Erratum: Health in Germany: Establishment of a population-based health panel

[This corrects the article on p. 2,21 in vol. 9, PMID: 38282983.].

Corrigendum: Health in Germany: Establishment of a population-based health panel

[This corrects the article DOI: 10.25646/11992.2.].

'German Health Update Fokus (GEDA Fokus)': Study Protocol of a Multilingual Mixed-mode Interview Survey among Residents with Croatian, Italian, Polish, Syrian or Turkish Citizenship in Germany

BACKGROUND

Germany has a long history of migration. In 2020, more than every fourth person had a statistically defined, so-called 'migration background' in Germany, meaning that the person or at least one of their parents was born with a citizenship other than German. People with a history of migration are not represented proportionately to the population within public health monitoring at the Robert Koch Institute (RKI), thus impeding differentiated analyses on migration and health. In order to develop strategies to improve the inclusion of people with a history of migration in health surveys, we conducted a feasibility study in 2018. Lessons learned were implemented in the health interview survey GEDA Fokus which was conducted among people with selected citizenships representing the major migrant groups in Germany.

OBJECTIVE

The main objective of GEDA Fokus was to collect comprehensive data on the health status and social, migration-related, and structural factors among people with selected citizenships in order to enable differentiated explanations on the associations between migration-related aspects and their impact on migrant health.

METHODS

GEDA Fokus was an interview survey among people with Croatian, Italian, Polish, Syrian, or Turkish citizenship living in Germany aged 18 - 79 years, with a targeted sample size of 1,200 participants per group. The gross sample of 33,436 people was drawn out of the residents' registration offices of 99 German municipalities based on citizenship. Sequentially, multiple modes of administration were offered. The questionnaire was available for self-administration (online and paper-based); in bigger municipalities, personal or phone interviews were possible later on. Study documents and the questionnaire were bilingual, in German and the respective translation language depending on the citizenship. Data collection took place from November 2021 until May 2022.

RESULTS

Overall, 6,038 respondents participated in the survey, 49.4% were female. The median age was 39 years, and the median duration of residence in Germany was 10 years, with 19.7% of the sample being born in Germany. The overall response rate was 18.4% (AAPOR response rate 1) and was 6.8% higher in the municipalities where personal interviews were offered (19.3% vs. 12.5%). Overall, 78.2% administered the questionnaire on their own, while 21.9% took part in a personal interview. A total of 41.9% answered the questionnaire in German language only, 16.7% exclusively used the translation, and 41.4% used both languages in the bilingual version of the questionnaire.

CONCLUSIONS

Offering different modes of administration, as well as multiple study languages, enabled us to recruit a heterogeneous sample of people with a history of migration. The data collected will allow differentiated analyses of the role and interplay of migration-related and social determinants of health and their impact on the health status of people with selected citizenships.

CLINICALTRIAL

Results and Strategies for a Diversity-Oriented Public Health Monitoring in Germany

Germany is a country of immigration; 27% of the population are people with a migration background (PMB). As other countries, Germany faces difficulties in adequately including hard-to-survey populations like PMB into national public health monitoring. The IMIRA project was initiated to develop strategies to adequately include PMB into public health monitoring and to represent diversity in public health reporting. Here, we aim to synthesize the lessons learned for diversity-oriented public health monitoring and reporting in Germany. We also aim to derive recommendations for further research on migration and health. We conducted two feasibility studies (interview and examination surveys) to improve the inclusion of PMB. Study materials were developed in focus groups with PMB. A systematic review investigated the usability of the concept of acculturation. A scoping review was conducted on discrimination as a health determinant. Furthermore, core indicators were defined for public health reporting on PMB. The translated questionnaires were well accepted among the different migrant groups. Home visits increased the participation of hard-to-survey populations. In examination surveys, multilingual explanation videos and video-interpretation services were effective. Instead of using the concept of acculturation, we derived several dimensions to capture the effects of migration status on health, which were more differentiated. We also developed an instrument to measure subjectively perceived discrimination. For future public health reporting, a set of 25 core indicators was defined to report on the health of PMB. A diversity-oriented public health monitoring should include the following: (1) multilingual, diversity-sensitive materials, and tools; (2) different modes of administration; (3) diversity-sensitive concepts; (4) increase the participation of PMB; and (5) continuous public health reporting, including constant reflection and development of concepts and methods.

Sociodemographic characteristics determine download and use of a Corona contact tracing app in Germany-Results of the COSMO surveys

During the SARS-CoV-2 pandemic mobile health applications indicating risks emerging from close contacts to infected persons have a large potential to interrupt transmission chains by automating contact tracing. Since its dispatch in Germany in June 2020 the Corona Warn App has been downloaded on 25.7 Mio smartphones by February 2021. To understand barriers to download and user fidelity in different sociodemographic groups we analysed data from five consecutive cross-sectional waves of the COVID-19 Snapshot Monitoring survey from June to August 2020. Questions on the Corona Warn App included information on download, use, functionality, usability, and consequences of the app. Of the 4,960 participants (mean age 45.9 years, standard deviation 16.0, 50.4% female), 36.5% had downloaded the Corona Warn App. Adjusted analysis found that those who had downloaded the app were less likely to be female (Adjusted Odds Ratio for men 1.16 95% Confidence Interval [1.02;1.33]), less likely to be younger (Adjusted Odds Ratio for age 18 to 39 0.47 [0.32;0.59] Adjusted Odds Ratio for age 40 to 64 0.57 [0.46;0.69]), less likely to have a lower household income (AOR 0.55 [0.43;0.69]), and more likely to live in one of the Western federal states including Berlin (AOR 2.31 [1.90;2.82]). Willingness to disclose a positive test result and trust in data protection compliance of the Corona Warn App was significantly higher in older adults. Willingness to disclose also increased with higher educational degrees and income. This study supports the hypothesis of a digital divide that separates users and non-users of the Corona Warn App along a well-known health gap of education, income, and region.

[Satellite data for recording health-relevant environmental conditions: examples and interdisciplinary potential]

Environmental conditions influence human health and interact with other factors such as DNA, lifestyle, or the social environment. Earth observations from space provide data on the most diverse manifestations of these environmental conditions and make it possible to quantify them spatially. Using two examples - the availability of open and recreational space and the spatial distribution of air pollution - this article presents the potential of Earth observations for health studies. In addition, possible applications for health-related issues are discussed. To this end, we try to outline key points for an interdisciplinary approach that meets the conceptual, data technology, and ethical challenges.

Interventions to Increase the Reachability of Migrants in Germany With Health Interview Surveys: Mixed-Mode Feasibility Study

BACKGROUND

Germany is a popular destination for immigrants, and migration has increased in recent years. It is therefore important to collect reliable data on migrants' health. The Robert Koch Institute, Berlin, Germany, has launched the Improving Health Monitoring in Migrant Populations (IMIRA) project to sustainably integrate migrant populations into health monitoring in Germany.

OBJECTIVE

One of IMIRA's objectives is to implement a feasibility study (the IMIRA survey) that focuses on testing various interventions to increase the reachability of migrants with health interview surveys. Possible causes of nonresponse should be identified so as to increase participation in future surveys.

METHODS

The survey target populations were Turkish, Polish, Romanian, Syrian, and Croatian migrants, who represent the biggest migrant groups living in Germany. We used probability sampling, using data from the registration offices in 2 states (Berlin and Brandenburg); we randomly selected 9068 persons by nationality in 7 sample points. We applied age (3 categories: 18-44, 45-64, and ≥65 years) and sex strata. Modes and methods used to test their usability were culturally sensitive materials, online questionnaires, telephone interviews, personal contact, and personal interviews, using multilingual materials and interviewers. To evaluate the effectiveness of the interventions, we used an intervention group (group A) and a control group (group B). There were also focus groups with the interviewers to get more information about the participants' motivation. We used the European Health Interview Survey, with additional instruments on religious affiliation, experience of discrimination, and subjective social status. We evaluated results according to their final contact result (disposition code).

RESULTS

We collected data from January to May 2018 in Berlin and Brandenburg, Germany. The survey had an overall response rate of 15.88% (1190/7494). However, final disposition codes varied greatly with regard to citizenship. In addition to the quantitative results, interviewers reported in the focus groups a "feeling of connectedness" to the participants due to the multilingual interventions. The interviewers were particularly positive about the home visits, because "if you are standing at the front door, you will be let in for sure."

CONCLUSIONS

The IMIRA survey appraised the usability of mixed-mode or mixed-method approaches among migrant groups with a probability sample in 2 German states. When conducting the survey, we were confronted with issues regarding the translation of the questionnaire, as well as the validity of some instruments in the survey languages. A major result was that personal face-to-face contact was the most effective intervention to recruit our participants. We will implement the findings in the upcoming health monitoring study at the Robert Koch Institute.

Population-based food consumption survey as an additional tool for foodborne outbreak investigations, Germany, 2017

We conducted a food consumption survey in the general adult population of 18 years and older in Germany to obtain data on the frequency of consumption of food items that caused foodborne disease outbreaks in the past. A total of 1010 telephone interviews were completed that queried the consumption of 95 food items in the 7-day period before the interview. Survey results were weighted to be representative. Six exemplary 'high risk' food items were consumed by 6% to 16% of the general population. These were raw ground pork: 6.5%; 'Teewurst' (=spreadable sausage-containing raw pork): 15.7%; unpasteurised milk consumed without prior heating: 9.0%; food items prepared with raw eggs: 9.8%; unheated sprouts or seedlings: 8.8% and frozen berries consumed without prior heating: 6.2%. Data from our food consumption survey were comparable to data obtained from control persons in case-control studies conducted during past foodborne disease outbreak investigations. We consider our survey an additional helpful tool that will allow comparison with food consumption data from case-patients obtained in exploratory, hypothesis-generating interviews early on in outbreak investigations, and which may assist in forming hypotheses regarding associations of illnesses with suspected food vehicles. This may facilitate and accelerate investigations of future foodborne disease outbreaks.

The IMIRA (Improving Health Monitoring in Migrant Populations) - project in Germany – Lessons learned und implications for health monitoring

Background

A quarter of the population living in Germany are people with a migration background (PMB). In this context, the Robert Koch Institute (RKI) has the task of designing the health monitoring system that has been established in recent years in such a way that PMB are adequately taken into account in statements on the health situation of the German population.

Methods

The Improving Health Monitoring in Migrant Populations (IMIRA) project was initiated at the end of 2016 with the aim of improving the inclusion of MMH in health monitoring. Literature research, expert interviews and feasibility studies were carried out to identify strategies for access routes, recruitment measures, the dismantling of language barriers and the inclusion of MHH, which are incorporated into the concept of Monitoring 4.0, the further development of RKI health monitoring.

Results

In order to sustainably improve the accessibility of PMB in RKI health monitoring, a sequential study design with multilingual administration modes is planned within interview surveys. Personal contact through home visits and face-to-face interviews as well as the use of interpretation are essential to increase the willingness to participate. Strengthening the diversity sensitivity of the staff, as well as anti-discriminatory reporting, and promoting the participation of PMB and practitioners are additional components.

Conclusions

The IMIRA project has led to important findings that will be implemented in the long-term health monitoring of the RKI. The improved accessibility of PMB for health surveys enables a reflected presentation of the health situation of PMB, which does justice to the heterogeneity of the population living in Germany.

Main messages

• In order to include PMB sustainably in health monitoring we need to, develop dynamic study designs, bridge language gaps, establish personal contact, increase diversity sensibility and encourage participation of PMB in development of research processes.

Improving the information base regarding the health of people with a migration background.Project description and initial findings from IMIRA

Germany is an immigration country and nearly a quarter of its population has a migration background. Thus, there is increasingly a need for reliable information on the health situation of people with a migration background. The Robert Koch Institute is in charge of expanding its health monitoring to improve the representation of people with a migration background in interview and examination surveys. Studies adequately need to reflect the health status of people with a migration background and currently the Robert Koch Institute’s representative interview and examination surveys for adults do not fully achieve this. At the end of 2016, therefore, the Improving Health Monitoring in Migrant Populations (IMIRA) project was initiated aiming to expand the Robert Koch Institute’s health monitoring to people with migration background and improve their involvement in health surveys in the long-term. This includes carrying out two feasibility studies to test strategies to reach and recruit people with migration background for interview surveys and develop measures to overcome language barriers in examination surveys. In order to expand health reporting on migration and health, a reporting concept and a core indicator set will be developed and the potential of (secondary) data sources will be tested. Furthermore, plans foresee the testing and further development of relevant specific migration sensitive survey instruments and indicators, as well as increasing networking with relevant stakeholders.

Ad hoc surveys at the Robert Koch Institute

The Robert Koch Institute (RKI) regularly conducts nationally representative cross-sectional studies (KiGGS, DEGS and GEDA) as part of the nationwide health monitoring system. In addition to these health surveys, data is collected in telephone interviews either on specific thematic fields (such as diabetes) or specific groups (such as medical staff) that were not or only insufficiently covered by the larger health surveys. As they are flexible and fast, ad hoc surveys conducted via telephone interviews can respond to specific epidemiological and health political questions. This article describes the procedures applied in ad hoc telephone interview surveys, which were newly introduced as a standardised method in 2017 and are applied by the Laboratory for Health Surveys at the RKI. The article presents the stages of project management such as concept development, establishment of a concept for data protection, questionnaire development, pre-test and field phase, calculation of weighting factors and provision of the final data set. The aim is to describe the process and shed light on the standardised procedures, the reported quality indicators and the breadth of possible scenarios of application.

First results from the study 'Disease knowledge and information needs - Diabetes mellitus (2017)'

Very little research has been undertaken into what people in Germany know about diabetes, the information they may require about the condition, where they look for such information and how they rate the information currently available. In 2017, the Robert Koch Institute (RKI) carried out a nationwide telephone survey aimed at answering these questions. The study entitled 'Disease knowledge and information needs - Diabetes mellitus (2017)' focused on people aged at least 18 years. A total of 2,327 people without diabetes and 1,479 people with diagnosed diabetes were interviewed for the study. First results show that 56.7% of people without diabetes and 92.8% of those with diabetes rate their knowledge about the condition as 'very good' or 'good'. People without diabetes were found to have the strongest need for information in terms of 'lifestyle changes, health promotion and disease prevention', whereas respondents with diabetes stressed the strongest need for information about 'treatment and therapy'. Almost a third of respondents without diabetes have actively sought information about diabetes at least once, mostly via print media. Patients with diabetes stated that their general practitioner was their most frequent source of information about the condition. In both groups, about half of respondents reported that they found it difficult to judge the trustworthiness of the information published in the media about diabetes. The results of the study form part of the German National Diabetes Surveillance, which is coordinated by the RKI. The data are also intended to be used by the Federal Centre for Health Education to develop a strategy to improve the information provided about diabetes.

KiGGS Wave 2 cross-sectional study - participant acquisition, response rates and representativeness

For the third time, wave 2 of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), which is conducted in the context of health monitoring at the Robert Koch Institute, now provides representative cross-sectional data for Germany. Completed in 2017, data for the cross-sectional component of KiGGS Wave 2 was collected in the form of an interview and examination survey. Interview survey data was collected from 15,023 participants, meaning that the required number of participants has been reached. A randomly selected subgroup of 3,567 participants was also examined. The overall response rate was 40.1%. Differences in response rates were registered regarding certain sociodemographic characteristics. Weighting was applied to compensate for differences in willingness to participate related to age, gender, geographic region, nationality and education factors. Weighting ensures that assessments of the health of children and adolescents in Germany are representative for the population. The data serves to estimate prevalence rates and, through comparison with the results from previous survey waves, to analyse trends. A set of measures were taken to recruit a sufficiently large group of participants and ensure that the net sample reflects the composition of the overall population to the highest degree. For future surveys, further measures ought to be taken in order to improve the integration of hard-to-reach subgroups.

Mixing modes in a population-based interview survey: comparison of a sequential and a concurrent mixed-mode design for public health research

Background

Population-based surveys currently face the problem of decreasing response rates. Mixed-mode designs are now being implemented more often to account for this, to improve sample composition and to reduce overall costs. This study examines whether a concurrent or sequential mixed-mode design achieves better results on a number of indicators of survey quality.

Methods

Data were obtained from a population-based health interview survey of adults in Germany that was conducted as a methodological pilot study as part of the German Health Update (GEDA). Participants were randomly allocated to one of two surveys; each of the surveys had a different design. In the concurrent mixed-mode design (n = 617) two types of self-administered questionnaires (SAQ-Web and SAQ-Paper) and computer-assisted telephone interviewing were offered simultaneously to the respondents along with the invitation to participate. In the sequential mixed-mode design (n = 561), SAQ-Web was initially provided, followed by SAQ-Paper, with an option for a telephone interview being sent out together with the reminders at a later date. Finally, this study compared the response rates, sample composition, health indicators, item non-response, the scope of fieldwork and the costs of both designs.

Results

No systematic differences were identified between the two mixed-mode designs in terms of response rates, the socio-demographic characteristics of the achieved samples, or the prevalence rates of the health indicators under study. The sequential design gained a higher rate of online respondents. Very few telephone interviews were conducted for either design. With regard to data quality, the sequential design (which had more online respondents) showed less item non-response. There were minor differences between the designs in terms of their costs. Postage and printing costs were lower in the concurrent design, but labour costs were lower in the sequential design. No differences in health indicators were found between the two designs. Modelling these results for higher response rates and larger net sample sizes indicated that the sequential design was more cost and time-effective.

Conclusions

This study contributes to the research available on implementing mixed-mode designs as part of public health surveys. Our findings show that SAQ-Paper and SAQ-Web questionnaires can be combined effectively. Sequential mixed-mode designs with higher rates of online respondents may be of greater benefit to studies with larger net sample sizes than concurrent mixed-mode designs.

Implementation of the European health interview survey (EHIS) into the German health update (GEDA)

Background

This methodological paper describes the integration of the ‘European Health Interview Survey wave 2’ (EHIS 2) into the ‘German Health Update’ 2014/2015 (GEDA 2014/2015-EHIS).

Methods

GEDA 2014/2015-EHIS is a cross-sectional health survey. A two-stage stratified cluster sampling approach was used to recruit persons aged 15 years and older with permanent residence in Germany. Two different modes of data collection were used, self-administered web questionnaire and self-administered paper questionnaire. The survey instrument implemented the EHIS 2 modules on health status, health care use, health determinants and social background variables and additional national questions. Data processing was conducted according to the quality and validation rules specified by Eurostat.

Results

In total, 24,824 questionnaires were completed. The response rate was 27.6%. The two-stage cluster sample method seems to have been successful in achieving a sample with high representativeness. The final micro data file was inspected, approved and certified by Eurostat. Access to micro data of the EHIS 2 can be provided by Eurostat via research contract and to the GEDA 2014/2015-EHIS public use file by the Research Data Centre of the Robert Koch Institute. First EHIS 2 results are available at the Eurostat website.

Conclusions

Integrating a multinational health survey into an existing national health monitoring system was a challenge in Germany. The national survey methodology for conducting the survey had to be further developed in order to meet the overarching goal of harmonizing the health information from national statistical offices and public health research institutes across the European Union. The harmonized EHIS 2 data source will profoundly impact international public health research in the near future. The next EHIS wave 3 will be conducted around 2019.

New data for action. Data collection for KiGGS Wave 2 has been completed

The fieldwork of the second follow-up to the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) was completed in August 2017. KiGGS is part of the Robert Koch Institute's Federal Health Monitoring. The study consists of the KiGGS cross-sectional component (a nationally representative, periodic cross-sectional survey of children and adolescents aged between 0 and 17) and the KiGGS cohort (the follow-up into adulthood of participants who took part in the KiGGS baseline study). KiGGS collects data on health status, health-related behaviour, psychosocial risk and protective factors, health care and the living conditions of children and adolescents in Germany. The first interview and examination survey (the KiGGS baseline study; undertaken between 2003 and 2006; n=17,641; age range: 0-17) was carried out in a total of 167 sample points in Germany. Physical examinations, laboratory analyses of blood and urine samples and various physical tests were conducted with the participants and, in addition, all parents and participants aged 11 or above were interviewed. The first follow-up was conducted via telephone-based interviews (KiGGS Wave 1 2009-2012; n=11,992; age range: 6-24) and an additional sample was included (n=4,455; age range: 0-6). KiGGS Wave 2 (2014-2017) was conducted as an interview and examination survey and consisted of a new, nationwide, representative cross-sectional sample of 0- to 17-year-old children and adolescents in Germany, and the second KiGGS cohort follow-up. The completion of the cross-sectional component of KiGGS Wave 2 means that the health of children and adolescents in Germany can now be assessed using representative data gained from three study waves. Trends can therefore be analysed over a period stretching to over ten years now. As the data collected from participants of the KiGGS cohort can be individually linked across the various surveys, in-depth analyses can be conducted for a period ranging from childhood to young adulthood and developmental processes associated with physical and mental health and the associated risk and protective factors can be explored. As such, KiGGS Wave 2 expands the resources available to health reporting, as well as policy planning and research, with regard to assessing the health of children and adolescents in Germany.

Factors associated with parental acceptance of seasonal influenza vaccination for their children - A telephone survey in the adult population in Germany

INTRODUCTION

Influenza vaccination of children with underlying chronic diseases is currently recommended in Germany, but targeting all children constitutes an alternative approach to control seasonal influenza. To inform the modelling of vaccination impact and possible communication activities, we aimed to assess among parents the acceptance of universal childhood vaccination against seasonal influenza and possible modifiers.

METHODS

We conducted a telephone survey in households in Germany using random digit dialing. We interviewed parents with children aged <18 years by constructing three hypothetical scenarios in subsequent order: (1) hearing about the influenza vaccination recommendation through the media, (2) the vaccine being recommended by a physician, and (3) being informed about the availability of the vaccine as a nasal spray. We calculated the proportion of parents who would immunize their child and used univariable and multivariable logistic regression to identify factors associated with influenza vaccination intention.

RESULTS

Response was between 22 and 46%. Of 518 participants, 74% were female, mean age was 41.3 years. Participants had on average 1.6 children with a mean age of 8.9 years. In scenario 1, 52% of parents would immunize their child, compared to 64% in scenario 2 (p<0.01) and to 45% in scenario 3 (p=0.20). Factors independently associated with vaccination acceptance in scenario 1 were previous influenza vaccination of the child or parent (adjusted odds ratio [aOR] 4.5 and 8.6, respectively), perceived severity of influenza (aOR=5.1) and living in eastern Germany (aOR=2.4).

CONCLUSION

If seasonal influenza vaccination was recommended for all children, more than half of the parents would potentially agree to immunize their child. Involving physicians in future information campaigns is essential to achieve high uptake. As intranasal vaccine administration is non-invasive and easily done, it remains unclear why scenario 3 was associated with low acceptance among parents, and the underlying reasons should be further explored.

German Health Update: New data for Germany and Europe: The background to and methodology applied in GEDA 2014/2015-EHIS

GEDA 2014/2015-EHIS is an up-to-date health survey of the adult population undertaken within the framework of the Robert Koch Institute's (RKI) health monitoring system. It uses the EHIS (European Health Interview Survey) Wave 2 questionnaire and includes four modules covering health status, health care, health determinants, and socio-economic variables. Data on nationally relevant issues is also collected. The study employs a mixed-mode design, using both online and paper-based questionnaires to gather data from 24,016 people aged 18 and above: the response rate was 26.9%. The Statistical Office of the European Union (Eurostat) provides prepared data from 28 European Union (EU) member states (plus Norway and Iceland) on the Eurostat website. National analyses for Germany are published as Fact sheets on health reporting in the Journal of Health Monitoring.

Risk Factors for Sporadic Non-Pregnancy Associated Listeriosis in Germany-Immunocompromised Patients and Frequently Consumed Ready-To-Eat Products

Non-pregnancy associated (N-PA) listeriosis, caused by Listeria monocytogenes, is a rare but severe disease, and is predominantly food-borne. Most cases appear sporadic and their infection vehicle remains unknown. Incidence has increased since 2008 in Germany. We aimed to identify underlying conditions and foods associated with sporadic N-PA listeriosis in Germany. We performed a nationwide case-control study from March 2012-December 2013. Cases were sporadic N-PA listeriosis patients notified to public health. Control subjects were age (40-65 years, 66-75 years, ≥ 76 years) frequency-matched persons from a nationwide random telephone sample. A structured questionnaire collected information on underlying diseases, therapies and >60 food items. We conducted multivariable logistic regression analysis, adjusting for host factors identified by causal diagram theory, and calculated population attributable fractions. We enrolled 109 cases and 1982 controls. Cases' median age was 69 years, 55% were male, 44% received immunosuppressive therapy within 3 months prior to illness onset; a further 28% had at least one immunocompromising disease. In multivariable analysis, immunosuppressive therapy (OR 8.8, 95%CI 4.9-15.6), immunocompromising disease (OR 2.7; 95%CI 1.4-5.2), gastric acid suppression (OR 3.0; 95%CI 1.4-6.3), the consumption of cold cooked sausages (OR 2.6; 95%CI 1.6-4.4), the preferred consumption of packaged cheese (OR 2.1; 95%CI 1.3-3.5) and pre-sliced cheese (OR 2.2; 95%CI 1.3-3.7) were significantly associated with N-PA listeriosis. These foods accounted for 59% of all cases. Typical high risk foods, e.g. cold seafood, certain types of cheeses, tended to be negatively associated with disease. In conclusion, immunosuppressive therapy and frequently consumed ready-to-eat foods are the main risk factors for sporadic N-PA listeriosis in Germany. To reduce their risk, immunocompromised persons should consume the identified foods well before the 'use-by' date. The microbiological criteria for Listeria monocytogenes in ready-to-eat foods may insufficiently protect persons who are markedly immunocompromised.

Why are older adults and individuals with underlying chronic diseases in Germany not vaccinated against flu? A population-based study

Background

Older adults and individuals with underlying chronic diseases are at increased risk of developing influenza-related complications and are target groups for seasonal influenza vaccination in many countries. In Germany, an annual national information campaign is conducted to increase influenza vaccination uptake in the target groups. However, data are lacking on knowledge and attitudes toward influenza vaccination among older adults and those with chronic diseases. The present study aimed to (i) estimate influenza vaccination uptake for the 2012/13 and 2013/14 seasons, (ii) assess knowledge and attitudes about influenza vaccination, and (iii) identify factors associated with vaccination uptake in two risk groups.

Methods

Between March and June 2014, we conducted a nationwide cross-sectional survey in adults (≥18 years) living in Germany using computer-assisted telephone interviewing. We calculated weighted vaccination coverage rates in two at-risk groups. Group 1 comprised participants aged 18–59 years with underlying chronic diseases. Group 2 comprised participants aged 60+, irrespective of underlying disease. We used univariate and multivariable logistic regression analyses to identify associations between influenza vaccination uptake and sociodemographic characteristics, and to evaluate attitudes and knowledge.

Results

In total, 1,519 interviews were conducted. Seasonal influenza vaccination uptake in people with underlying chronic diseases aged 18–59 years was 24 % in 2012/2013 and 23 % in 2013/2014. In older adults, uptake was 50 % and 49 % in 2012/13 and 2013/14 respectively. There were considerable vaccination-related knowledge gaps among respondents. For example, about half of the participants who aged ≥60 years and/or suffered from underlying chronic diseases believed that influenza vaccination could cause influenza. The most commonly stated reasons for not being immunized were mistrust of the vaccination (22 %) and the perception that influenza is not dangerous (21 %). For both groups, vaccination uptake was independently associated with sex, perceived severity of influenza, perceived vaccination effectiveness, and the perceived likelihood or severity of vaccination side effects. For older adults, additional factors influencing vaccination uptake were age, underlying chronic diseases, and recent advice through physician consultation.

Conclusions

Influenza vaccination coverage rates in Germany remain low. Individual perceptions regarding harms and benefits are crucial in the decision-making process. Communication strategies should focus on improving understanding and perception of personal risks arising from the disease and the vaccination.

Knowledge, attitude, and uptake related to human papillomavirus vaccination among young women in Germany recruited via a social media site

BACKGROUND

Many industrialized countries have introduced human papillomavirus (HPV) vaccination of young women, but vaccine uptake often remains suboptimal. This study aimed to investigate whether a social media site like Facebook is an appropriate tool to assess knowledge, attitude and uptake related to HPV vaccination in young women in Germany.

METHODS

Between December 2012 and January 2013 two different targeting strategies were implemented on Facebook, providing a link to an online questionnaire. Advertisements were displayed to female Facebook users aged 18-25 years living in Germany. During the simple targeting strategy, advertisements comprised health-related images along with various short titles and text messages. During the focused strategy, advertisements were targeted to users who in addition had certain fashion brands or pop stars listed on their profiles. The targeting strategies were compared with respect to participant characteristics. Univariate and multivariate analyses were used to identify factors associated with HPV vaccine uptake.

RESULTS

A total of 1161 women participated. The two targeting strategies resulted in significant differences regarding educational status and migrant background. Overall, awareness of HPV was high, but only 53% received at least one vaccine dose. In multivariate analysis, HPV vaccine uptake was independently associated with a physician's recommendation and trust in vaccine effectiveness. Concerns of adverse effects were negatively associated with vaccine uptake.

DISCUSSION

Social network recruitment permits fast and convenient access to young people. Sample characteristics can be manipulated by adjusting targeting strategies. There is further need for promoting knowledge of HPV vaccination among young women. Physicians have a major role in the vaccination decision-making process of young women.

Prevalence and comorbidity of diabetes mellitus among non-institutionalized older adults in Germany - results of the national telephone health interview survey 'German Health Update (GEDA)' 2009

Background

Despite the major public health impact of diabetes, recent population-based data regarding its prevalence and comorbidity are sparse.

Methods

The prevalence and comorbidity of diabetes mellitus were analyzed in a nationally representative sample (N = 9133) of the non-institutionalized German adult population aged 50 years and older. Information on physician-diagnosed diabetes and 20 other chronic health conditions was collected as part of the national telephone health interview survey ‘German Health Update (GEDA)’ 2009. Overall, 51.2% of contacted persons participated. Among persons with diabetes, diabetes severity was defined according to the type and number of diabetes-concordant conditions: no diabetes-concordant condition (grade 1); hypertension and/or hyperlipidemia only (grade 2); one comorbidity likely to represent diabetes-related micro- or macrovascular end-organ damage (grade 3); several such comorbidities (grade 4). Determinants of diabetes severity were analyzed by multivariable ordinal regression.

Results

The 12-month prevalence of diabetes was 13.6% with no significant difference between men and women. Persons with diabetes had a significantly higher prevalence and average number of diabetes-concordant as well as diabetes-discordant comorbidities than persons without diabetes. Among persons with diabetes, 10.2%, 46.8%, 35.6% and 7.4% were classified as having severity grade 1–4, respectively. Determinants of diabetes severity included age (cumulative odds ratio 1.05, 95% confidence interval 1.03-1.07, per year) and number of discordant comorbidities (1.40, 1.25-1.55). With respect to specific discordant comorbidities, diabetes severity was correlated to depression (2.15, 1.29-3.56), respiratory disease (2.75, 1.72-4.41), musculoskeletal disease (1.53, 1.06-2.21), and severe hearing impairment (3.00, 1.21-7.41).

Conclusions

Diabetes is highly prevalent in the non-institutionalized German adult population 50 years and older. Diabetes comorbidities including diabetes-concordant and diabetes-discordant conditions need to be considered in epidemiological studies, in order to monitor disease burden and quality of diabetes care. Definitional standards of diabetes severity need to be refined and consented.