Benchmark (ACI-BENCH) corpus, the largest dataset to date tackling the problem of AI-assisted note generation from visit dialogue. We also present the benchmark performances of several common state-of-the-art approaches.

A Novel Methodological Approach to Measure Linear Trends in Health Inequalities: Proof of Concept With Adolescent Smoking in Europe

We describe a new method for presenting and interpreting linear trends in health inequalities, and present a proof-of-concept analysis of inequalities in smoking among adolescents in Europe. We estimated the regression line of the assumed linear relationship between smoking prevalence in low- and high-socioeconomic status (SES) youth over time. Using simulation, we constructed a 95% confidence interval (CI) for the smoking prevalence in low-SES youth for when this would be 0% in high-SES youth, and we calculated the likelihood of eradicating smoking inequality (<5% for both low and high SES). This method was applied to data on adolescents aged 15-16 years (n = 250,326) from 23 European countries, derived from the 2003-2015 European Survey Project on Alcohol and Other Drugs. Smoking prevalence decreased more slowly among low- than among high-SES adolescents. The estimated smoking prevalence was 9.4% (95% CI: 6.1, 12.7) for boys and 5.4% (95% CI: 1.4, 9.2) for girls with low SES when 0% with high SES. The likelihood of eradicating smoking inequality was <1% for boys and 37% for girls. We conclude that this novel methodological approach to trends in health inequalities is feasible in practice. Applying it to trends in smoking inequalities among adolescents in Europe, we found that Europe is currently not on track to eradicate youth smoking across SES groups.

Temporal Dynamics of Socioeconomic Inequalities in COVID-19 Outcomes Over the Course of the Pandemic—A Scoping Review

Objectives: International evidence of socioeconomic inequalities in COVID-19 outcomes is extensive and growing, but less is known about the temporal dynamics of these inequalities over the course of the pandemic.

Methods: We systematically searched the Embase and Scopus databases. Additionally, several relevant journals and the reference lists of all included articles were hand-searched. This study follows the PRISMA guidelines for scoping reviews.

Results: Forty-six studies were included. Of all analyses, 91.4% showed stable or increasing socioeconomic inequalities in COVID-19 outcomes over the course of the pandemic, with socioeconomically disadvantaged populations being most affected. Furthermore, the study results showed temporal dynamics in socioeconomic inequalities in COVID-19, frequently initiated through higher COVID-19 incidence and mortality rates in better-off populations and subsequent crossover dynamics to higher rates in socioeconomically disadvantaged populations (41.9% of all analyses).

Conclusion: The identified temporal dynamics of socioeconomic inequalities in COVID-19 outcomes have relevant public health implications. Socioeconomic inequalities should be monitored over time to enable the adaption of prevention and interventions according to the social particularities of specific pandemic phases.

Trends and Changes in Socio-Economic Inequality in Self-Rated Health among Migrants and Non-Migrants: Repeated Cross-Sectional Analysis of National Survey Data in Germany, 1995-2017

Socio-economic inequalities in health may change over time, and monitoring such change is relevant to inform adequate policy responses. We aimed to quantify socio-economic inequalities in health among people with direct, indirect and without migration background in Germany and to assess temporal trends and changes between 1995 and 2017. Using nationally representative survey data from the Socio-Economic Panel (SOEP), we quantified absolute and relative socio-economic inequalities in self-reported general health by calculating the slope (SII) and relative index of inequality (RII) with 95% confidence intervals (CI) among each group and year (1995−2017) in a repeated cross-sectional design. Temporal trends were assessed using a GLM regression over the SII and RII, respectively. The total sample size comprised 492,489 observations, including 108,842 (22.23%) among people with migration background. About 31% of the population with and 15% of the population without migration background had a low socio-economic status. Socio-economic inequalities in health persisted in the group with migration background (1995 to 2017), while inequalities in the non-migrant population increased (SII: βTrend = 0.04, p < 0.01) and were on a higher level. The highest socio-economic inequalities in health were found among those with direct migration background (βSII, min = −0.23, p< 0.01; βSII, max = −0.33, p < 0.01). The results show that the magnitude and temporal dynamics of inequalities differ among populations with direct, indirect and without migration background. Monitoring systems can capture and investigate these inequalities if migrant populations are adequately integrated into the respective systems.

Trends in educational disparities in preventive behaviours, risk perception, perceived effectiveness and trust in the first year of the COVID-19 pandemic in Germany

BACKGROUND

Educational disparities in health and health behaviours have always been relevant in public health research and are particularly challenging in the context of the COVID-19 pandemic. First studies suggest that factors important for the containment of the COVID-19 pandemic, such as prevention behaviour, risk perception, perceived effectiveness of containment measures, and trust in authorities handling the pandemic, vary by educational status. This study builds on recent debate by examining trends in absolute and relative educational disparities in these factors in the first year of the COVID-19 pandemic in Germany.

METHODS

Data stem from four waves of the GESIS Panel surveyed between March and October 2020 in Germany (15,902 observations from 4,690 individuals). Trends in absolute and relative disparities were examined for preventive behaviour, risk perception, perceived effectiveness of COVID-19 containment measures, and trust in individuals and institutions handling the COVID-19 pandemic by educational status using sex, age, residence, nationality, children under 16 living in household, family status, household size, the Big Five Inventory, and income class as control factors. Descriptive statistics as well as unadjusted and adjusted linear regression models and random effects models were performed.

RESULTS

We observed an initially rising and then falling trend in preventive behaviour with consistent and significant absolute and relative disparities with a lower preventive behaviour among low educated individuals. Indication of a U-shaped trend with consistent significantly lower values among lower educated individuals was found for risk perception, whereas perceived effectiveness and trust decreased significantly over time but did not significantly vary by educational status.

CONCLUSIONS

Results indicate persistent educational disparities in preventive behaviour and risk perception and a general decline in perceived effectiveness and trust in the first year of the COVID-19 pandemic in Germany. To address this overall downward trend and existing disparities, comprehensive and strategic management is needed to communicate the risks of the pandemic and the benefits of COVID-19 containment measures. Both must be adapted to the different needs of educational groups in particular in order to overcome gaps in preventive behaviour and risk perception by educational status.

Association Between Health Literacy and Work Ability in Employees With Health-Related Risk Factors: A Structural Model

INTRODUCTION

In workplace health promotion (WHP), health literacy and work ability are considered as outcomes of high interest. Therefore, the question arises as to what extent individual health literacy skills have an impact on work ability alongside sociodemographic influences.

OBJECTIVES

This study aimed to examine the associations between a structural model of health literacy as well as sociodemographic context factors and the work ability among employees with health-related risk factors.

MATERIALS AND METHODS

The study was based on baseline data of a workplace-related intervention (158 employees with health-related risk factors, 53.8% women, 48 ± 10 years). Health literacy skills were assessed with Lenartz's Questionnaire (measuring "self-perception", "proactive approach to health", "dealing with health information", "self-control", "self-regulation", and "communication and cooperation"). Work ability was measured by the German Short Form of the Work Ability Index (WAI). As sociodemographic context factors, sex, age, and educational level were assessed. The associations were examined using structural equation modeling with partial least squares (SmartPLS 2.0.M3). Common quality criteria were applied and significance level was set at α = 5%.

RESULTS

Model's reliability, validity, and structure could be validated. Regarding the impact on work ability, "self-regulation" showed a statistically significant direct effect (ß = 0.32, t (∞) = 4.00, p < 0.01, f 2 = 0.09) and "self-perception" had a significant indirect effect (ß = 0.13, t (∞) = 2.53, p < 0.05). The only additional association with work ability was found for age (ß = -0.25, t (∞) = 3.82, p < 0.01, f 2 = 0.04). The WAI score variance was explained to 17.5% by the health literacy skills and to 27.5% considering the additional sociodemographic context factors.

CONCLUSION

According to the structural model of health literacy, in employees with health-related risk factors, a target group-specific WHP approach could be the encouragement of self-regulation and self-perception. However, additional resources and conditions influencing work ability should be considered.

Small-Area Factors and Their Impact on Low Birth Weight-Results of a Birth Cohort Study in Bielefeld, Germany

Introduction: The location of residence is a factor possibly contributing to social inequalities and emerging evidence indicates that it already affects perinatal development. The underlying pathways remain unknown; theory-based and hypothesis-driven analyses are lacking. To address these challenges, we aim to establish to what extent small-area characteristics contribute to low birth weight (LBW), independently of individual characteristics. First, we select small-area characteristics based on a conceptual model and measure them. Then, we empirically analyse the impact of these characteristics on LBW. Material and methods: Individual data were provided by the birth cohort study "Health of infants and children in Bielefeld/Germany." The sample consists of 892 eligible women and their infants distributed over 80 statistical districts in Bielefeld. Small-area data were obtained from local noise maps, emission inventory, Google Street View and civil registries. A linear multilevel analysis with a two-level structure (individuals nested within statistical districts) was conducted. Results: The effects of the selected small-area characteristics on LBW are small to non-existent, no significant effects are detected. The differences in proportion of LBW based on marginal effects are small, ranging from zero to 1.1%. Newborns from less aesthetic and subjectively perceived unsafe neighbourhoods tend to have higher proportions of LBW. Discussion: We could not find evidence for negative effects of small-area factors on LBW, but our study confirms that obtaining adequate sample size, reliable measure of exposure and using available data for operationalisation of the small-area context represent the core challenges in this field of research.