Cross-national data on informal caregivers of older people with long-term care needs in the European population: time for a more coordinated and comparable approach.

To promote long-term care policies for older adults, accurate mapping of the often invisible and insufficiently recognized role of their informal caregivers is needed. This paper measures the prevalence of informal caregivers in the European population, illustrates current difficulties in gathering unequivocal information on this topic and deals with the scientific and policy implications of the problem. Using the European Health Interview Survey (EHIS), the European Quality of Life Survey (EQLS) and the Study on Health and Ageing in Europe (SHARE), the current difficulties in gathering unequivocal information on this topic are illustrated. In most countries, the share of informal caregivers varies, sometimes markedly, among the three surveys. As for the sex of caregivers, while confirming the well-known higher prevalence of caregivers among women than among men, large variations emerge across the three surveys in most countries in respect of the two sexes. The takeaway message of the paper is that it is urgent to promote international concerted action in gathering comprehensive informal caregiving information and/or exploring in greater depth the different intercultural understandings of informal care itself.

Frequent attenders in the German healthcare system: determinants of high utilization of primary care services. Results from the cross-sectional German health interview and examination survey for adults (DEGS).

BACKGROUND: In Germany, patients are consulting general practitioners increasingly frequently, resulting in a high burden on the healthcare system. This study aimed to identify factors associated with frequent primary care attendance in the German healthcare system. METHODS: The German Health Interview and Examination Survey for Adults (DEGS) is part of Germany's national health monitoring, and includes a large representative sample of the German population aged 18-79 years. We defined the 10% of participants with the highest number of general practitioner contacts in the preceding 12 months as frequent attenders of primary care services. Binary logistic regression models with average marginal effects were used to identify potential determinants for frequent use of primary care services. RESULTS: The sample comprised 7956 participants. Significant effects on frequent use of primary care were observed for low socioeconomic status, stressful life events, factors related to medical need for care such as medically diagnosed chronic conditions and for subjective health. In the full model, the number of non-communicable diseases and subjective health status had the strongest effect on frequent primary care use. We found an interaction effect suggesting that the association between subjective health status and frequent attendance vanishes with a higher number of non-communicable diseases. CONCLUSIONS: We observed strong associations between frequent primary care attendance and medical need for care as well as subjective health-related factors. These findings suggest that better coordination of care may be a preferred method to manage health services utilization and to avoid redundant examinations and uncoordinated clinical pathways. Further research is needed to clarify moderating and mediating factors contributing to high utilization of primary care services.

[Federal health reporting at the Robert Koch Institute-status quo and current developments]. / Gesundheitsberichterstattung des Bundes am Robert Koch-Institut ­ Status quo und aktuelle Entwicklungen.

Health reporting as an integral part of public health plays an important role in the development of strategies and concepts that aim to improve the health of all population groups. This article provides an overview of the definition and tasks of federal health reporting and describes important health reporting components in their current form. The publication format of the Journal of Health Monitoring, which was developed for different user groups of health monitoring, is presented. Examples of the uses and effects of health reporting are also presented. Health reporting is designed as a flexible system: changes in databases as well as forms of communication are taken into account in the further development of health reporting.The further development of health reporting requires close interdisciplinary cooperation between different actors in order to integrate current research results from various scientific disciplines into the processes of health reporting, as well as to further expand the scope and impact of health reporting. In addition, to further develop health reporting on a scientific level, the expansion of participatory elements and a stronger internationalization will be important future tasks.

[Prevalence and incidence of documented diabetes based on health claims data-reference analysis for diabetes surveillance in Germany]. / Prävalenz und Inzidenz des dokumentierten Diabetes mellitus ­ Referenzauswertung für die Diabetes-Surveillance auf Basis von Daten aller gesetzlich Krankenversicherten.

BACKGROUND: The prevalence and incidence of documented diabetes are two essential indicators intended to be reported on a periodic basis within the framework of diabetes surveillance in Germany. METHODOLOGY: Data provided based on the Data Transparency Act were analyzed. The data contain information on outpatient and inpatient care for all approximately 70 million persons with statutory health insurance. The case definition for the prevalence of documented diabetes comprises a confirmed outpatient diagnosis in at least two quarters of a year or an inpatient diagnosis in at least one quarter of a year in accordance with ICD-10 codes E10.- to E14.-. The incidence was calculated based on the same definition and with one year of diagnosis-free lead time. RESULTS: In 2011, a prevalence of 9.7% (women: 9.4%, men: 10.1%) was observed for persons with statutory health insurance. There are considerable differences in prevalence between the federal states and the maximum gap is 7.1 percentage points (age standardized: 4.0 percentage points). Type 2 and type 1 diabetes show a documented prevalence of 7.5% and 0.28%, respectively. Unspecified diabetes is documented relatively frequently with 1.9%. In 0.21% of persons, the diagnosis diabetes is documented via one inpatient secondary diagnosis. In addition, 0.17% of people without documented diabetes have at least one prescription of an antidiabetic drug. In 2012, 565,040 insured persons were newly diagnosed with diabetes; this corresponds to 1.0% of the insured persons (women: 1.0%, men: 1.1%). DISCUSSION: The developed reference analysis is suitable for reporting the prevalence and incidence of documented diabetes within the framework of diabetes surveillance. The differentiation of diabetes types is difficult due to coding practice.

[Utilization of outpatient medical services and satisfaction with care in children and adolescents with a migration background-results of the KiGGS study]. / Inanspruchnahme ambulant ärztlicher Leistungen und Zufriedenheit mit der Versorgung bei Kindern und Jugendlichen mit Migrationshintergrund ­ Ergebnisse der KiGGS-Studie.

BACKGROUND AND AIM: Reasons for lower use of medical services by children and adolescents with migration background have not yet been investigated. The aim is therefore to identify factors that are related to the utilization of outpatient medical care and subjective patient satisfaction as well as explain differences according to migration background. METHODS: On the basis of the "German Health Interview and Examination Survey for Children and Adolescents" (KiGGS, baseline study: 2003-2006), in which 17,640 children and adolescents participated, prevalences with 95% confidence intervals as well as multivariate binary logistic regression analyzes on the relationship between migration background, country of origin, the use of outpatient medical care services in the last 12 months, and satisfaction with the last medical treatment were calculated. RESULTS: Children up to age 13 with two-sided migration background had lower utilization of specialist doctors compared to those without migration background (OR = 0.64 [0.56-0.74]). However, among the 14- to 17-year-olds, the utilization did not differ significantly (OR = 0.79 [0.60-1.03]). The lower use of outpatient medical care is associated with a shorter length of stay and limited German language skills. In addition, parents from Poland and the former Soviet Union are less likely to be very satisfied with the last outpatient treatment of their 0­ to 13-year-old child, even after adjustments for German language skills and length of stay. CONCLUSION: To make it easier for children with migration background to access specialist services, it is important to reduce language barriers in outpatient medical care and to promote processes of intercultural opening.

[AdvanceGender-Joint project for sex/gender-sensitive and intersectional research and health reporting]. / AdvanceGender ­ Verbundprojekt für eine geschlechtersensible und intersektionale Forschung und Gesundheitsberichterstattung.

Health reporting provides information on the health of the population and thus forms the basis for adequate health promotion, prevention, and care. In order to better represent social diversity, the joint project AdvanceGender (funded by the German Federal Ministry for Education and Research) aims to promote the development of a gender-sensitive and intersectional approach to population-based studies and health reporting. The three subprojects research study participation, data analysis, and health reporting. Based on the results, recommendations for epidemiological studies and for health reporting will be developed.

[ICD coding of causes of death: challenges for calculating the burden of disease in Germany]. / ICD-Codierung von Todesursachen: Herausforderungen bei der Berechnung der Krankheitslast in Deutschland.

In the project BURDEN 2020 - "The burden of disease in Germany and its regions" - the years of life lost (YLL) due to premature mortality are calculated on the basis of official cause-of-death statistics. This requires the identification and redistribution of the so-called ill-defined ICD codes. "Ill-defined" means that an ICD code does not sufficiently reflect the cause of death, such that it is not informative for the calculation of the burden of disease.The first steps on the way to calculating cause-specific YLL are presented. Different frameworks of ill-defined codes are compared. The number of deaths with ill-defined codes that can be found in the German cause-of-death statistics in absolute and relative terms are analyzed, including how they are distributed by age, sex, and region.According to the WHO framework, 15.6% of the 925,200 deaths in Germany in 2015 can be identified as ill-defined. According to the framework of the Institute for Health Metrics and Evaluation (IHME) in the Global Burden of Disease Study (GBD), the proportion of ill-defined codes is 26.6%. The ICD-related distribution patterns hardly differ between WHO and IHME classifications. Considerable differences exist between the federal states, with shares of ill-defined codes between 16 and 35% (IHME framework).The cause-of-death statistics in Germany contain a considerable proportion of ill-defined codes. The differences between the federal states can only partially be explained by different electronic data processing. Due to further dissemination and improvement of electronic data collection, higher quality of cause-of-death statistics can be expected in the future.

Erratum to: BURDEN 2020-Burden of disease in Germany at the national and regional level.

Erratum to:Bundesgesundheitsbl (2018) https://doi.org/10.1007/s00103-018-2793-0 The original publication of this article contained an error in the list of the authors, in which the contributing author Christian Schmidt was missing. The full list of authors has now been updated. The original article ….

BURDEN 2020-Burden of disease in Germany at the national and regional level.

BACKGROUND: Evidence-based policy measures need non-interest-guided information about the health status of a population and the diseases that affect the population the most. In such cases, a national burden of disease study can provide reliable insights at the regional level. AIM: This article presents the potential of the BURDEN 2020 project and its expected outcome for Germany at the national and regional level. METHODS: The BURDEN 2020 project uses several indicators including years of life lost (YLL) to cover the impact of mortality and years lived with disability (YLD) to cover morbidity. The sum of both is the measure of population health called disability adjusted life years (DALY). RESULTS: The study ranks individual diseases and risk factors based on their impact on population health. The burden of disease approach is assumed to be sensitive to subnational differences and may generate immediate benefits for regional planning. The BURDEN 2020 study will pilot a national burden of disease study for Germany that will later be transformed into a continuous data processing and visualization tool. This is done by using, modifying and supplementing the methodology employed by the Global Burden of Disease (GBD) study to better fit the needs of health policy in Germany. This study is aimed at calculating the disease burden for up to 17 preselected diseases. Furthermore, the estimates of burden of disease are attributed to a selected set of risk factors. CONCLUSION: The Burden 2020 study will provide the results of a new, health-related data processing system to the public. This includes a noninterest-guided presentation of the burden of disease (DALY) in Germany at the national and regional level.

[What potential do geographic information systems have for population-wide health monitoring in Germany? : Perspectives and challenges for the health monitoring of the Robert Koch Institute]. / Welches Potenzial haben Geoinformationssysteme für das bevölkerungsweite Gesundheitsmonitoring in Deutschland? : Perspektiven und Herausforderungen für das Gesundheitsmonitoring am Robert Koch-Institut.

Geographic information systems (GISs) are computer-based systems with which geographical data can be recorded, stored, managed, analyzed, visualized and provided. In recent years, they have become an integral part of public health research. They offer a broad range of analysis tools, which enable innovative solutions for health-related research questions. An analysis of nationwide studies that applied geographic information systems underlines the potential this instrument bears for health monitoring in Germany. Geographic information systems provide up-to-date mapping and visualization options to be used for national health monitoring at the Robert Koch Institute (RKI). Furthermore, objective information on the residential environment as an influencing factor on population health and on health behavior can be gathered and linked to RKI survey data at different geographic scales. Besides using physical information, such as climate, vegetation or land use, as well as information on the built environment, the instrument can link socioeconomic and sociodemographic data as well as information on health care and environmental stress to the survey data and integrate them into concepts for analyses. Therefore, geographic information systems expand the potential of the RKI to present nationwide, representative and meaningful health-monitoring results. In doing so, data protection regulations must always be followed. To conclude, the development of a national spatial data infrastructure and the identification of important data sources can prospectively improve access to high quality data sets that are relevant for the health monitoring.

[Men's health report - Conclusion and challenges for sex- and gender-sensitive health reporting]. / Bericht zur gesundheitlichen Lage der Männer in Deutschland - Fazit und Herausforderungen für eine gendersensible Gesundheitsberichterstattung.

In December 2014, the Federal Health Reporting published the first official report on men's health in Germany. The report covers a wide range of topics, from diseases and causes of death to health-related behaviors and male-specific prevention. Special chapters put the focus on the impact that working life and certain living arrangements may have on health. Based on preliminary methodological work on gender-sensitive health reporting, a step-wise approach was pursued. In addition to mere comparisons between men and women, differences within men were taken into account with respect to certain stressors, risks and resources. Moreover, guided by theory, findings were interpreted and discussed in the context of changing political and societal conditions. In the present article, the project team takes a critical look at its work: What steps towards sex- and gender-sensitive health reporting could be taken? And to what extent does the current approach leave room for improvement? In contributing to a better description of the health of men and women, gender-sensitive health reporting may provide a sound empirical basis for the implementation of gender-appropriate health care.

[Health status of people with a migrant background and impact of socio-economic factors: First results of the German Health Interview and Examination Survey for Adults (DEGS1)]. / Die gesundheitliche Lage von Menschen mit Migrationshintergrund und die Bedeutung des sozioökonomischen Status : Erste Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1).

People with a migrant background (PMB) have specific health-related risk factors and resources compared to the non-migrant population (NMP). The analysis focuses on the relationship between migrant background and health and health-related behavior. Moreover, the study analyses whether socio-economic status (SES) contributes to the explanation of differences between PMB and the NMP. The research is based on the German Health Interview and Examination Survey for Adults (DEGS1) (2008-2012, n = 8151). The population for cross-sectional analyses contains 1107 PMB (weighted 19.8 %). The research question is addressed on the basis of nine exemplary health outcomes. All analyses are gender specific and make a distinction between first and second generation PMB. Logistic regression is calculated adjusting for age and SES. The results reveal clear gender-specific patterns: For women, differences are statistically significant mainly for first generation PMB. Compared to the NMP their self-assessed health status is lower, they are less physically active, consume less alcohol, feel less informed about cancer screening programs and make less use of preventive health services. However, daily smoking is more prevalent in second generation women. For men, differences are statistically significant for first and second generation PMB. Men with a migrant background show more symptoms of depression, consume less alcohol and feel less informed about cancer screening programs. After adjusting for SES the impact of migrant background on health status and health-related behavior largely remains stable. The study shows that the DEGS1 data offers valuable results and new insights into the health status of people with a migrant background. The use of this data for further research requires a differentiated approach to the concept of migrant background and a careful interpretation of results.

Outpatient Health Service Utilization Among Adults with Diabetes, Hypertension and Cardiovascular Disease During the COVID-19 Pandemic - Results of Population-Based Surveys in Germany from 2019 to 2021.

Purpose: Fear of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and lockdown measures may have an impact on health care utilization particularly for people with chronic diseases. We investigated changes in outpatient utilization behavior in pandemic phases among people with selected chronic diseases in Germany. Methods: The nationwide population-based telephone surveys German Health Update (GEDA) 2019/2020 (April 2019 to September 2020) and GEDA 2021 (July to December 2021) covered 4 out of 7 pandemic phases from the pre-pandemic to the 4th pandemic wave. Data on hypertension, diabetes and major cardiovascular diseases (CVD) in the past 12 months and visiting a general practitioner (GP) or a specialist (excluding dentist) in the past 4 weeks was collected using a standardized questionnaire. Proportions and odds ratios were derived from logistic regression models adjusted for age, sex, education and federal states. Results: Among 27,967 participants aged ≥16 years, 8,449, 2,497 and 1,136 individuals had hypertension, diabetes and major CVD. Participants with these chronic diseases visited a GP or specialist significantly more often than the overall study population, irrespective of pandemic phases. Compared to the pre-pandemic phase, a significant reduction in specialist-visiting was found in the first pandemic wave among people with hypertension (34.3% vs 24.1%), diabetes (39.5% vs 25.5%) and major CVD (41.9% vs 25.6%). GP-visiting was lower only among people with hypertension (53.0% vs 46.0%). No difference in GP or specialist visiting was found in the 4th pandemic wave compared to the pre-pandemic phase. Conclusion: The observed decrease particularly in specialist utilization among people with the selected chronic diseases at the beginning of the pandemic was not observed for the second half of 2021 despite the ongoing pandemic. Further studies are required to examine whether the temporary changes in the utilization of ambulatory health care have affected the disease management of people with chronic diseases.

Cervical cancer trend in the Republic of Kazakhstan and attitudes towards cervical cancer screening in urban and rural areas.

Cervical cancer (CC) continues to be a significant global health issue, which in part can be attributed to disparities in access to CC screening services. This study aims to conduct a trend of CC in Kazakhstan and to compare attitudes towards the screening program between women living in urban and rural areas. In the first stage, we conducted a trend study of CC indicators in Kazakhstan using official statistics. In the second stage, a cross-sectional study was conducted using a structured questionnaire to assess adherence to screening. The trend study reveals a decline in cervical cancer mortality rates (from 7.15 to 5.93 per 100,000 female inhabitants) over the period studied, while the incidence remains stable (from 18.51 to 19.38 per 100,000 female inhabitants). Regional variations in Period Prevalence rates were observed. Significant differences were found in screening participation rates between urban n = 41 (74%) and rural n = 23 (38%) women, p < 0.001, as well as awareness of the screening program (urban: n = 15 (27%), rural: n = 35 (58%), p < 0.001). The trend study highlights a decrease in cervical cancer mortality rates over the specified period, accompanied by a consistent incidence rate. Additionally, regional disparities in period prevalence rates of cervical cancer were observed. The primary factor contributing to the low adherence of rural women to screening was found to be a lack of awareness regarding the screening program. Therefore, increasing awareness about the importance of screening is crucial for improving adherence rates among rural women in Kazakhstan.

The mortality burden related to COVID-19 in 2020 and 2021 - years of life lost and excess mortality in 13 countries and sub-national regions in Southern and Eastern Europe, and Central Asia.

Introduction: Between 2021 and 2023, a project was funded in order to explore the mortality burden (YLL-Years of Life Lost, excess mortality) of COVID-19 in Southern and Eastern Europe, and Central Asia. Methods: For each national or sub-national region, data on COVID-19 deaths and population data were collected for the period March 2020 to December 2021. Unstandardized and age-standardised YLL rates were calculated according to standard burden of disease methodology. In addition, all-cause mortality data for the period 2015-2019 were collected and used as a baseline to estimate excess mortality in each national or sub-national region in the years 2020 and 2021. Results: On average, 15-30 years of life were lost per death in the various countries and regions. Generally, YLL rates per 100,000 were higher in countries and regions in Southern and Eastern Europe compared to Central Asia. However, there were differences in how countries and regions defined and counted COVID-19 deaths. In most countries and sub-national regions, YLL rates per 100,000 (both age-standardised and unstandardized) were higher in 2021 compared to 2020, and higher amongst men compared to women. Some countries showed high excess mortality rates, suggesting under-diagnosis or under-reporting of COVID-19 deaths, and/or relatively large numbers of deaths due to indirect effects of the pandemic. Conclusion: Our results suggest that the COVID-19 mortality burden was greater in many countries and regions in Southern and Eastern Europe compared to Central Asia. However, heterogeneity in the data (differences in the definitions and counting of COVID-19 deaths) may have influenced our results. Understanding possible reasons for the differences was difficult, as many factors are likely to play a role (e.g., differences in the extent of public health and social measures to control the spread of COVID-19, differences in testing strategies and/or vaccination rates). Future cross-country analyses should try to develop structured approaches in an attempt to understand the relative importance of such factors. Furthermore, in order to improve the robustness and comparability of burden of disease indicators, efforts should be made to harmonise case definitions and reporting for COVID-19 deaths across countries.

Informal caregivers in Germany - who are they and which risks and resources do they have?

Background: The aim of this study is to describe the social characteristics, the health and living situation and the prevalence of behavioral risk factors of adult informal caregivers compared to non-caregivers in Germany. Methods: We used data from the German Health Update (GEDA 2019/2020-EHIS survey) which is a cross-sectional population-based health interview survey conducted between 04/2019 and 09/2020. The sample comprised 22,646 adults living in private households. Three mutually exclusive groups of providing informal care or assistance were differentiated: intense caregivers (informal care ≥10 h/week), less-intense caregivers (informal care<10 h/week) and non-caregivers. For the three groups weighted prevalences of social characteristics, health status (self-perceived health, health-related activity limitations, chronic diseases, low back disorder or other chronic back defect, depressive symptoms), behavioral risk factors (at-risk drinking, current smoking, insufficient physical activity, non-daily fruit and vegetable consumption, obesity) and social risk factors (single household, low social support) were calculated and stratified by gender. Separate regression analyses adjusted for age-group were conducted to identify significant differences between intense and less-intense caregivers vs. non-caregivers, respectively. Results: Overall, 6.5% were intense caregivers, 15.2% less-intense caregivers and 78.3% non-caregivers. Women provided care more often (23.9%) than men (19.3%). Informal care was most frequently provided in the age group of 45 to 64 years. Intense caregivers reported worse health status, were more often current smokers, physical inactive, obese and lived less often alone than non-caregivers. However, in age-group adjusted regression analyses only few significant differences were seen: Female and male intense caregivers had more often a low back disorder and lived less often alone compared to non-caregivers. In addition, male intense care-givers reported more often worse self-perceived health, health-related activity limitation, and the presence of chronic diseases. In contrast, less-intense caregivers and non-caregivers differed in favor of the less-intense caregivers. Discussion: A substantial proportion of the adult German population provides informal care regularly, especially women. Intense caregivers are a vulnerable group for negative health outcomes, especially men. In particular measures to prevent low back disorder should be provided. As the necessity of providing informal care will probably increase in the future, this will be important for the society and public health.

Exploring HPV vaccine knowledge, attitudes, barriers and information sources among parents, health professionals and teachers in Kazakhstan: a mixed-methods study protocol.

INTRODUCTION: Human papillomavirus (HPV) is a prevalent sexually transmitted infection linked to certain types of malignant neoplasms, notably cervical cancer (CC). In Kazakhstan, a high prevalence of high oncogenic HPV types (HR-HPV) has been observed, and CC ranks as the second most common malignancy among women with a crude incidence rate of 18.3 cases per 100 000 women. The HPV vaccine, developed as the primary prevention measure against HPV infection, including the most prevalent HR-HPV, received approval from the WHO in 2009. In 2014, Kazakhstan initiated HPV vaccination as a pilot project in four sub-national regions; however, it was later in 2017 discontinued due to widespread parental refusal influenced by negative media reports. This study aims to examine knowledge, attitudes, information sources, barriers to HPV vaccination and factors associated with HPV vaccination hesitancy among different target groups in Kazakhstan prior to the HPV vaccine re-launch announced by the Ministry of Health. METHODS AND ANALYSIS: This mixed-method-designed research comprises quantitative and qualitative components. Data on HPV awareness, attitudes towards HPV vaccination and sources of information will be collected through an online survey administered by parents and legal guardians, health professionals, and schoolteachers in the Republic of Kazakhstan between January 2023 and January 2024. Additionally, qualitative data on Kazakhstani parental beliefs and attitudes toward HPV vaccination will be collected through online focus group discussions. ETHICS AND DISSEMINATION OF RESULTS: The study has been approved by the local ethics committee at the Kazakhstan Medical University "Higher School of Public Health" (KMU "KSPH") (No. 138 of 31.05.2021). The results will be reported in publications, at conferences among researchers and healthcare and school education professionals in Kazakhstan, and internationally.

Health of people with selected citizenships: results of the study GEDA Fokus.

Background: The health situation of people with a history of migration is influenced by a variety of factors. This article provides an overview of the health of people with selected citizenships using various indicators. Methods: The analyses are based on the survey 'German Health Update: Fokus (GEDA Fokus)', which was conducted from November 2021 to May 2022 among people with Croatian, Italian, Polish, Syrian and Turkish citizenship. The prevalence for each health outcome is presented and differentiated by sociodemographic and migration-related characteristics. Poisson regressions were performed to identify relevant factors influencing health situation. Results: Self-assessed general health, the presence of depressive symptoms, prevalence of current smoking and the utilisation of general and specialist healthcare differed according to various factors considered here. In addition to sociodemographic determinants, the sense of belonging to society in Germany and self-reported experiences of discrimination were particularly associated with health outcomes. Conclusions: This article highlights the heterogeneity of the health situation of people with a history of migration and points to the need for further analyses to identify the reasons for health inequalities.

The Burden of Disease due to COVID-19 (BoCO-19): A study protocol for a secondary analysis of surveillance data in Southern and Eastern Europe, and Central Asia.

INTRODUCTION: The COVID-19 pandemic has had an extensive impact on public health worldwide. However, in many countries burden of disease indicators for COVID-19 have not yet been calculated or used for monitoring. The present study protocol describes an approach developed in the project "The Burden of Disease due to COVID-19. Towards a harmonization of population health metrics for the surveillance of dynamic outbreaks" (BoCO-19). The process of data collection and aggregation across 14 different countries and sub-national regions in Southern and Eastern Europe and Central Asia is described, as well as the methodological approaches used. MATERIALS AND METHODS: The study implemented in BoCO-19 is a secondary data analysis, using information from national surveillance systems as part of mandatory reporting on notifiable diseases. A customized data collection template is used to gather aggregated data on population size as well as COVID-19 cases and deaths. Years of life lost (YLL), as one component of the number of Disability Adjusted Life Years (DALY), are calculated as described in a recently proposed COVID-19 disease model (the 'Burden-EU' model) for the calculation of DALY. All-cause mortality data are collected for excess mortality sensitivity analyses. For the calculation of Years lived with disability (YLD), the Burden-EU model is adapted based on recent evidence. Because Covid-19 cases vary in terms of disease severity, the possibility and suitability of applying a uniform severity distribution of cases across all countries and sub-national regions will be explored. An approach recently developed for the Global Burden of Disease Study, that considers post-acute consequences of COVID-19, is likely to be adopted. Findings will be compared to explore the quality and usability of the existing data, to identify trends across age-groups and sexes and to formulate recommendations concerning potential improvements in data availability and quality. DISCUSSION: BoCO-19 serves as a collaborative platform in order to build international capacity for the calculation of burden of disease indicators, and to support national experts in the analysis and interpretation of country-specific data, including their strengths and weaknesses. Challenges include inherent differences in data collection and reporting systems between countries, as well as assumptions that have to be made during the calculation process.

Survey of sex/gender diversity in the GEDA 2019/2020-EHIS study - objectives, procedure and experiences.

Sex/gender diversity is increasingly recognised by society and should be taken into account more in population-representative studies, as they are important data sources for targeting health promotion, prevention and care. In 2019, the Robert Koch Institute started a population-representative health survey with the study Health in Germany Update (GEDA 2019/2020-EHIS) with a modified, two-stage measures of sex/gender. The survey covered sex registered at birth and gender identity with an open response option. This article describes the aims, the procedure and the experiences with the operationalisation of sex/gender and the results. Out of 23,001 respondents, 22,826 persons are classified as cisgender, 113 persons as transgender and 29 persons as gender-diverse. 33 respondents were counted as having missing values. A survey of interviewers showed that the two-stage measures of sex/gender had a high level of acceptance overall and that there were only a few interview drop-outs. On the basis of previous experience, the modified query can be used for further surveys, but should also be adapted in perspective. For this purpose, participatory studies are desirable that focus on how the acceptance of measures of sex/gender can be further improved and how hurtful experiences in the context of the questions asked can be avoided.