Age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy in Germany, 2003-21: an ecological study

BACKGROUND

Earlier death among people in socioeconomically deprived circumstances has been found internationally and for various causes of death, resulting in a considerable life-expectancy gap between socioeconomic groups. We examined how age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy have changed at the area level in Germany over time.

METHODS

In this ecological study, official German population and cause-of-death statistics provided by the Federal Statistical Office of Germany for the period Jan 1, 2003, to Dec 31, 2021, were linked to district-level data of the German Index of Socioeconomic Deprivation. Life-table and decomposition methods were applied to calculate life expectancy by area-level deprivation quintile and decompose the life-expectancy gap between the most and least deprived quintiles into age-specific and cause-specific mortality contributions.

FINDINGS

Over the study period, population numbers varied between 80 million and 83 million people per year, with the number of deaths ranging from 818 000 to 1 024 000, covering the entire German population. Between Jan 1, 2003, and Dec 31, 2019, the gap in life expectancy between the most and least deprived quintiles of districts increased by 0·7 years among females (from 1·1 to 1·8 years) and by 0·1 years among males (from 3·0 to 3·1 years). Thereafter, during the COVID-19 pandemic, the gap increased more rapidly to 2·2 years in females and 3·5 years in males in 2021. Between 2003 and 2021, the causes of death that contributed the most to the life-expectancy gap were cardiovascular diseases and cancer, with declining contributions of cardiovascular disease deaths among those aged 70 years and older and increasing contributions of cancer deaths among those aged 40-74 years over this period. COVID-19 mortality among individuals aged 45 years and older was the strongest contributor to the increase in life-expectancy gap after 2019.

INTERPRETATION

To reduce the socioeconomic gap in life expectancy, effective efforts are needed to prevent early deaths from cardiovascular disease and cancer in socioeconomically deprived populations, with cancer prevention and control becoming an increasingly important field of action in this respect.

FUNDING

German Cancer Aid and European Research Council.

[Socioeconomic deprivation and premature mortality in Germany, 1998-2021 : An ecological study with what-if scenarios of inequality reduction]

BACKGROUND

Earlier mortality in socioeconomically disadvantaged population groups represents an extreme manifestation of health inequity. This study examines the extent, time trends, and mitigation potentials of area-level socioeconomic inequalities in premature mortality in Germany.

METHODS

Nationwide data from official cause-of-death statistics were linked at the district level with official population data and the German Index of Socioeconomic Deprivation (GISD). Age-standardized mortality rates before the age of 75 were calculated stratified by sex and deprivation quintile. A what-if analysis with counterfactual scenarios was applied to calculate how much lower premature mortality would be overall if socioeconomic mortality inequalities were reduced.

RESULTS

Men and women in the highest deprivation quintile had a 43% and 33% higher risk of premature death, respectively, than those in the lowest deprivation quintile of the same age. Higher mortality rates with increasing deprivation were found for cardiovascular and cancer mortality, but also for other causes of death. Socioeconomic mortality inequalities had started to increase before the COVID-19 pandemic and further exacerbated in the first years of the pandemic. If all regions had the same mortality rate as those in the lowest deprivation quintile, premature mortality would be 13% lower overall.

DISCUSSION

The widening gap in premature mortality between deprived and affluent regions emphasizes that creating equivalent living conditions across Germany is also an important field of action for reducing health inequity.

Education and pandemic SARS-CoV-2 infections in the German working population - the mediating role of working from home

OBJECTIVES

SARS-CoV-2 infections were unequally distributed during the pandemic, with those in disadvantaged socioeconomic positions being at higher risk. Little is known about the underlying mechanism of this association. This study assessed to what extent educational differences in SARS-CoV-2 infections were mediated by working from home.

METHODS

We used data of the German working population derived from the seroepidemiological study "Corona Monitoring Nationwide - Wave 2 (RKI-SOEP-2)" (N=6826). Infections were assessed by seropositivity against SARS-CoV-2 antigens and self-reports of previous PCR-confirmed infections from the beginning of the pandemic until study participation (November 2021 - February 2022). The frequency of working from home was assessed between May 2021 and January 2022.We used the Karlson-Holm-Breen (KHB) method to decompose the effect of education on SARS-CoV-2 infections.

RESULTS

Individuals with lower educational attainment had a higher risk for SARS-CoV-2 infection (adjusted prevalence ratio of low versus very high = 1.76, 95% confidence interval 1.08-2.88; P=0.023). Depending on the level of education, between 27% (high education) and 58% (low education) of the differences in infection were mediated by the frequency of working from home.

CONCLUSIONS

Working from home could prevent SARS-CoV-2 infections and contribute to the explanation of socioeconomic inequalities in infection risks. Wherever possible, additional capacities to work remotely, particularly for occupations that require lower educational attainment, should be considered as an important measure of pandemic preparedness. Limitations of this study are the observational cross-sectional design and that the temporal order between infection and working from home remained unclear.

Social Inequalities in Long-Term Health Effects After COVID-19-A Scoping Review

Objectives: We aimed to map and synthesize evidence about social inequalities in long-term health effects after COVID-19 (LTHE), often referred to as "long COVID" or "post-COVID-19 conditions." Methods: We conducted a scoping review of peer-reviewed articles by searching the databases Embase and Scopus. According to predefined inclusion criteria, titles/abstracts and full texts were screened for eligibility. Additionally, reference lists of all included studies were hand-searched for eligible studies. This study followed the PRISMA guidelines for scoping reviews. Results: Nineteen articles were included. LTHE were analysed according to ethnicity, education, income, employment and deprivation indices. The studies varied significantly in their definitions of LTHE. Eighty-two analyses showed no statistically significant associations. At least 12 studies had a high risk of type II errors. Only studies associating deprivation indices and long COVID tended to show a higher prevalence of LTHE in deprived areas. Conclusion: Although some studies indicated social inequalities in LTHE, evidence was generally weak and inconclusive. Further studies with larger sample sizes specifically designed to detect social inequalities regarding LTHE are needed to inform future healthcare planning and public health policies.

Widening area-based socioeconomic inequalities in cancer mortality in Germany between 2003 and 2019

Cancer mortality has declined in recent decades, but-due to a lack of national individual-level data-it remains unclear whether this applies equally to all socioeconomic groups in Germany. Using an area-based approach, this study investigated socioeconomic inequalities in cancer mortality and their secular trends on a German nationwide scale for the first time. Official cause-of-death data from 2003 to 2019 were linked to the district-level German Index of Socioeconomic Deprivation. Age-standardised mortality rates for all cancers combined and the most common site-specific cancers were calculated according to the level of regional socioeconomic deprivation. To quantify the extent of area-based socioeconomic inequalities in cancer mortality, absolute (SII) and relative (RII) indices of inequality were estimated using multilevel Poisson models. On average, cancer mortality was 50% (women) and 80% (men) higher in Germany's most deprived than least deprived districts (absolute difference: 84 deaths per 100,000 in women and 185 deaths per 100,000 in men). As declines in cancer mortality were larger in less deprived districts, the socioeconomic gap in cancer mortality widened over time. This trend was observed for various common cancers. Exceptions were cancers of the lung in women and of the pancreas in both sexes, for which mortality rates increased over time, especially in highly deprived districts. Our study provides first evidence on increasing socioeconomic inequalities in cancer mortality on a nationwide scale for Germany. Area-based linkage allows to examine socioeconomic inequalities in cancer mortality across Germany and identify regions with high needs for cancer prevention and control.

Socioeconomic Differences in SARS-CoV-2 Infection and Vaccination in Germany: A Seroepidemiological Study After One Year of COVID-19 Vaccination Campaign

Objective: To evaluate the socioeconomic patterns of SARS-CoV-2 antigen contacts through infection, vaccination or both ("hybrid immunity") after 1 year of vaccination campaign. Methods: Data were derived from the German seroepidemiological Corona Monitoring Nationwide study (RKI-SOEP-2; n = 10,448; November 2021-February 2022). Combining serological and self-report data, we estimated adjusted prevalence ratios (PR) of SARS-CoV-2 infection, COVID-19 vaccination, basic immunization (at least two SARS-CoV-2 antigen contacts through vaccination and/or infection), and three antigen contacts by education and income. Results: Low-education groups had 1.35-times (95% CI 1.01-1.82) the risk of SARS-CoV-2 infection compared to high-education groups. COVID-19 vaccination (at least one dose) and basic immunization decreased with lower education and income. Low-education and low-income groups were less likely to have had at least three antigen contacts (PR low vs. high education: 0.74, 95% CI 0.65-0.84; PR low vs. high income: 0.66, 95% CI 0.57-0.77). Conclusion: The results suggest a lower level of protection against severe COVID-19 for individuals from low and medium socioeconomic groups. Pandemic response and vaccination campaigns should address the specific needs and barriers of these groups.

[Occupational differences of COVID-19 morbidity and mortality in Germany. An analysis of health insurance data from 3.17 million insured persons]

INTRODUCTION

During the COVID-19 pandemic, occupation was assumed to play a central role in the occurrence of infection and disease. For Germany, however, there are only a few studies that analyse occupational differences in risk of COVID-19, COVID-19-associated hospitalisation, and mortality.

METHODS

The study uses longitudinal health insurance data from the research database of the Institute for Applied Health Research (InGef) with information on 3.17 million insured persons aged 18-67 years (1,488,452 women; 1,684,705 men). Outcomes (morbidity, hospitalisation, and mortality) were determined on the basis of submitted COVID-19 diagnoses between 1 January 2020 and 31 December 2021. Occupations were classified according to four groupings of the official German classification of occupations. In addition to cumulative incidences, relative risks (RR) were calculated - separately for men and women.

RESULTS

There is an increased risk of disease in personal service occupations, especially in health care, compared to other occupations (RR for women 1.46; for men 1.30). The same applies to social and cultural service occupations (but only for women) and for manufacturing occupations (only for men). In addition, the risks for hospitalisation and mortality are increased for cleaning occupations and transport and logistics occupations (especially for men). For all three outcomes, the risks are higher in non-managerial occupations and differ by skill level (highest for unskilled jobs and lowest for expert positions).

CONCLUSION

The study provides important findings on work- and gender-related differences in COVID-19 morbidity and mortality in Germany, which indicate starting points for structural infection protection measures.

Social differences in COVID-19 vaccination status - Results of the GEDA 2021 study

Background

The COVID-19 vaccination is a key measure to contain the pandemic. It aims to restrict new infections and to reduce severe courses of the disease. This paper examines the influence of various social determinants on COVID-19 vaccination status.

Methods

The analyses are based on data from the study German Health Update (GEDA 2021), a nationwide telephone-based survey of the adult population in Germany, which was conducted between July and December 2021. In addition to bivariate analyses, the association between the COVID-19 vaccination status and the social determinants was examined using Poisson regression.

Results

A total of 86.7% of people aged 18 years and older who participated in GEDA 2021 have been received at least one dose of COVID-19 vaccine. Social differences are evident: The proportion of people vaccinated against COVID-19 increases with age, income and higher education group. Lower vaccination rates are found among people with a history of migration, people living in rural areas and people from East Germany. An age-differentiated analysis shows that the social differences in COVID-19 vaccination uptake are lower among those aged 60 years and older.

Conclusions

The presented results should be considered when designing targeted interventions to overcome potential barriers to COVID-19 vaccination uptake. Further research is needed regarding the explanatory factors for the social differences in vaccination behaviour, such as structural and group-specific barriers or psychological determinants.

Socioeconomic differences in the reduction of face-to-face contacts in the first wave of the COVID-19 pandemic in Germany

BACKGROUND

The COVID-19 pandemic has led to physical distancing measures to control the spread of SARS-CoV-2. Evidence on contact dynamics in different socioeconomic groups is still sparse. This study aimed to investigate the association of socioeconomic status with private and professional contact reductions in the first COVID-19 wave in Germany.

METHODS

Data from two especially affected municipalities were derived from the population-based cross-sectional seroepidemiological CORONA-MONITORING lokal study (data collection May-July 2020). The study sample (n = 3,637) was restricted to working age (18-67 years). We calculated the association of educational and occupational status (low, medium, high) with self-reported private and professional contact reductions with respect to former contact levels in the first wave of the pandemic. Multivariate Poisson regressions were performed to estimate prevalence ratios (PR) adjusted for municipality, age, gender, country of birth, household size, contact levels before physical distancing measures, own infection status, contact to SARS-CoV-2 infected people and working remotely.

RESULTS

The analyses showed significant differences in the initial level of private and professional contacts by educational and occupational status. Less private contact reductions with lower educational status (PR low vs. high = 0,79 [CI = 0.68-0.91], p = 0.002; PR medium vs. high = 0,93 [CI = 0.89-0.97], p = 0.001) and less professional contact reductions with lower educational status (PR low vs. high = 0,87 [CI = 0.70-1.07], p = 0.179; PR medium vs. high = 0,89 [CI = 0.83-0.95], p = 0.001) and lower occupational status (PR low vs. high = 0,62 [CI = 0.55-0.71], p < 0.001; PR medium vs. high = 0,82 [CI = 0.77-0.88], p < 0.001) were observed.

CONCLUSIONS

Our results indicate disadvantages for groups with lower socioeconomic status in private and professional contact reductions in the first wave of the pandemic. This may be associated with the higher risk of infection among individuals in lower socioeconomic groups. Preventive measures that a) adequately explain the importance of contact restrictions with respect to varying living and working conditions and b) facilitate the implementation of these reductions especially in the occupational setting seem necessary to better protect structurally disadvantaged groups during epidemics.

German Index of Socioeconomic Deprivation (GISD): Revision, update and applications

Background

Regional deprivation indices enable researchers to analyse associations between socioeconomic disadvantages and health outcomes even if the health data of interest does not include information on the individuals' socioeconomic position. This article introduces the recent revision of the German Index of Socioeconomic Deprivation (GISD) and presents associations with life expectancy as well as age-standardised cardiovascular mortality rates and cancer incidences as applications.

Methods

The GISD measures the level of socioeconomic deprivation using administrative data of education, employment, and income situations at the district and municipality level from the INKAR database. The indicators are weighted via principal component analyses. The regional distribution is depicted cartographically, regional level associations with health outcomes are presented.

Results

The principal component analysis indicates medium to high correlations of the indicators with the index subdimensions. Correlation analyses show that in districts with the lowest deprivation, the average life expectancy of men is approximately six years longer (up to three years longer for women) than for those from districts with the highest deprivation. A similar social gradient is observed for cardiovascular mortality and lung cancer incidence.

Conclusions

The GISD provides a valuable tool to analyse socioeconomic inequalities in health conditions, diseases, and their determinants at the regional level.

Depressive symptoms in the general population before and in the first year of the COVID-19 pandemic: Results of the GEDA 2019/2020 study

BACKGROUND

Study results on the impact of the COVID-19 pandemic on mental health in the first year of the pandemic are contradictory. The GEDA 2019/2020 study makes it possible to examine changes in depressive symptoms in the population.

METHODS

A standardised telephone interview was used to survey a random sample of the population in Germany aged 15 and older. To exclude seasonal effects, 10,220 interviewees from the period April 2019 to January 2020 were compared with 11,900 from the period April 2020 to January 2021. Depressive symptoms were assessed with the internationally established 8-item Patient Health Questionnaire (PHQ-8).

RESULTS

The prevalence of depressive symptoms decreased from 9.2% to 7.6% in the first year of the pandemic. Changes differ between women and men as well as between age and education groups. The analysis of individual symptoms suggests that it is not about a reduction of mental disorders of the depressive type in the narrower sense, but rather a decrease in stress-associated individual symptoms.

CONCLUSIONS

The decrease in stress-associated depressive symptoms in parts of the population can be interpreted as an indication that pandemic-related changes in everyday life and the working environment may have had a positive effect on individual areas of mental health in certain groups, at least temporarily in the first year of the pandemic. The continuing strong social inequality in depressive symptoms to the disadvantage of low education groups confirms that the need for social situation-related health promotion and prevention with regard to the living and working conditions of socially disadvantaged people must not be lost sight of in times of pandemic. For groups in the population that partly showed a worsening of symptoms in this phase of the pandemic, e.g. the diminished ability to concentrate of very old men, targeted support options should be created in the future.

Socioeconomic Status, Overweight, and Obesity in Childhood and Adolescence

BACKGROUND

Overweight and obesity in early life increase the risk of chronic disease and ill health later on. We studied secular trends in the prevalence of overweight and obesity among young people in Germany, with consideration of socioeconomic status (SES).

METHODS

We used repeated cross-sectional data from 3- to 17-year-olds from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Overweight and obesity were defined according to the body mass index, based on measured height and weight from the KiGGS baseline survey (2003-2006) and the KiGGS second wave (2014-2017). SES was assessed with a composite index of parental education, occupation, and income.

RESULTS

In both study periods, the prevalence of overweight and obesity was highest among girls and boys from families of low SES. In the group with lowest SES, the prevalence of overweight rose from 20.0% in 2003-2006 (95% CI [18.0; 22.1]) to 25.5% [20.5; 31.2] in 2014-2017 (p = 0.043). Thus, social differences in the prevalence of overweight increased over time. No such trend was found for the prevalence of obesity.

CONCLUSION

Social differences in the prevalence of overweight among children and adolescents increased from the early 2000s to the mid-2010s. Structural measures are needed to help prevent overweight among young people in socially disadvantaged circumstances.

Nationally representative results on SARS-CoV-2 seroprevalence and testing in Germany at the end of 2020

Pre-vaccine SARS-CoV-2 seroprevalence data from Germany are scarce outside hotspots, and socioeconomic disparities remained largely unexplored. The nationwide representative RKI-SOEP study (15,122 participants, 18-99 years, 54% women) investigated seroprevalence and testing in a supplementary wave of the Socio-Economic-Panel conducted predominantly in October-November 2020. Self-collected oral-nasal swabs were PCR-positive in 0.4% and Euroimmun anti-SARS-CoV-2-S1-IgG ELISA from dry-capillary-blood antibody-positive in 1.3% (95% CI 0.9-1.7%, population-weighted, corrected for sensitivity = 0.811, specificity = 0.997). Seroprevalence was 1.7% (95% CI 1.2-2.3%) when additionally correcting for antibody decay. Overall infection prevalence including self-reports was 2.1%. We estimate 45% (95% CI 21-60%) undetected cases and lower detection in socioeconomically deprived districts. Prior SARS-CoV-2 testing was reported by 18% from the lower educational group vs. 25% and 26% from the medium and high educational group (p < 0.001, global test over three categories). Symptom-triggered test frequency was similar across educational groups. Routine testing was more common in low-educated adults, whereas travel-related testing and testing after contact with infected persons was more common in highly educated groups. This countrywide very low pre-vaccine seroprevalence in Germany at the end of 2020 can serve to evaluate the containment strategy. Our findings on social disparities indicate improvement potential in pandemic planning for people in socially disadvantaged circumstances.

Trends of socioeconomic inequalities in overweight and obesity in children and adolescents in Germany

Background

Overweight and obesity in early life are risk factors for chronic health conditions in the later life course. Children and adolescents from socioeconomically disadvantaged families are more likely to be overweight or obese than their better-off peers. This study examined post-millennial trends of socioeconomic inequalities in the prevalence of overweight and obesity among young people in Germany.

Methods

Repeated cross-sectional data were used from the German health interview and examination survey for children and adolescents (KiGGS). Overweight and obesity were assessed by body mass index, based on measured height and weight of 3- to 17-year-old participants in KiGGS baseline (2003-06) and KiGGS wave 2 (2014-17). Socioeconomic position (SEP) was measured using a composite index of parental education, occupation and income. The regression-based slope index of inequality (SII) and relative index of inequality (RII) were calculated to estimate the extent of absolute and relative inequalities in the prevalence of overweight and obesity.

Results

The overall prevalence of overweight and obesity among 3- to 17-year-olds in Germany did not change over time and was recently 15.4% and 5.9%, respectively. In both survey waves, overweight and obesity were more prevalent in lower SEP-groups. From 2003-06 to 2014-17, overweight increased in the low-SES group, whereas it tended to decrease in those with higher SES. This trend was concomitant with increasing socioeconomic inequalities in overweight over the observation period (SII from 0.11 to 0.19, p = 0.054; RII from 2.1 to 3.7, p = 0.021). No such trend was found for obesity.

Conclusions

Socioeconomic inequalities in overweight have widened among the young in Germany since the early 2000s. Structural interventions that are effective in preventing and reducing overweight in young people from socially disadvantaged backgrounds are still needed.

Key messages

Social differences in COVID-19 vaccination rates–Findings from a German nationwide study

Background

The COVID-19 vaccination aims to prevent the transmission of the novel coronavirus (SARS-CoV-2) as well as to reduce severe courses of the disease and deaths. But various studies indicate social differences in willingness to be vaccinated. This study aims to examine the influence of different social determinants on COVID-19 vaccination in Germany.

Methods

The analyses are based on data from the sixth follow-up survey of the German Health Update (GEDA 2021), a nationwide cross-sectional telephone survey of the adult population living in Germany. COVID-19 vaccination rates are analyzed considering age, education, income, urban-rural residence and migration background. Poisson regressions were used to examine associations of each social determinant with COVID-19 vaccination rates. Adjustments were made for age, sex, (education) and date of participation.

Results

Overall, the rate of COVID-19 vaccination for the survey period was 86.7%, with significant differences in vaccination rate by social determinants. The vaccination rate increases significantly with age (94.2% for over 60-year-olds), higher level of education (91.5%) or income (93.0%). In addition, people living in rural areas in Germany (83.5%) and people with an own migration experience (79.1%) had a significantly lower vaccination rate. An age-differentiated analysis also showed the social differences in COVID-19 vaccination rate are significantly lower among those over 60-years old.

Conclusions

The results suggest social differences in COVID-19 vaccination especially in younger age groups. This should be considered when designing targeted measures to overcome potential barriers to vaccination. However, a large number of other factors affecting vaccination behavior must be taken into account like structural barriers, confidence in decision-makers, the safety of vaccination, and a sense of responsibility towards the community.

Key messages

• Sociodemographic and socioeconomic determinants affect COVID-19 vaccination rates.

• The social differences in COVID-19 vaccination are lower among those over 60-years old.

Socioeconomic differences in contact reduction in the first COVID-19-wave in Germany (CoMoLo-study)

Background

The COVID-19 pandemic has led to physical distancing measures across a range of countries to control the spread of the virus. Evidence referring to contact dynamics in different socioeconomic populations is still sparse and may contribute to the explaining of socioeconomic inequality of infections.

Methods

Data came from two early COVID-19 hotspots in Germany using the CORONA-MONITORING-lokal study (CoMoLo). The sample (n = 3,637) was restricted to working age (18-67 years). We calculated the association of individual education and occupation status (low, middle, high) and self-reported private and professional contact reductions. Using weighting factors (adaptation to local age, gender and education distribution), we performed multivariate Poisson regressions (prevalence ratios; PR) with different sets of covariates: hotspot, age, sex, country of birth, household size, contact level before physical distancing measures and home office.

Results

The descriptive analyses show a clear socioeconomic gradient in private (low education: 70,0%; middle: 79,1%; high: 86,2%) and professional contact reductions (low education: 54,6%; middle: 61,3; high: 77,2%). The multivariate analyses confirm these associations, with a stronger gradient for professional contacts (private contact reduction: PR low vs. high education = 0,83 [KI:0.74-0.93]; professional contact reduction: PR low vs. high education = 0,75 [KI:0.64-0.89]) as well as for professional contact reduction when occupational status is considered instead of education.

Conclusions

Our results show disadvantages in groups with lower educational or occupational status in private and professional contact reductions in the first pandemic wave. This might result in a higher risk of infection. Preventive measures that a) adequately explain the importance of contact restrictions and b) facilitate the implementation of these reductions seem necessary to better protect structurally disadvantaged people during epidemics.

Key messages

• Groups with lower educational or occupational status were less likely of being able to reduce their private and professional contacts in the first wave of the pandemic.

• Socioeconomic differences were more pronounced in professional contact reduction compared to private contact reduction.

Temporal dynamics of socioeconomic inequalities in COVID-19 – a scoping review

Background

International evidence shows a socially unequal burden of SARS-CoV-2 infections and COVID-19 outcomes across different socioeconomic groups. However, less is known about the temporal dynamics of socioeconomic inequalities in COVID-19 throughout the pandemic. We conducted a scoping review to systematically map and synthesize the available evidence.

Methods

We conducted a systematic literature search in Embase and Scopus with pre-defined eligibility criteria, including empirical research from 1 January 2020 to 24 August 2021. Additionally, several journals and the reference lists of all included articles were hand-searched to identify relevant studies. We used a standardized charting approach to extract relevant content and narratively synthesized the included evidence. The study follows the PRISMA guidelines for scoping reviews.

Results

From 8,011 identified records, we finally included 46 articles in the analysis. 50.0% of all included studies were conducted in the United States. The majority of all studies analyzed surveillance data (n = 44) and used area-based socioeconomic indicators on an ecological level (92.5%). The study results show temporal dynamics in COVID-19 inequalities, frequently initiated through higher outcome rates in more affluent populations and subsequent crossover dynamics to higher rates in more deprived populations (41.9%). Furthermore, 91.4% of the analyses show maintaining or worsening social inequalities in health with ongoing pandemic progression, which hit the most deprived populations the hardest.

Conclusions

The results show worsening social inequalities in COVID-19 over the course of the pandemic, with the most disadvantaged populations most affected during its progression. Targeted prevention and interventions, such as low-threshold testing and vaccination programs, infection protection for precarious jobs or living conditions, and targeted information are crucial to face socioeconomic inequalities throughout pandemics.

Key messages

Do regional characteristics predict developmental delay? Analyses of German school entry examination

Background

Children's health and development are strongly linked to their living situation, including their family's socioeconomic position (SEP) and living region. However, research on the impact of the living region on children's development beyond family SEP is scarce. This study evaluated whether rurality and regional socioeconomic deprivation (DEP) are associated with children's development independently of family SEP.

Methods

The study used population-based data of 5-6.5 years old children (n = 22,801) from mandatory school entry examinations (SEE) in the German federal state of Brandenburg, which were examined in 2018/2019. The SEE data have been linked with data on i. rurality that was defined by an inverted population density and ii. regional DEP that were provided by the German Index of Socioeconomic Deprivation. By binary multilevel models, the predictive values of rurality and regional DEP for global developmental delay (GDD) were evaluated, while adjusting for family SEP.

Results

Children with high family SEP showed reduced odds for GDD compared to medium family SEP (female: OR = 4.26, CI95=3.14-5.79, male: OR = 3.46, CI95=2.83-4.22) and low family SEP (female: OR = 16.58, CI95=11.90-23.09, male: OR = 12.79, CI95=10.13-16.16). Regional DEP additionally predicted GDD, with higher odds for children from more deprived regions (female: OR = 1.35, CI95=1.13-1.62, male: OR = 1.20, CI95=1.05-1.39). Rurality did not predict GDD beyond family SEP and regional DEP.

Conclusions

In addition to family SEP, the regional DEP has an effect on children's developmental delay. Hence, Public Health should take into account regional socioeconomic conditions as determinant of health over the life course in addition to family SEP.

Key messages

• Regional socioeconomic deprivation contributes to inequalities in children's development and health.

• Besides family SEP, regional socioeconomic circumstances are of particular interest to promote health over the life course.

Smoking behaviour and passive smoke exposure of adults - Results from GEDA 2019/2020-EHIS

Background

Smoking is a significant health risk and the leading cause of premature death. Passive smoke causes the same negative effects on health as smoking, albeit to a lesser extent. The reduction of tobacco consumption and the protection against passive smoke are thus important health objectives.

Methods

The study German Health Update (GEDA 2019/2020-EHIS) is a cross-sectional telephone survey (04/2019 to 09/2020) of the resident population in Germany with questions relating to the current smoking behaviour and relating to the passive smoke exposure. The analysis sample comprises 22,708 persons from 18 years of age.

Results

24.0% of women and 33.9% of men from 18 years of age smoke currently, at least occasionally. Among both sexes, adults from 65 years of age smoke significantly more rarely than adults in the younger age groups. 4.1% of adults, who do not smoke themselves, are subjected daily to passive smoke exposure indoors. This affects in particular young adults and men. There are educational differences in tobacco consumption and in passive smoke exposure to the disadvantage of adults from lower educational groups.

Conclusions

In Germany, there is still a need for action for effective measures for tobacco prevention, smoking cessation and tobacco control policy, which are effective in all population groups and which take into account the concerns of socially disadvantaged 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.

Association of regional socioeconomic deprivation and rurality with global developmental delay in early childhood: Data from mandatory school entry examinations in Germany

BACKGROUND

From birth to young adulthood, health and development of young people are strongly linked to their living situation, including their family's socioeconomic position (SEP) and living environment. The impact of regional characteristics on development in early childhood beyond family SEP has been rarely investigated. This study aimed to identify regional predictors of global developmental delay at school entry taking family SEP into consideration.

METHOD

We used representative, population-based data from mandatory school entry examinations of the German federal state of Brandenburg in 2018/2019 with n=22,801 preschool children. By applying binary multilevel models, we hierarchically analyzed the effect of regional deprivation defined by the German Index of Socioeconomic Deprivation (GISD) and rurality operationalized as inverted population density of the children's school district on global developmental delay (GDD) while adjusting for family SEP (low, medium and high).

RESULTS

Family SEP was significantly and strongly linked to GDD. Children with the highest family SEP showed a lower odds for GDD compared to a medium SEP (female: OR=4.26, male: OR=3.46) and low SEP (female: OR=16.58, male: OR=12.79). Furthermore, we discovered a smaller, but additional and independent effect of regional socioeconomic deprivation on GDD, with a higher odds for children from a more deprived school district (female: OR=1.35, male: OR=1.20). However, rurality did not show a significant link to GDD in preschool children beyond family SEP and regional deprivation.

CONCLUSION

Family SEP and regional deprivation are risk factors for child development and of particular interest to promote health of children in early childhood and over the life course.

Time Trends and Income Inequalities in Cancer Incidence and Cancer-Free Life Expectancy - a Cancer Site-Specific Analysis of German Health Insurance Data

Cancer represents a major burden of morbidity and mortality globally. So far, however, little is known on time trends and inequalities in the lengths of life spent free of any cancer. This study steps into this gap by analyzing time trends and income inequalities in cancer-free life expectancy (CFLE). For this retrospective cohort study, data of a large German health insurer were used (N = 3,405,673individuals, 2006-2018). Income inequalities were assessed using individual income (<60% of German average income (GAI) and ≥60% of GAI). Trends in incidence risks were analysed employing proportional-hazard regression models by splitting the observation time into three periods of 52 months. Trends in CFLE in total and for the most common site-specific cancers were calculated based on multiple decrement life tables. Incidence rates declined in almost all cancers and CFLE increased substantially over time (49.1 (95% CI 48.8-49.4) to 51.9 (95% CI 51.6-52.2) years for men, 53.1 (95% CI 52.7-53.5) to 55.4 (95% CI 55.1-55.8) years for women at age 20 for total cancer) and income groups. Considerable income inequalities in cancer risks were evident in both sexes, but were more pronounced in men (total cancer HR 0.86 (95% CI 0.85-0.87)), with higher-income individuals having lower risks. The highest income inequalities were found in colon (HR 0.90 (95% CI 0.87-0.93)), stomach (HR 0.78 (95% CI 0.73-0.84)), and lung cancer (HR 0.58 (95% CI 0.56-0.60)) in men. A reverse gradient was found for skin (HR 1.39 (95% CI 1.30-1.47) men; HR 1.27 (95% CI 1.20-1.35) women) and prostate cancer (HR 1.13 (95% CI 1.11-1.15)). The proportion of CFLE in total life expectancy declined for lung, skin and cervical cancer in women, indicating a relative shortening of lifetime spent cancer-free. In contrast, increasing proportions were found in breast and prostate cancer. To our knowledge, this is the first study analysing trends and income inequalities in CFLE. The life span free of cancer increased clearly over time. However, not all cancer types contributed equally to this positive development. Income inequalities persisted or tended to widen, which underlines the need for increased public health efforts in socioeconomically vulnerable groups.

Emerging socio-economic disparities in COVID-19-related deaths during the second pandemic wave in Germany

Over the course of the second pandemic wave in late 2020, new infections with severe acute respiratory syndrome coronavirus-2 shifted from the most affluent to the most deprived regions of Germany. This study investigated how this trend in infections played out for deaths due to coronavirus disease 2019 (COVID-19) by examining area-level socio-economic disparities in COVID-19-related mortality during the second pandemic wave in Germany. The analysis was based on nationwide data on notified deaths, which were linked to an area-based index of socio-economic deprivation. In the autumn and winter of 2020/2021, COVID-19-related deaths increased faster among residents in Germany's more deprived districts. From late 2020 onwards, the mortality risks of men and women in the most deprived districts were 1.52 (95% confidence interval [CI] 1.27-1.82] and 1.44 (95% CI 1.19-1.73) times higher than among those in the most affluent districts, respectively, after adjustment for age, urbanization and population density. To promote health equity in the pandemic and beyond, deprived populations should receive increased attention in pandemic planning, infection control and disease prevention.

Socioeconomic position and SARS-CoV-2 infections: seroepidemiological findings from a German nationwide dynamic cohort

Background

Evidence on the relationship between socioeconomic position (SEP) and infections with SARS-CoV-2 is still limited as most of the available studies are ecological in nature. This is the first German nationwide study to examine differences in the risk of SARS-CoV-2 infections according to SEP at the individual level.

Methods

The ‘CORONA-MONITORING bundesweit’ (RKI-SOEP) study is a seroepidemiological survey among a dynamic cohort of the German adult population (n=15 122; October 2020–February 2021). Dried blood samples were tested for SARS-CoV-2 antibodies and oral-nasal swabs for viral RNA. SEP was measured by education and income. Robust logistic regression was used to examine adjusted associations of SARS-CoV-2 infections with SEP.

Results

288 participants were seropositive, PCR positive or self-reported a previous laboratory-confirmed SARS-CoV-2 infection. The adjusted odds of SARS-CoV-2 infection were 1.87-fold (95% CI 1.06 to 3.29) higher among low-educated than highly educated adults. Evidence was weaker for income differences in infections (OR=1.65; 95% CI 0.89 to 3.05). Highly educated adults had lower odds of undetected infection.

Conclusion

The results indicate an increased risk of SARS-CoV-2 infection in low-educated groups. To promote health equity in the pandemic and beyond, social determinants should be addressed more in infection protection and pandemic planning.

Socioeconomic inequalities in the prevalence and perceived dangerousness of SARS-CoV-2 infections in two early German hotspots: findings from a seroepidemiological study

OBJECTIVE

Evidence on socioeconomic inequalities in infections with the novel coronavirus (SARS-CoV-2) is still limited as most of the available studies are ecological in nature and individual-level data is sparse. We therefore analysed individual-level data on socioeconomic differences in the prevalence and perceived dangerousness of SARS-CoV-2 infections in local populations. Data were obtained from a population-based seroepidemiological study of adult individuals in two early German SARS-CoV-2 hotspots (n = 3903). Infection was determined by IgG antibody ELISA, RT-PCR testing and self-reports on prior positive PCR tests. The perceived dangerousness of an infection and socioeconomic position (SEP) were assessed by self-reports. Logistic and linear regression were applied to examine associations of multiple SEP measures with infection status and perceptions of dangerousness.

RESULTS

We found no evidence of socioeconomic inequalities in SARS-CoV-2 infections by education, occupation, income and subjective social status. Participants with lower education and lower subjective social status perceived an infection as more dangerous than their better-off counterparts. In successfully contained local outbreaks of SARS-CoV-2 in Germany, infections may have been equally distributed across the socioeconomic spectrum. But residents in disadvantaged socioeconomic groups might have experienced a higher level of mental distress due to the higher perceived dangerousness of an infection.

[Social inequalities in the regional spread of SARS-CoV-2 infections]

Hintergrund und Ziel

Ob sozioökonomische Faktoren die Ausbreitung von SARS-CoV‑2 beeinflussen, ist nicht ausreichend beantwortet, da frühere Studien in der Regel kumulative Inzidenzen betrachtet und die zeitliche Entwicklung der Ausbreitung außer Acht gelassen haben. Dieser Beitrag konzentriert sich daher auf die Entwicklung von regionalen Neuinfektionen in Zusammenhang mit sozioökonomischen Faktoren. Ausgehend vom internationalen Forschungsstand präsentieren wir eigene Analysen von Meldedaten aus Deutschland.

Methoden

Diese Studie untersucht regionale Daten gemeldeter COVID-19-Fälle für die 401 Landkreise und kreisfreien Städte (Kreisebene) in Deutschland und vergleicht den zeitlichen Verlauf entlang sozioökonomischer Merkmale der Kreise. Betrachtet werden altersstandardisierte wöchentliche Inzidenzen für den Zeitraum 03.02.2020–28.03.2021. Sozial- und Wirtschaftsindikatoren auf Kreisebene stammen aus der INKAR(Indikatoren und Karten zur Raum- und Stadtentwicklung)-Datenbank (z. B. Einkommen, Beschäftigtenquote, Wohnfläche).

Ergebnisse

Während in der ersten und zu Beginn der zweiten Welle der Pandemie Kreise mit höherem mittleren Haushaltseinkommen höhere Inzidenzen hatten, stiegen sie in Kreisen mit niedrigem Einkommen ab Dezember 2020 deutlich an. Kreise mit einem hohen Anteil an Beschäftigten allgemein und speziell solchen im Produktionssektor hatten gerade in der zweiten und dritten Welle hohe Inzidenzen. Kreise mit einer geringen Wohnfläche je Einwohner hatten ab November 2020 ausgeprägt höhere Inzidenzen.

Schlussfolgerung

Der regionale Verlauf der Pandemie unterscheidet sich nach Sozial- und Wirtschaftsindikatoren. Eine differenzierte Betrachtung dieser Unterschiede könnte Hinweise auf zielgruppenspezifische Schutz- und Teststrategien geben und helfen, soziale Faktoren zu identifizieren, die Infektionen begünstigen.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03387-w) enthalten.

Seroepidemiological study on the spread of SARS-CoV-2 in Germany: Study protocol of the CORONA-MONITORING bundesweit' study (RKI-SOEP study)

The SARS-CoV-2 coronavirus has spread rapidly across Germany. Infections are likely to be under-recorded in the notification data from local health authorities on laboratory-confirmed cases since SARS-CoV-2 infections can proceed with few symptoms and then often remain undetected. Seroepidemiological studies allow the estimation of the proportion in the population that has been infected with SARS-CoV-2 (seroprevalence) as well as the extent of undetected infections. The ‘CORONA-MONITORING bundesweit’ study (RKI-SOEP study) collects biospecimens and interview data in a nationwide population sample drawn from the German Socio-Economic Panel (SOEP).

Participants are sent materials to self-collect a dry blood sample of capillary blood from their finger and a swab sample from their mouth and nose, as well as a questionnaire. The samples returned are tested for SARS-CoV-2 IgG antibodies and SARS-CoV-2 RNA to identify past or present infections.

The methods applied enable the identification of SARS-CoV-2 infections, including those that previously went undetected. In addition, by linking the data collected with available SOEP data, the study has the potential to investigate social and health-related differences in infection status. Thus, the study contributes to an improved understanding of the extent of the epidemic in Germany, as well as identification of target groups for infection protection.

Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review

Background

Utilization of primary-care and specialist physicians seems to be associated differently with socioeconomic status (SES). This review aims to summarize and compare the evidence on socioeconomic inequalities in consulting primary-care or specialist physicians in the general adult population in high-income countries.

Methods

We carried out a systematic search across the most relevant databases (Web of Science, Medline) and included all studies, published since 2004, reporting associations between SES and utilization of primary-care and/or specialist physicians. In total, 57 studies fulfilled the eligibility criteria.

Results

Many studies found socioeconomic inequalities in physician utilization, but inequalities were more pronounced in visiting specialists than primary-care physicians. The results of the studies varied strongly according to the operationalization of utilization, namely whether a physician was visited (probability) or how often a physician was visited (frequency). For probabilities of visiting primary-care physicians predominantly no association with SES was found, but frequencies of visits were higher in the most disadvantaged. The most disadvantaged often had lower probabilities of visiting specialists, but in many studies no link was found between the number of visits and SES.

Conclusion

This systematic review emphasizes that inequalities to the detriment of the most deprived is primarily a problem in the probability of visiting specialist physicians. Healthcare policy should focus first off on effective access to specialist physicians in order to tackle inequalities in healthcare.

PROSPERO registration number

CRD42019123222.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01375-1.

Serology- and PCR-based cumulative incidence of SARS-CoV-2 infection in adults in a successfully contained early hotspot (CoMoLo study), Germany, May to June 2020

Three months after a coronavirus disease (COVID-19) outbreak in Kupferzell, Germany, a population-based study (n = 2,203) found no RT-PCR-positives. IgG-ELISA seropositivity with positive virus neutralisation tests was 7.7% (95% confidence interval (CI): 6.5-9.1) and 4.3% with negative neutralisation tests. We estimate 12.0% (95% CI: 10.4-14.0%) infected adults (24.5% asymptomatic), six times more than notified. Full hotspot containment confirms the effectiveness of prompt protection measures. However, 88% naïve adults are still at high COVID-19 risk.

Seroepidemiological study on the spread of SARS-CoV-2 in populations in especially affected areas in Germany - Study protocol of the CORONA-MONITORING lokal study

At a regional and local level, the COVID-19 pandemic has not spread out uniformly and some German municipalities have been particularly affected. The seroepidemiological data from these areas helps estimate the proportion of the population that has been infected with SARS-CoV-2 (seroprevalence), as well as the number of undetected infections and asymptomatic cases. In four municipalities which were especially affected, 2,000 participants will be tested for an active SARS-CoV-2 infection (oropharyngeal swab) or a past infection (blood specimen IgG antibody test). Participants will also be asked to fill out a short written questionnaire at study centres and complete a follow-up questionnaire either online or by telephone, including information on issues such as possible exposure, susceptability, symptoms and medical history. The CORONA-MONITORING lokal study will allow to determine the proportion of the population with SARS-CoV-2 antibodies in four particularly affected locations. This study will increase the accuracy of estimates regarding the scope of the epidemic, help determine risk and protective factors for an infection and therefore also identify especially exposed groups and, as such, it will be crucial towards planning of prevention measures.

Socioeconomic inequalities in the risk of SARS-CoV-2 infection - First results from an analysis of surveillance data from Germany

Experiences with acute respiratory diseases which caused virus epidemics in the past and initial findings in the research literature on the current COVID-19 pandemic suggest a higher SARS-CoV-2 infection risk for socioeconomically disadvantaged populations. Nevertheless, further research on such a potential association between socioeconomic status and SARS-CoV-2 incidence in Germany is required. This article reports on the results of a first Germany-wide analysis of COVID-19 surveillance data to which an area-level index of socioeconomic deprivation was linked. The analysis included 186,839 laboratory-confirmed COVID-19 cases, the data of which was transferred to the Robert Koch Institute by 16 June 2020, 00:00. During the early stage of the epidemic up to mid-April, the data show a socioeconomic gradient with higher incidence in less deprived regions of Germany. Over the course of the epidemic, however, this gradient becomes less measurable and finally reverses in south Germany, the region hardest hit by the epidemic, to the greater detriment of the more deprived regions. These results highlight the need to continue monitoring social epidemiological patterns in COVID-19 and analysing the underlying causes to detect dynamics and trends early on and countering a potential exacerbation of health inequalities.

Socioeconomic inequalities and COVID-19 - A review of the current international literature

Social epidemiological research describes correlations between socioeconomic status and the population's risk to become diseased or die. Little research of such correlations for SARS-CoV-2 and COVID-19 has so far been conducted. This scoping review provides an overview of the international research literature. Out of the 138 publications found, 46 were later included in the analysis. For the US and the UK, the reported findings indicate the presence of socioeconomic inequalities in infection risks as well as the severity of the course of the disease, with socioeconomically less privileged populations being hit harder. There are far fewer findings for Germany to date, as is the case for most other European countries. However, the scant evidence available so far already indicates that social inequalities are a factor in COVID-19. Most of these analyses have been ecological studies with only few studies considering socioeconomic inequalities at the individual level. Such studies at the individual level are particularly desirable as they could help to increase our understanding of the underlying pathways that lead to the development of inequalities in infection risks and the severity of disease and thereby could provide a basis to counteract the further exacerbation of health inequalities.

Soziale Ungleichheit und COVID-19: Sozialepidemiologische Perspektiven auf die Pandemie

Die neue Coronavirus-Erkrankung (COVID-19) trifft bestimmte Bevölkerungsgruppen stärker als andere. Sozialepidemiologische Muster der Pandemie, die über Alters- und Geschlechterunterschiede hinausgehen, sind bislang jedoch kaum erforscht. Für Deutschland liegen bisher nur sehr wenige Befunde zu den sozialen Determinanten von COVID-19 vor. Erste Berichte aus anderen westlichen Industrieländern lassen erkennen, dass Menschen in sozioökonomisch deprivierten Regionen und People of Color ein erhöhtes Risiko haben, schwer an COVID-19 zu erkranken und daran zu versterben. Hierfür dürften soziale Ungleichheiten im Infektionsrisiko, die sich durch unterschiedliche Lebens- und Arbeitsbedingungen ergeben, wie auch soziale Ungleichheiten in der Suszeptibilität und den Risikofaktoren für schwere COVID-19-Krankheitsverläufe, insbesondere das Vorhandensein von Vorerkrankungen, eine wesentliche Rolle spielen. Diese sind auch für Deutschland umfassend dokumentiert. Somit kann angenommen werden, dass auch hierzulande Menschen mit einem niedrigen sozioökonomischen Status besonders stark betroffen sein könnten, was vermutlich erst im weiteren Verlauf der Pandemie mehr zutage treten wird. Auch die sozialen, ökonomischen und psychosozialen Folgen der Maßnahmen, die zur Eindämmung der Pandemie getroffen werden, könnten verschiedene sozioökonomische Gruppen ungleich stark treffen. Damit hat die COVID-19-Pandemie insgesamt das Potenzial, soziale und gesundheitliche Ungleichheiten zu verstärken. Es braucht sozialepidemiologische Untersuchungen des COVID-19-Geschehens, um Maßnahmen des Gesundheits- und Infektionsschutzes zielgruppengerecht, evidenzbasiert und unter Berücksichtigung gesundheitlicher Chancengerechtigkeit weiterentwickeln zu können.

Educational differences in the prevalence of behavioural risk factors in Germany and the EU - Results from the European Health Interview Survey (EHIS) 2

This article examines educational differences in the prevalence of behavioural risk factors among adults and compares the results for Germany with the average from the European Union (EU). Data were derived from the second wave of the European Health Interview Survey, which took place between 2013 and 2015 (EHIS 2). Analyses were conducted using a regression-based calculation of relative and absolute educational differences in the prevalence of behavioural risk factors, based on self-reported data from women and men aged between 25 and 69 (n=217,215). Current smoking, obesity, physical activity lasting less than 150 minutes per week, heavy episodic drinking and non-daily fruit or vegetable intake are more prevalent among people with a low education level than those with a high education level. This applies to Germany as well as the EU average. Overall, the relative educational differences identified for these risk factors place Germany in the mid-range compared to the EU average. However, relative educational differences in current smoking and heavy episodic drinking are more manifest among women in Germany than the EU average, with the same applying to low physical activity among men. In contrast, relative educational differences in non-daily fruit or vegetable intake are less pronounced among women and men in Germany than the average across the EU. Increased efforts are needed in various policy fields to improve the structural conditions underlying health behaviour, particularly for socially disadvantaged groups, and increase health equity.

Area-level and individual correlates of active transportation among adults in Germany: A population-based multilevel study

This study aimed at estimating the prevalence in adults of complying with the aerobic physical activity (PA) recommendation through transportation-related walking and cycling. Furthermore, potential determinants of transportation-related PA recommendation compliance were investigated. 10,872 men and 13,144 women aged 18 years or older participated in the cross-sectional 'German Health Update 2014/15 - EHIS' in Germany. Transportation-related walking and cycling were assessed using the European Health Interview Survey-Physical Activity Questionnaire. Three outcome indicators were constructed: walking, cycling, and total active transportation (≥600 metabolic equivalent, MET-min/week). Associations were analyzed using multilevel regression analysis. Forty-two percent of men and 39% of women achieved ≥600 MET-min/week with total active transportation. The corresponding percentages for walking were 27% and 28% and for cycling 17% and 13%, respectively. Higher population density, older age, lower income, higher work-related and leisure-time PA, not being obese, and better self-perceived health were positively associated with transportation-related walking and cycling and total active transportation among both men and women. The promotion of walking and cycling among inactive people has great potential to increase PA in the general adult population and to comply with PA recommendations. Several correlates of active transportation were identified which should be considered when planning public health policies and interventions.

Subjective status comparisons and depressive symptoms among migrants and refugees to Germany

Background

Prior research has identified perceptions of relative social status to affect mental health. We investigated whether migrants to Germany who perceive that they would have a higher relative social status if they were still in their country of origin experience more depressive symptoms than those who perceive no such status discrepancy.

Methods

Cross-sectional data were derived from a random sample of residents in the Berlin-Brandenburg region with a Croatian, Polish, Romanian, Syrian and/or Turkish citizenship (n = 728). Participants’ perception of their relative social status in Germany was measured using the MacArthur Scale of subjective social status (SSS). An adapted version of this scale was used to assess respondents’ hypothetical SSS in their country of origin if they had not migrated. Depressive symptoms were measured with the eight-item depression scale of the Patient Health Questionnaire. Diagonal reference models were used to examine whether discrepancies between the two status ratings were associated with depressive symptom severity.

Results

Most respondents reported a higher (35.6%) or similar (49.0%) hypothetical SSS in their country of origin compared to their SSS in Germany. Respondents whose SSS in Germany was lower than their hypothetical SSS in their country of origin experienced the most severe depressive symptoms. In the diagonal reference models, this association remained statistically significant (p &lt; 0.05), even after adjusting for objective socioeconomic position and other covariates. The pattern was similar for both refugees and non-refugees.

Conclusions

Our findings indicate that perceptions of having a lower social status in Germany than hypothetically in one’s country of origin are concomitant with poorer mental health among migrants. Prospective data are needed to address questions of causation and the direction of effects.

Key messages

Migrants who perceived that they would have a higher social status if they had not left their country of origin reported higher depressive symptoms than those with no such status discrepancy. This association persisted after adjusting for objective socioeconomic position in Germany.

Inequalities in the utilisation of primary and specialist physicians in Europe - a systematic review

Background

The evidence on inequalities in health clearly shows that people with lower socioeconomic status (SES) have poorer health and higher mortality. Nevertheless, generalized evidence for inequalities in healthcare is lacking. So far, the international literature was only summarised with regard to inequalities in the utilisation of disease-specific treatment. Therefore, our aim was to synthetize the literature on socioeconomic inequalities in the utilisation of primary and specialist physicians in the general population.

Methods

This systematic review searched Medline und Web of Science from 2004 to 2018. Articles that reported quantitative data on the association of SES with utilisation of primary or specialist physicians in Europe were included. Title and abstract screening were performed by two independent researchers and 50 full texts are currently sifted whether they fulfil the inclusion criteria.

Results

The studies analysed utilisation of physicians in terms of probability or frequency. The initial check of the studies indicates that socioeconomic inequalities in the utilisation of physicians differ between primary and specialist care. Specialist physicians were found to be visited with a higher probability and more often by the least disadvantaged in most studies. Inequalities in the utilisation of primary physicians revealed to be more diverse with a weak pattern of equally distributed probability of GP visits and more frequent utilisation by the disadvantaged.

Conclusions

The preliminary results indicate that pro-rich utilisation seems to be more pronounced in visiting specialists compared to primary health care. Aiming to reduce inequalities in healthcare, public health actions might primarily focus on reaching a needs-based consultation of specialist physicians.

Key messages

Socioeconomic inequalities in the utilisation of physicians exist and differ between primary and specialist care. Inequalities to the disadvantage of the population with low SES are more pronounced in the utilisation of specialists compared to general practitioners.