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.

Causal graph analysis of COVID-19 observational data in German districts reveals effects of determining factors on reported case numbers

Several determinants are suspected to be causal drivers for new cases of COVID-19 infection. Correcting for possible confounders, we estimated the effects of the most prominent determining factors on reported case numbers. To this end, we used a directed acyclic graph (DAG) as a graphical representation of the hypothesized causal effects of the determinants on new reported cases of COVID-19. Based on this, we computed valid adjustment sets of the possible confounding factors. We collected data for Germany from publicly available sources (e.g. Robert Koch Institute, Germany's National Meteorological Service, Google) for 401 German districts over the period of 15 February to 8 July 2020, and estimated total causal effects based on our DAG analysis by negative binomial regression. Our analysis revealed favorable effects of increasing temperature, increased public mobility for essential shopping (grocery and pharmacy) or within residential areas, and awareness measured by COVID-19 burden, all of them reducing the outcome of newly reported COVID-19 cases. Conversely, we saw adverse effects leading to an increase in new COVID-19 cases for public mobility in retail and recreational areas or workplaces, awareness measured by searches for "corona" in Google, higher rainfall, and some socio-demographic factors. Non-pharmaceutical interventions were found to be effective in reducing case numbers. This comprehensive causal graph analysis of a variety of determinants affecting COVID-19 progression gives strong evidence for the driving forces of mobility, public awareness, and temperature, whose implications need to be taken into account for future decisions regarding pandemic management.

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.

Domain-specific physical activity patterns and cardiorespiratory fitness among adults in Germany

Background

Studies show that occupational physical activity (OPA) has less health-enhancing effects than leisure-time physical activity (LTPA). The spare data available suggests that OPA rarely includes aerobic PAs with little or no enhancing effects on cardiorespiratory fitness (CRF) as a possible explanation. This study aims to investigate the associations between patterns of OPA and LTPA and CRF among adults in Germany.

Methods

1,204 men and 1,303 women (18-64 years), who participated in the German Health Interview and Examination Survey 2008-2011, completed a standardized sub-maximal cycle ergometer test to estimate maximal oxygen consumption (VO2max). Job positions were coded according to the level of physical effort to construct an occupational PA index and categorized as low vs. high OPA. LTPA was assessed via questionnaires and dichotomized in no vs. any LTPA participation. A combined LTPA/OPA variable was used (high OPA/ LTPA, low OPA/LTPA, high OPA/no LTPA, low OPA/no LTPA). Information on potential confounders was obtained via questionnaires (e.g., smoking and education) or physical measurements (e.g., waist circumference). Multi-variable logistic regression was used to analyze associations between OPA/LTPA patterns and VO2max.

Results

Preliminary analyses showed that less-active men were more likely to have a low VO2max with odds ratios (ORs) of 0.80 for low OPA/LTPA, 1.84 for high OPA/no LTPA and 3.46 for low OPA/no LTPA compared to high OPA/LTPA. The corresponding ORs for women were 1.11 for low OPA/LTPA, 3.99 for high OPA/no LTPA and 2.44 for low OPA/no LTPA, indicating the highest likelihood of low fitness for women working in physically demanding jobs and not engaging in LTPA.

Conclusions

Findings confirm a strong association between LTPA and CRF and suggest an interaction between OPA and LTPA patterns on CRF within the workforce in Germany. Women without LTPA are at high risk of having a low CRF, especially if they work in physically demanding jobs.

Key messages

Women not practicing leisure-time physical activity are at risk of having a low cardiorespiratory fitness, especially if they work in physically demanding jobs. Different impact of domains of physical activity should be considered when planning interventions to enhance fitness among the adult population.

[Time trends of occupational differences in smoking behaviour of employed men and women in Germany : Results of the 1999-2013 microcensus]

BACKGROUND

Studies show that people with a low occupational status are more likely to smoke than those with a high occupational status. Against the background of a general decline in tobacco consumption, time trends of occupational differences in smoking behaviour of employed men and women in Germany were examined.

METHODS

The analyses were based on the last five waves of the German microcensus that included questions about smoking (1999, 2003, 2005, 2009 and 2013), taking only employed men and women aged 18-64 years into account (n = 688,746). Information on occupational position was summarised using international classifications of occupation (ISEI-08 and ISCO-08). Raw and model-based standardized prevalence estimates of current smoking were calculated.

RESULTS

Between 1999 and 2013, the proportion of smokers in the working population fell from 39.9 to 34.4% (men) and from 30.6 to 26.8% (women). Differences between occupational status groups increased significantly: while the prevalence of smoking among employees with high occupational status decreased, it remained largely stable in the low status group. In 2013, the occupations with the highest proportion of smokers were waste disposal workers, cleaning staff, unskilled workers, truck and bus drivers, salespeople and cashiers, and employees in the catering industry.

CONCLUSION

Since the beginning of the 2000s, the prevalence of smoking in the working population has declined. The strengthened tobacco control policy - e. g. the establishment of smoke-free workplace laws - might have contributed to this trend. In the context of workplace health promotion, tobacco prevention and cessation measures should be targeted at those professions in which smoking is still particularly common.

Social differences in mortality and life expectancy in Germany. Current situation and trends

Social differences in mortality and life expectancy are a clear demonstration of the social and health-related inequalities that exist within a particular population. According to data from the Socio-Economic Panel (SOEP) for the period ranging from 1992 to 2016, 13% of women and 27% of men in the lowest income group died before the age of 65; the same can be said for just 8% of women and 14% of men in the highest income group. The difference between mean life expectancy at birth among the lowest and highest income groups is 4.4 years for women and 8.6 years for men. Substantial differences also exist between income groups regarding further life expectancy at the age of 65: women in the lowest income group have a 3.7-year shorter life expectancy than women in the highest income group. Similarly, men in the lowest income group have a 6.6-year shorter life expectancy than men in the highest income group. Finally, results from the trend analyses suggest that social differences in life expectancy have remained relatively stable over the last 25 years.

Gender inequalities in the association between area deprivation and perceived social support: a cross-sectional multilevel analysis at the municipality level in Germany

OBJECTIVES

To investigate the association between area deprivation at municipality level with low perceived social support, independent of individual socioeconomic position and demographic characteristics. To assess whether there are gender inequalities in this association.

DESIGN

Cross-sectional multilevel analysis of survey data.

SETTING

Germany.

PARTICIPANTS

3350 men and 3665 women living in 167 municipalities throughout Germany participating in the 'German Health Interview and Examination Survey for Adults' (DEGS1 2008-2011) as part of the national health monitoring.

OUTCOME

Perceived social support as measured by Oslo-3 Social Support Scale.

RESULTS

Prevalence of low perceived social support was 11.4% in men and 11.1% in women. Low social support was associated in men and women with sociodemographic characteristics that indicate more disadvantaged living situations. Taking these individual-level characteristics into account, municipal-level deprivation was independently associated with low perceived social support in men (OR for the most deprived quintile: 1.80 (95% CI 1.14 to 2.84)), but not in women (OR 1.22 (95% CI 0.78 to 1.90)).

CONCLUSION

The results of our multilevel analysis suggest that there are gender inequalities in the association of municipal-level deprivation with the prevalence of low perceived social support in Germany independent of individual socioeconomic position. Community health interventions aiming at promotion of social support among residents might profit from a further understanding of the observed gender differences.

Post-millennial trends of socioeconomic inequalities in chronic illness among adults in Germany

Objective

Time trends in health inequalities have scarcely been studied in Germany as only few national data have been available. In this paper, we explore trends in socioeconomic inequalities in the prevalence of chronic illness using Germany-wide data from four cross-sectional health surveys conducted between 2003 and 2012 (n = 54,197; ages 25–69 years). We thereby expand a prior analysis on post-millennial inequality trends in behavioural risk factors by turning the focus to chronic illness as the outcome measure. The regression-based slope index of inequality (SII) and relative index of inequality (RII) were calculated to estimate the extent of absolute and relative socioeconomic inequalities in chronic illness, respectively.

Results

The results for men revealed a significant increase in the extent of socioeconomic inequalities in chronic illness between 2003 and 2012 on both the absolute and relative scales (SII₂₀₀₃ = 0.06, SII₂₀₁₂ = 0.17, p-trend = 0.013; RII₂₀₀₃ = 1.18, RII₂₀₁₂ = 1.57, p-trend = 0.013). In women, similar increases in socioeconomic inequalities in chronic illness were found (SII₂₀₀₃ = 0.05, SII₂₀₁₂ = 0.14, p-trend = 0.022; RII₂₀₀₃ = 1.14, RII₂₀₁₂ = 1.40, p-trend = 0.021). Whereas in men this trend was driven by an increasing prevalence of chronic illness in the low socioeconomic group, the trend in women was predominantly the result of a declining prevalence in the high socioeconomic group.

Socioeconomic status and subjective social status measurement in KiGGS Wave 2

This article describes the method applied to measure socioeconomic status (SES) and subjective social status (SSS) in the current wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2), which was conducted over three years between 2014 and 2017. The composite multidimensional SES index was calculated as a sum of point scores for the parents' education level, occupational status and equivalised disposable income. SSS was assessed in the 11 to 17 year age group using a German version of the MacArthur Scale for children and adolescents. To demonstrate the use of both instruments, we present examples that highlight the association between SES and SSS with the general health of children and adolescents in the 3 to 17 and/or 11 to 17 age groups. Over 95% of parents rated the general health of their children as 'very good' or 'good'. However, the analyses clearly reveal that children and adolescents from families with low SES and SSS have poorer general health than their better-off peers. Even when mutually adjusted, both low SES and SSS are independently associated with poorer general health. In addition to the SES index, studies on the health of children and adolescents should therefore also consider SSS. In this way, additional aspects of the socioeconomic conditions of families can be taken into account.

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

Social epidemiological research has consistently demonstrated that people with a low socioeconomic status are particularly at risk of diseases, health complaints and functional limitations, and die at younger ages than those with a higher socioeconomic status. Greater stresses and strains in the workplace, family and living environment are under discussion as possible explanations. Health-related behaviours, psycho-social factors and personal resources, which are important in coping with everyday demands, certainly also play a role. From a public health and health policy perspective, reducing these health inequalities is an important goal. Insights into developments and trends in health inequalities over time can contribute towards highlighting new and emerging problems, and can thus help identify possible target groups and settings for relevant interventions. At the same time, these insights provide a basis upon which the success of policies and programmes that have already been implemented can be analysed and measured. Against this background, this review examines how health inequalities in Germany have developed over the last 20 to 30 years and places its findings within the context of the latest international research in this field.

Corrigendum: The utilization of psychiatric and psychotherapeutic services in Germany - individual determinants and regional differences

[This corrects the article on p. 3-22 in vol. 2.].

The utilization of psychiatric and psychotherapeutic services in Germany - individual determinants and regional differences

In Germany, the provision of health services to people with mental disorders is an issue that is subject to controversial debate. On the one hand, regional differences exist in the distribution of psychotherapists in Germany. On the other hand, patients are often willing to accept the extra effort of having to travel further in order to access treatment even in case of a low supply. Thus, in addition to issues of access, an analysis of care provision also needs to take into account the actual level of services utilization. The present paper analyses the utilization of outpatient psychiatric and psychotherapeutic services and identifies individual and regional determinants. The German Health Update (GEDA) is a nationwide survey of the adult population that is conducted by the Robert Koch Institute in the context of its population-based health monitoring. The GEDA 2014/2015-EHIS study (n=24,016) is based on a two-stage stratified random sample drawn from the population registers of 301 local authorities in Germany. The main outcome is the utilization of psychotherapeutic or psychiatric services during the last 12 months. In addition to the consideration of individual factors, the survey data was combined with information describing the regional distribution of providers of outpatient psychotherapeutic and neurological care. The data was analysed using logistic multi-level regression. In Germany, 11.3% of women and 8.1% of men report that they have used psychotherapeutic or psychiatric treatment within the last 12 months. Among respondents with current depressive symptoms, these rates are 35.0% in women and 31.0% in men. This means that approximately two thirds of people with current depressive symptoms do not seek the services of these health professionals during this period. Apart from current depressive symptoms the utilization of psychiatric and psychotherapeutic services is associated with not living with a partner and with low levels of social support. Furthermore, in regions with a high density of care providers, the proportion of people with current depressive symptoms using such services is about 15 percentage points higher than in regions with a low density. The conditions for the utilization of the respective services should not only be improved by increasing the number of care providers, but also by implementing accompanying measures. Innovations in health care aiming at rapid and low-threshold access as well as approaches for a better cooperation between primary and specialist care should therefore be evaluated regarding their contribution to an improved early treatment.

Perceived exposure to hazardous working conditions in Germany

Data on the prevalence of perceived exposure to hazardous working conditions were gathered for the GEDA 2014/2015-EHIS study using a simple graduated question. Approximately one-fifth of people in employment state that they face serious or very serious occupational health hazards. However, women (18.6%) are significantly less likely to have this perception than men (27.0%). The differences between women and men can be explained by the variation in working hours and by the continued gender specific division of the labour market (segregation). There are pronounced differences among men with regard to educational and vocational qualifications, with lower qualified men viewing their employment as posing a higher risk to their health than higher qualified men; no similar differences exist between women. Finally, perceived health risks are highest among women and men in the passenger and freight transport sectors. The results of this study underline the importance of occupational safety and workplace health promotion.

Corrigendum: Regional health differences - developing a socioeconomic deprivation index for Germany

[This corrects the article on p. 98-114 in vol. 2.].

Regional health differences - developing a socioeconomic deprivation index for Germany

For Germany, regional differences for various health indicators, which are also associated with socioeconomic factors, have been documented. This article aims to develop a regional socioeconomic deprivation index for Germany that (1) can be used to analyse regional socioeconomic inequalities in health and (2) provides a basis for explaining regional health differences in Germany. The core data stem from the INKAR (indicators and maps on spatial and urban development in Germany and Europe) database compiled by Germany's Federal Institute for Research on Building, Urban Affairs and Spatial Development. Factor analysis is used for indexing and the weighting of indicators for the three dimensions of education, occupation and income. The German Index of Socioeconomic Deprivation (GISD) is generated at the levels of associations of municipalities, administrative districts and administrative regions for the years 1998, 2003, 2008 and 2012. Aggregate data and individual data from the German Health Update 2014/2015-EHIS (GEDA 2014/2015-EHIS) study are used to analyse associations between the index and selected health indicators. For around two thirds of the causes of death, the German Index of Socioeconomic Deprivation reveals significant socioeconomic inequalities at the level of Germany's administrative regions. At district level, life expectancy in the bottom fifth of districts presenting the highest levels of deprivation is, depending on the observation period, 1.3 years lower for women and 2.6 years lower for men in comparison to the upper fifth of districts presenting the lowest levels of deprivation. The index can explain 45.5% and 62.2% of regional differences in life expectancy for women and men, respectively. Moreover, the population in regions characterised by high levels of deprivation has significantly higher rates of smokers, engages less frequently in leisure-time physical activities and is more often obese. The German Index of Socioeconomic Deprivation illustrates regional socioeconomic differences at different spatial levels and contributes to explaining regional health differences. This index is intended for use in research as well as by federal and federal state health reporting systems and should enable access to new sources of data for investigating the links between social inequalities and health in Germany.

Individual and Regional Determinants for Physical Therapy Utilization in Germany: Multilevel Analysis of National Survey Data

BACKGROUND

Physical therapy is included in many clinical guidelines and is a commonly used health service. However, access to its benefits should not strongly depend on social or demographic factors.

OBJECTIVE

The present study used the Andersen model to explain to what extent physical therapy utilization in Germany depends on factors beyond medical need.

METHODS

The German Health Interview and Examination Survey for Adults (DEGS, 2008-2011; target population, 18-79 years) is part of the German health-monitoring system. Two-stage stratified cluster sampling resulted in a sample of 8152 participants. Data were matched with district-related information on social structures and service supply. Following Andersen's Behavioral Model of Health Services Use, this study identified predisposing, enabling, and need factors for physical therapy utilization using multilevel logistic regression analyses.

RESULTS

Physical therapy was used by 23.4% (95% CI: 22.0-24.8) of the German population within one year, with a higher proportion of females (26.8%; 95% CI: 25.1-28.6) than males (19.9%; 95% CI: 18.1-21.8) and an increase with age. Beyond medical need, physical therapy utilization depended on higher education, migrant background, nonsmoking (predisposing), social support, higher income, private health insurance, and gatekeeping service contact (enabling). Variation among districts partly reflected regional supply.

LIMITATIONS

Because the present study was cross-sectional, its findings provide representative information on physical therapy use but do not establish final causal links or identify whether utilization or supply in certain districts or population groups is adequate.

CONCLUSIONS

Whether certain regions are under- or overserved and whether further regulations are needed is of political interest. Physicians and therapists should develop strategies to improve both adherence of hard-to-reach groups and supply in low-supply regions.

[Employment, family and health in men of working age in Germany : Results of the GEDA studies 2009-2012]

BACKGROUND

Today's men want to participate in their children's upbringing more than in the past, but they are heavily involved in their occupation at the same time. This article describes the significance of parenthood, partnership and occupation in relation to health and health behaviours among men of working age in Germany.

DATA

We summarised data from the "German Health Update" (GEDA) studies conducted in 2009, 2010 and 2012. Data on 18,465 men aged 18-64 years were available, 11,429 of which were living with children. We included mental health problems, general health awareness, sports activity and smoking as outcomes.

RESULTS

Full-time employees working more than 48 h per week and unemployed persons had mental health problems more frequently (OR 1.44 and 2.35, p < 0.05) than full-time employees working 48 h or fewer. Similar associations can be shown for health awareness, physical activity and smoking. Concerning partnership and parenthood, the associations were considerably weaker: men living together with children and a partner in the household were overall less burdened and their behaviour was also healthier than single men without children. After simultaneous consideration of employment status, parenthood and partnership, our results show that the unemployed and employees with long working hours were the most burdened.

DISCUSSION

The results provide supporting evidence regarding health problems of men in Germany due to unemployment and long working hours that are of importance for their health whether they are living with a partner and/or with children or not. The association between health and occupation was stronger than between health and fatherhood or partnership.

Occupational Injuries in Germany: Population-Wide National Survey Data Emphasize the Importance of Work-Related Factors

Unintentional injuries cause much of the global mortality burden, with the workplace being a common accident setting. Even in high-income economies, occupational injury figures remain remarkably high. Because risk factors for occupational injuries are prone to confounding, the present research takes a comprehensive approach. To better understand the occurrence of occupational injuries, sociodemographic factors and work- and health-related factors are tested simultaneously. Thus, the present analysis aims to develop a comprehensive epidemiological model that facilitates the explanation of varying injury rates in the workplace. The representative phone survey German Health Update 2010 provides information on medically treated occupational injuries sustained in the year prior to the interview. Data were collected on sociodemographics, occupation, working conditions, health-related behaviors, and chronic diseases. For the economically active population (18-70 years, n = 14,041), the 12-month prevalence of occupational injuries was calculated with a 95% confidence interval (CI). Blockwise multiple logistic regression was applied to successively include different groups of variables. Overall, 2.8% (95% CI 2.4-3.2) of the gainfully employed population report at least one occupational injury (women: 0.9%; 95% CI 0.7-1.2; men: 4.3%; 95% CI 3.7-5.0). In the fully adjusted model, male gender (OR 3.16) and age 18-29 (OR 1.54), as well as agricultural (OR 5.40), technical (OR 3.41), skilled service (OR 4.24) or manual (OR 5.12), and unskilled service (OR 3.13) or manual (OR 4.97) occupations are associated with higher chances of occupational injuries. The same holds for frequent stressors such as heavy carrying (OR 1.78), working in awkward postures (OR 1.46), environmental stress (OR 1.48), and working under pressure (OR 1.41). Among health-related variables, physical inactivity (OR 1.47) and obesity (OR 1.73) present a significantly higher chance of occupational injuries. While the odds for most work-related factors were as expected, the associations for health-related factors such as smoking, drinking, and chronic diseases were rather weak. In part, this may be due to context-specific factors such as safety and workplace regulations in high-income countries like Germany. This assumption could guide further research, taking a multi-level approach to international comparisons.

[Measurement of socioeconomic status in the KiGGS study: first follow-up (KiGGS Wave 1)]

This article describes the measurement of socioeconomic status in the first follow-up of the KiGGS study (KiGGS Wave 1) conducted from 2009 to 2012. A multidimensional index score was used. The score is the sum of three metric components: Education and Occupational Qualification, Occupational Status, and Net Income. Compared with the approach in the KiGGS baseline study, some modifications were made in accordance with changes in the other components of the health-monitoring program at the Robert Koch Institute, i.e., the German Health Update (GEDA) and the German Health Interview and Examination Survey for Adults (DEGS1). These changes facilitate the analysis of temporal developments and trends, ensure international comparability of the data, and support the transfer of the results into politics and practice. In order to demonstrate the application of the revised instrument, we report on exemplary results of KiGGS Wave 1 regarding the relationship between socioeconomic status and the general health status of children and adolescents aged 3-17 years.

Occupation and educational inequalities in laryngeal cancer: the use of a job index

BACKGROUND

Previous studies tried to assess the association between socioeconomic status and laryngeal cancer. Alcohol and tobacco consumption explain already a large part of the social inequalities. Occupational exposures might explain a part of the remaining but the components and pathways of the socioeconomic contribution have yet to be fully disentangled. The aim of this study was to evaluate the role of occupation using different occupational indices, differentiating between physical, psycho-social and toxic exposures and trying to summarize the occupational burden into one variable.

METHODS

A population-based case-control study conducted in Germany in 1998-2000 included 208 male cases and 702 controls. Information on occupational history, smoking, alcohol consumption and education was collected with face-to-face interviews. A recently developed job-classification index was used to account for the occupational burden. A sub-index focussed on jobs involving potentially carcinogenic agents (CAI) for the upper aero digestive tract.

RESULTS

When adjusted for smoking and alcohol consumption, higher odds ratios (ORs) were found for lower education. This OR decreased after further adjustment using the physical and psycho-social job indices (OR = 3.2, 95%-CI: 1.5-6.8), similar to the OR using the sub-index CAI (OR = 3.0, 95%-CI: 1.4-6.5).

CONCLUSIONS

The use of an easily applicable control variable, simply constructed on standard occupational job classifications, provides the possibility to differentiate between educational and occupational contributions. Such an index might indirectly reflect the effect of carcinogenic agents, which are not collected in many studies.

To what degree is the association between educational inequality and laryngeal cancer explained by smoking, alcohol consumption, and occupational exposure?

OBJECTIVES

The aim of this study was to measure the extent to which the association between socioeconomic status and laryngeal cancer among males is mediated by smoking, alcohol consumption, and occupational exposure.

METHODS

We used Karlson et al's decomposition method for logit models, which returns the percentage of change in odds ratios (OR) due to confounding. This population-based, case-control study on laryngeal cancer was conducted in Germany in 1998-2000 and included 208 male cases and 702 controls. Information on occupational history, smoking, alcohol consumption, and education was collected through face-to-face interviews. Jobs coded according to ISCO-68 were linked to a recently developed job-classification index covering physical and psychosocial dimensions. A sub-index focused on jobs involving potentially carcinogenic agents (CAI) for the upper-aero digestive tract.

RESULTS

When adjusted for smoking and alcohol consumption, higher OR were found for lower education. This OR decreased after further adjustment using the overall job index [2.9, 95% confidence interval (95% CI) 1.4-6.2], similar to the OR using the sub-index CAI (OR 2.7, 95% CI 1.3-5.8). Applying the Karlson et al method, 25.4% (95% CI 22.6-28.2%) of the reduction in these OR was due to occupational exposure (CAI), while smoking and alcohol consumption contributed to around 26.1% (95% CI 23.2-28.9%) and 2.7% (95% CI 1.7-3.8%), respectively.

CONCLUSIONS

Occupational aspects, in particular the exposure to carcinogenic agents, explain a large portion of the association between low educational level and laryngeal cancer risk among males. Occupational effects are now easier to quantify using this recently developed and easily applicable index.

Direct costs of inequalities in health care utilization in Germany 1994 to 2009: a top-down projection

Background

Social inequalities in health are a characteristic of almost all European Welfare States. It has been estimated, that this is associated with annual costs that amount to approximately 9% of total member state GDP. We investigated the influence of inequalities in German health care utilization on direct medical costs.

Methods

We used longitudinal data from a representative panel study (German Socio-Economic Panel Study) covering 1994 to 2010. The sample consisted of respondents aged 18 years or older. We used additional data from the German Health Interview and Examination Survey for Children and Adolescents, conducted between 2003 and 2006, to report utilization for male and female participants aged from 0 to 17 years. We analyzed inequalities in health care using negative binomial regression models and top-down cost estimates.

Results

Men in the lowest income group (less than 60% of median income) had a 1.3-fold (95% CI: 1.2-1.4) increased number of doctor visits and a 2.2-fold (95% CI: 1.9-2.6) increased number of hospital days per year, when compared with the highest income group; the corresponding differences were 1.1 (95% CI: 1.0-1.1) and 1.3 (95% CI: 1.2-1.5) for women. Depending on the underlying scenario used, direct costs for health care due to health inequalities were increased by approximately 2 billion to 25 billion euros per year. The best case scenario (the whole population is as healthy and uses an equivalent amount of resources as the well-off) would have hypothetically reduced the costs of health care by 16 to 25 billion euros per year.

Conclusions

Our findings indicate that inequalities and inequities in health care utilization exist in Germany, with respect to income position, and are associated with considerable direct costs. Additional research is needed to analyze the indirect costs of health inequalities and to replicate the current findings using different methodologies.

[Health Inequality among employed men and women - results of the German health update (GEDA) 2010]

BACKGROUND

The study is based on representative data and gives an overview on the extent of health inequalities in working men and women in Germany.

METHODS

We use data of the study German Health Update (GEDA) 2010 to analyze health differences by occupational status for men and women. Occupational Status was measured using the "International Socio-, Economic Index of Occupational Status' (ISEI). Outcomes are self-rated health status, work/and commuting accidents, self-assessed health risks at work, days with physical or emotional problems and sick leave from work.

RESULTS

Men and women with high occupational status are in a better health situation than those with low status in respect to all outcomes analyzed. The risk for a poor self-rated health status, high health risks at work and for the occurrence of accidents at work is significantly 2.4- to 4.6-fold (men) and 1.8- to 3.3-fold (women) increased after controlling for age and work hours. Further Analyses with regard to self-assessed health risks at work showed that occupational status differences with men and women do not differ significantly. In those analyses, about 50% of the status differences regarding risks at work could be explained for men and women by their qualification, working conditions and health behavior.

CONCLUSION

The present findings show that significant and persistent health inequalities among the employed exist in Germany. The relationship proved equally strong in both men and women.

Sozialkapital und Gesundheit in Deutschland

The concept of social capital has been intensively discussed in public health during the last years. But there is only little empirical evidence regarding its association with health in Germany up to now. We have used data of the German Socio-Economic Panel (GSOEP) of 2003 to analyse the health utility of social capital. The results suggest a clear positive association among different forms of social capital (trust, norms of reciprocity, participation, social integration) and subjective health. Men and women who are poorly socially integrated regard their own health relatively often as limited. In contrast to these, men and women who hold any form of social capital rate their own health status to be noticeably better. In the multivariate analysis, socio-economic differences in subjective health could be traced back partly to the stock of social capital. In addition to its health utility, social capital may therefore make a contribution to understand the emergence of social inequalities in health. All in all, our results suggest that the concept of social capital should be considered even more in public health. Due to the present lack of empirical evidence, social capital has to be incorporated into more studies in Germany.

[Income differences in health and life expectancy--cross-sectional and longitudinal findings of the German Socio-Economic Panel (GSOEP)]

Income is an important determinant of individual standards of living and participation in social life. Data from the German Socio-Economic Panel shows that the level of income also affects a person's health and life expectancy. People's self-assessment of their health and health-related quality of life follow a distribution pattern which can be described as a gradient: the lower the income, the more frequent the impairments to subjective health. Life expectancy statistics also reflect income differences, primarily due to premature deaths among lower-income groups. Clues for explaining income-related differences in health and life expectancy can be found in the results on health-related behaviour and use of the medical system: people in the lower income groups smoke more frequently, are slaker in sports and are less likely to go to a doctor when their health is impaired. Furthermore, work environment and job-specific influences, stress burdens and reactions, social comparison processes and disease-induced processes of declining social mobility and social exclusion are discussed as possible explanations.