The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review.

BACKGROUND: Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use. METHODS: We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered. RESULTS: Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies. CONCLUSIONS: Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Tanning bed use in Germany between 2015 and 2022: Representative data of 28,000 individuals on indoor tanning, risk awareness and reasons for use.

BACKGROUND: Tanning beds were classified as first-group carcinogens in 2009. Nonetheless, research shows that people in industrialized Western countries use tanning beds. Based on the National Cancer Aid Monitoring (NCAM) including representative data on 28,000 individuals from Germany, we quantified the prevalence as a trend from 2015 to 2022, identified determinants of tanning bed use and analysed risk awareness and reasons for use. METHODS: We used NCAM data from 2015 to 2022 to analyse the trends in the prevalence of tanning bed use (n = 28,000). To determine the characteristics of tanning bed users, risk awareness and reasons, we combined data from the waves 2019 to 2022 (n = 16,000, 49.2% female, 16-65 years) in a pooled dataset to have sufficient power to detect even smaller associations. RESULTS: Tanning bed use decreased to 5.1% in 2022. The use of tanning beds in spas, fitness and beauty facilities increased, except during the COVID-19 pandemic, while the use in tanning salons decreased. Typical tanning bed users were female, middle-aged, occupied, higher educated, had an immigrant background and were former or current smokers. Risk awareness was the lowest among the current users. The most frequently mentioned reasons were relaxation, enhancement of attractiveness and pre-tanning. DISCUSSION: Our nationwide representative data showed that the prevalence of indoor tanning has decreased. Of concern are the lower risk awareness among current users and the shift in place of use towards facilities associated with health and wellness. To further reduce the use of tanning beds, targeted information, educational campaigns and extended legislation are considered helpful.

Sunburn and sun protection during recreational outdoor sport in summer: Findings from the German general population aged 16-65 years.

BACKGROUND: Sunburn can increase one's risk of developing skin cancer. We aimed to quantify the prevalence of sunburn during recreational outdoor sport (ROS) in summer, to explore the use of different sun protection measures, and to examine factors associated with sunburn during ROS using a population-based sample from Germany. METHODS: For this cross-sectional study, 2081 individuals aged 16-65 years who reported being engaged in ROS in summer were surveyed via standardized telephone interviews in 2020 (National Cancer Aid Monitoring, NCAM). RESULTS: Overall, 16.7% reported experiencing at least one sunburn during ROS in the past twelve months. Sunburn occurrence was negatively associated with the age of the participants (e.g. OR = 0.49 in 56-65 year-olds, p < .001), and positively associated with skin type I/II (OR = 1.55, p < .001) and with having a higher number of nevi (OR = 1.42, p = .005). While wearing sleeved shirts was the most frequently-used sun protection measure during ROS (74.9%), wearing headgear was least common in our sample (29.0%). In multivariate analyses, sunburn was positively associated with the use of sun protection measures (e.g. OR = 1.32 for wearing sleeved shirts, p = .02). CONCLUSIONS: Our nationwide data show that ROS is one of the settings where sun protection should play a greater role. Especially in organized sports, particular attention should be devoted to organizational (e.g. exercise outside peak hours) or contextual measures (e.g. shade by the natural or built environment) to prevent skin cancer in later life.

Health inequalities among young workers: the mediating role of working conditions and company characteristics.

OBJECTIVE: Few studies have investigated health inequalities among young workers. The objectives of this study are to assess the extent of health inequalities in a sample of job starters and to explore the contribution of job demands and organisational factors. METHODS: We analyze data from the BIBB/BAuA Youth Employment Survey 2012. The cross-sectional survey includes a representative sample of 3214 German employees, apprentices, and trainees aged 15-24 years. Individuals were grouped by their years of schooling into low (< 12 years) and high levels of education (≥ 12 years). Regression analysis estimated the link between education and four health outcomes: self-rated health, number of health events, musculoskeletal symptoms, and mental health problems over the last 12 months. Counterfactual mediation analysis tested for indirect effects of education via working conditions (i.e., physical and psychosocial job demands) and company characteristics (i.e., company size, health prevention measures, financial situation, downsizing). All analyses were adjusted for age, sex, nationality, region, working hours, job tenure, employment relationship, and economic sector. RESULTS: Highly educated workers reported better self-rated health (b = 0.24, 95% CI 0.18-0.31) and lower numbers of health events (Rate Ratio (RR) = 0.74, 95% CI 0.67-0.82), musculoskeletal symptoms (RR = 0.73, 95% CI 0.66-0.80) and mental health problems (RR = 0.84, 95% CI 0.76-0.93). Total job demands explained between 21.6% and 87.2% of the educational differences (depending on health outcome). Unfavourable company characteristics were associated with worse health, but showed no or only small mediation effects. CONCLUSIONS: Health inequalities are already present at the early working career due to socio-economically stratified working hazards. To enhance prevention measures that aim at reducing inequalities in workplace health, we propose shifting attention towards earlier stages of life.

Setting-based skin cancer prevention at the workplace: A survey among German outdoor workers.

BACKGROUND: Outdoor workers are at increased risk of developing skin cancer. Setting-based prevention at the workplace can reduce the UV exposure of outdoor workers through appropriate technical or organizational measures. We explored the implementation of setting-based UV protection at the workplace in Germany from the perspective of outdoor workers. METHODS: A Germany-wide sample of 319 outdoor workers from different employment sectors (64.3% male) was surveyed via telephone on different technical and organizational measures for UV protection at the workplace. Bivariate analyses were performed to explore associations with job-related characteristics. RESULTS: In general, 28.0% were rarely or never provided with a place in the shade during working hours, and 27.4% rarely or never provided with a shaded place during breaks. One-third had rarely or never the opportunity to work in the shade on hot summer days. Overall, 51.9% reported receiving protective clothing from their employer, 45.5% were provided with headgear, and 25.1% with sunscreen. About one-third had often or always the option of starting work earlier in the morning on hot summer days to work less in the sun, while 18.6% had to work overtime on such days. One-third (35.4%) had been educated at work about risks of solar radiation and sun protection measures. CONCLUSIONS: Our study is among the first to present findings on the implementation of different setting-based UV protection measures at the workplace and provides starting points for employers and policy makers to improve UV protection at the workplace.

Young people's health and well-being during the school-to-work transition: a prospective cohort study comparing post-secondary pathways.

BACKGROUND: At the end of secondary education, young people can either start vocational training, enter university, directly transition to employment or become unemployed. Research assumes that post-secondary pathways have immediate and/or long-term impacts on health and well-being, but empirical investigations on this are scarce and restricted to few countries. Therefore, this study traced the development of health and well-being throughout the highly institutionalised school-to-work transition (STWT) in Germany. METHODS: We used longitudinal data of the National Educational Panel Study (NEPS), a representative sample of 11,098 school-leavers (50.5% girls) repeatedly interviewed between 2011 and 2020. We estimated the effect of post-secondary transitions on self-rated health and subjective well-being by applying fixed-effects (FE) regression, eliminating bias resulting from time-constant confounding and self-selection into different pathways. A multiple-sample strategy was used to account for the increasing diversity of STWTs patterns. Models were controlled for age, as well as household and residential changes to minimise temporal heterogeneity. RESULTS: Findings indicate that leaving school was good for health and well-being. Compared with participants who did not find a training position after school, direct transitions to vocational training or university were linked to higher absolute levels of health and well-being, but also to a lower relative decline over time. Furthermore, upward transitions (e.g. to programs leading to better education or from unemployment to employment) were associated with improvements in health and well-being, while downward transitions were followed by deteriorations. CONCLUSION: Findings suggest that school-leave is a sensitive period and that post-secondary pathways provide young people with different abilities to maintain health and well-being. Youth health interventions might benefit when setting a stronger focus on unsuccessful school-leavers.

Associations of individual factors and early childhood education and care (ECEC) centres characteristics with preschoolers' BMI in Germany.

BACKGROUND: The number of obese children is rising worldwide. Many studies have investigated single determinants of children's body mass index (BMI), yet studies measuring determinants at different potential levels of influence are sparse. The aim of this study is to investigate the independent role of parental socioeconomic position (SEP), additional family factors at the micro level, as well as early childhood education and care (ECEC) centre characteristics at the meso level regarding BMI. METHODS: Analyses used the baseline data of the PReschool INtervention Study (PRINS) including up to 1,151 children from 53 ECEC centres. Multi-level models first estimated the associations of parental SEP indicators (parental school education, vocational training, and household income) with the children's standard deviation scores for BMI (SDS BMI, standardised for age and gender). Second, structural (number of siblings), psychosocial (strained family relationships), and nutrition behavioural (soft-drink consumption, frequency of fast-food restaurant visits) family factors at the micro level were included. Third, characteristics of the ECEC centre at the meso level in terms of average group size, the ratio of overweight children in the group, ECEC centre type (all-day care), and the location of the ECEC centre (rural vs urban) were included. All analyses were stratified by gender and adjusted for age, migration background, and parental employment status. RESULTS: Estimates for boys and girls appeared to differ. In the full model, for boys the parental SEP indicators were not related to SDS BMI. Factors related to SDS BMI in boys were: two or more siblings; B = -.55; p = 0.045 [ref.: no sibling]), the characteristics of the ECEC centre in terms of average group size (20 - 25 children; B = -.54; p = 0.022 [ref.: < 20 children]), and the ratio of overweight children (more overweight children B = -1.39; p < 0.001 [ref.: few overweight children]). For girls the number of siblings (two and more siblings; B = .67; p = 0.027 [ref.: no sibling]) and average group size (> 25 children; B = -.52; p = 0.037 [ref.: < 20 children]) were related to SDS BMI. CONCLUSIONS: The BMI of preschool children appears to be associated with determinants at the micro and meso level, however with some gender differences. The identified factors at the micro and meso level appear largely modifiable and can inform about possible interventions to reduce obesity in preschool children.

Melanoma care during one year pandemic in Berlin: decreasing appointment cancellations despite increasing COVID-19 concern.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic poses a great challenge for cancer patients. Our aim was to assess its influence on treatment and appointments of melanoma patients after one year of pandemic. METHODS: Melanoma patients treated in the Vivantes Skin Cancer Centre in Berlin, Germany completed a postal survey on pandemic-related alterations in melanoma care. Impact factors on changes of appointments were examined with descriptive analyses and multivariate logistic regression. Data after one year of pandemic were compared to those after its first wave. RESULTS: Among 366 participants (57.7 % males; mean age 69.2 years, response rate: 36.1 %), 38 (10.1 %) reported postponed or missed appointments, mostly on their own demand (71.1 %) due to fear of COVID-19 (52.6 %). Current treatment was associated with a lower risk of changing appointments (Odds Ratio [OR]: 0.194, p = 0.002), higher age (OR: 1.037, p = 0.039), longer disease duration (OR: 1.007, p = 0.028), and higher school degree (OR: 2.263, p = 0.043) with higher probability. Among 177 patients currently receiving therapy, only 1.7 % experienced pandemic-related treatment alterations. Concern about COVID-19 was significantly higher after one year of pandemic than after its first wave, but the number of missed appointments was lower. CONCLUSIONS: Pandemic-related changes were rare in our cohort and decreased over time despite increasing concern.

Melanomversorgung während eines Jahres Pandemie in Berlin: abnehmende Terminstornierungen trotz zunehmender Besorgnis über COVID-19.

HINTERGRUND UND ZIELE: Die COVID-19-Pandemie stellt für Krebspatienten eine große Herausforderung dar. Unser Ziel war es, ihren Einfluss auf die Behandlung und auf Arzttermine von Melanompatienten nach einem Jahr Pandemie zu untersuchen. PATIENTEN UND METHODIK: Melanompatienten, die im Vivantes Hauttumorzentrum in Berlin behandelt wurden, beantworteten eine postalische Umfrage zu Pandemie-bedingten Änderungen ihrer Melanomversorgung. Einflussfaktoren auf Terminänderungen wurden mit deskriptiven Analysen und multivariater logistischer Regression untersucht. Daten nach einem Jahr Pandemie wurden mit Daten nach der ersten Welle verglichen. ERGEBNISSE: Von den 366 Teilnehmern (57,7 % Männer; Durchschnittsalter 69,2 Jahre, Rücklaufquote: 36,1 %) berichteten 38 (10,1 %) über verschobene oder verpasste Arzttermine, meist auf eigenen Wunsch (71,1 %) aus Angst vor COVID-19 (52,6 %). Eine aktuelle Therapie war mit einem geringeren Risiko, Termine zu verpassen, assoziiert (Odds Ratio [OR]: 0,194, p = 0,002), höheres Alter (OR: 1,037, p = 0,039), längere Krankheitsdauer (OR: 1,007, p = 0,028) und ein höherer Schulabschluss (OR: 2,263, p = 0,043) mit höherer Wahrscheinlichkeit. Von den 177 Patienten, die aktuell eine Therapie erhielten, erfuhren nur 1,7 % Pandemie-bedingte Behandlungsänderungen. Die Besorgnis über COVID-19 war nach einem Jahr Pandemie signifikant größer als nach der ersten Welle, die Zahl der verpassten Arzttermine jedoch niedriger. SCHLUSSFOLGERUNGEN: Pandemie-bedingte Änderungen waren in unserer Kohorte selten und nahmen trotz zunehmender Besorgnis mit der Zeit ab.

Is the quality of skin cancer screening in Germany related to the specialization of the physician who performs it?: Results of a nationwide survey among participants of skin cancer screening.

BACKGROUND: Skin cancer screening (SCS) is an important measure for secondary prevention of skin cancer, which is the most common cancer type worldwide. This study aimed to describe patient-reported quality of SCS in Germany according to the specialization of the performing physician and different patient characteristics. METHODS: Data from 1260 participants 35-65 years of age (54.4% female) who underwent SCS and participated in National Cancer Aid Monitoring in 2019 were evaluated using chi-squared tests. RESULTS: Waiting times for SCS from a dermatologist were significantly longer than those for other physicians (31.1 versus [vs.] 15.7 days; P < .001). Each body area examined during the standardized inspection was examined significantly more frequently by dermatologists than by other physicians (eg, upper body, 96.6% vs. 91.7%; P < .001). Dermatologists more often offered consultation for skin cancer prevention (74.0% vs. 67.6%; P = .026) and provided written information (47.8% vs. 34.8%; P < .001). Patients with statutory insurance had to pay more frequently for additional services during SCS from a dermatologist than from other physicians (24.7% vs. 17.1%, P = .012). CONCLUSION: Results of this study revealed differences in the provision of preventive information and the quality of visual examination during SCS between dermatologists and other physicians. These results highlight the need for quality assurance measures.

[Social Inequalities in Health and Health Behaviors among University Students]. / Sozialbedingte Ungleichheiten von Gesundheit und Gesundheitsverhalten bei Studierenden.

AIM OF THE STUDY: Disease prevention and health science research have focused increasingly on students in recent years. However, students are usually perceived as a homogeneous group. The aim of this article was to examine if there exist health inequalities among students. METHODS: A nationwide student survey, the so-called NuPhA study, was used to answer this question (n=689, 69.5% female, average age: 22.69 years). RESULTS AND CONCLUSIONS: We found that socio-economic indicators were associated with health and health behavior. For instance, being a scholarship holder was associated with a better general, mental, and physical health. In particular, subjective social status was positively associated with better general, mental, and physical health as well as higher physical activity. The results indicate that while students initially appeared to form a homogenous group, health inequalities exist among them. This suggests the need for a differentiated view on the student group and the importance of examining and explaining health inequalities among students in depth and to finally reduce them.

Who Are the Nonusers of Sunscreen, and What Are Their Reasons? Development of a New Item Set.

Sunscreen use is an important aspect of sun protective behavior. Previous studies revealed deficits in sunscreen use. Our aim was to quantify sunscreen use in a nationwide representative study in Germany as well as to develop and test an item battery on reasons for none use of sunscreen. We analyzed data of the National Cancer Aid Monitoring (NCAM; wave 4; n = 3000, aged 14-45). To describe those who only use sunscreen rarely or never, we used chi2 statistics and logistic regression analysis. In addition, we utilized a newly developed item battery on barriers to sunscreen use. Here, we used Cronbach's alpha to investigate reliability. In total, 20.7% reported using sunscreen rarely or never. Infrequent or none use of sunscreen was associated with male sex, immigrant background, none or rare sunbathing in summer, and current or past use of sunbeds. Participants with higher skin cancer risk (e.g., pale skin) were less likely to use sunscreen infrequently or never. The major reasons for not using sunscreen were inconvenience and no perceived need for applying sunscreen. Overall, internal consistency of the item battery on potential barriers to sunscreen use was very good (Cronbach's alpha = 0.865). We found deficits in sunscreen use especially in sunbed users, men, and individuals with immigrant background. Our results give important implications for future prevention and health promotion campaigns on sunscreen use.

Patient preferences for treatment of advanced melanoma: impact of comorbidities.

BACKGROUND AND OBJECTIVES: Choice of treatment for advanced melanoma is crucially influenced by comorbidities and patient preferences. Our study aimed to investigate the impact of comorbidities on preferences. PATIENTS AND METHODS: 150 patients with melanoma stage IIC-IV completed a discrete choice experiment to determine preferences for outcome (overall response rate [ORR], 2-year survival, progression-free survival [PFS], time to response [TTR], kind of adverse events [AE], AE-related treatment discontinuation) and process attributes (frequency and route of administration [RoA], frequency of consultations) of systemic melanoma treatments. The impact of comorbidities was assessed by analysis of variance and multivariate regression. RESULTS: Participants with hypertension and other cardiovascular diseases attached significantly greater importance to TTR and RoA than others. Respondents with arthropathy cared more about TTR (ß = 0.179, P = 0.047) and RoA, but less about ORR (ß = -0.209, P =  0.021). Individuals with diabetes considered AE (ß = 0.185, P = 0.039) and frequency of consultations more essential, but ORR less relevant. Those with other malignancies were particularly worried about treatment discontinuation (ß = 0.219, P =  0.008), but less about ORR (ß = -0.202, P =  0.015). Participants with depression focused more on PFS (ß = 0.201, P =  0.025) and less on TTR (ß = -0.201, P =  0.023) and RoA (ß = -0.167, P =  0.050). CONCLUSIONS: Treatment preferences of melanoma patients vary significantly dependent on comorbidities.

Patient Preferences in Adjuvant and Palliative Treatment of Advanced Melanoma: A Discrete Choice Experiment.

Treatment paradigms for advanced melanoma have changed fundamentally over recent years. A discrete choice experiment was performed to explore patient preferences regarding outcome (overall response rate, 2-year survival rate, progression-free survival, time to response, type of adverse events, probability of adverse event-related treatment discontinuation) and process attributes (frequency and route of administration, frequency of consultations) of modern treatments for melanoma. Mean preferences of 150 patients with melanoma stage IIC-IV were highest for overall response rate (relative importance score (RIS) 26.8) and 2-year survival (RIS 21.6), followed by type of adverse events (RIS 11.7) and probability of adverse event-related treatment discontinuation (RIS 9.2). Interest in overall response rate and 2-year survival declined with increasing age, whereas process attributes gained importance. Participants who had experienced treatment with immune checkpoint inhibitors valued overall response rate more highly and worried less about the type of adverse events. In conclusion, patients with advanced melanoma consider efficacy of treatment options most important, followed by safety, but preferences vary with individual and disease-related characteristics.

Attractiveness as a motive for tanning: Results of representative nationwide survey in Germany.

BACKGROUND: In previous research, enhancing attractiveness is reported to be an important aspect of tanning motivation. Our aim was to analyze attractiveness as a reason for tanning in a large representative sample in relation to sociodemographic characteristics, perceived risks of ultraviolet radiation (UVR), and exposure to natural and artificial UVR. METHODS: We analyzed data from 3000 participants (14-45 years) in the German representative National Cancer Aid Monitoring (wave 3). Attractiveness was measured using the General Attractiveness Subscale of the Physical Appearance Reasons for Tanning Scale. Associations were analyzed using chi-square tests and logistic regression analyses. RESULTS: Attractiveness played a larger role for participants aged 18-35, those with an immigrant background, medium educational level, and not in a relationship. Significant associations were also identified with a low risk perception of UVR. For sunbathing, the highest OR (9.96, P < .001) was found for high scores on General Attractiveness Subscale, whereas risk perception of UVR was not related to sunbathing in multivariate analyses. For sunbed use, risk perception also only played a minor role as a preventing factor, while higher associations could be identified for age (OR18-25 years  = 8.21, P < .001) and attractiveness (OR = 3.55, P < .001). CONCLUSION: Our study showed that people who tan to enhance their attractiveness are more likely to perceive fewer risks of UVR and to show higher UVR exposure behavior and are therefore at greater risk of developing skin cancer. Measures for prevention of UVR-related skin damage should therefore focus more on reducing the positive perception of a tanned appearance instead of only emphasizing the risks of UVR.

'When I have time pressure, sport is the first thing that is cancelled': A mixed-methods study on barriers to physical activity among university students in Germany.

The transition from school to university has been found to be associated with a decline in physical activity (PA). As regular engagement in PA plays an important role in preventing obesity and various chronic diseases such as type 2 diabetes and cardiovascular diseases, a deeper understanding on barriers that hinder university students from being physically active is necessary. We therefore conducted a mixed-methods study which built, first, on conducting a quantitative online survey across Germany (n = 689; 69.5% female) to examine barriers among university students. Afterwards, we explored these barriers in more detail by conducting 20 in-depth qualitative interviews (65.0% female). While we identified in our quantitative survey that especially time-related and motivational barriers hindered university students to engage in PA, our qualitative interviews indicate that connections between these barriers seem to exist. Moreover, the qualitative interviews enabled us to identify additional transition-related barriers (e.g., missing routines in everyday life, difficulties in finding a new sports club) that were not included in the quantitative questionnaire. Thus, such barriers should be incorporated into quantitative instruments to assess these barriers in larger samples of university students in the future. Moreover, our findings provide potential starting points for promoting PA in German university settings.

Profile of sunless tanning product users: Results from a nationwide representative survey.

BACKGROUND: Sunless tanning products (STPs) are often seen as "healthy alternative" to sunbathing and indoor tanning. However, STP use may entail indirect risks such as overestimating an individual's natural skin type, resulting in risky (natural and artificial) tanning behavior. We aimed to explore STP use in combination with other health-related risk behaviors (eg, smoking), skin cancer risk, risk awareness of ultraviolet radiation, and preventive behavior. METHODS: We used data from the NCAM, a nationwide representative cross-sectional sample (n = 3000, aged 14-45, 48.6% female) interviewed via telephone. Differences between STP users and nonusers regarding the abovementioned aspects were identified using chi²-test. RESULTS: The 1-year prevalence of STP use was 7.5%. Tanning bed users showed a higher prevalence of STP use than past and never users (16.1% vs 9.6% vs 5.8%, P < 0.05). Although STP users had a higher skin cancer risk based on individual characteristics, they were less likely to have participated in a skin cancer screen. CONCLUSION: The identified parallel use of STPs and tanning beds can have severe health consequences, since the "fake tan" of STPs may lead to an overestimation of the individual's skin type, which may result in overdosed UV exposure. The lower risk awareness among STP users accompanied with their higher skin cancer risk calls for target group-specific prevention.

Optimistically biased perception of one's own skin cancer risk: Representative nationwide findings.

BACKGROUND: Previous research has shown that individuals tend to have unrealistic comparative optimism (UCO) for different diseases and health outcomes. Our aim was to analyze UCO in relation to skin cancer for the first time in a representative nationwide sample. The results will be important for planning future prevention. METHODS: The National Cancer Aid Monitoring on Sunbed Use (NCAM, wave 3) is a representative nationwide German survey (n = 3,000, 14-45 years). We assessed UCO in relation to skin cancer and analyzed its association with sociodemographics, tanning and health-related risk behaviors, skin cancer risk, and skin cancer risk awareness. RESULTS: Four out of ten (43.3 %) respondents believed themselves to have a lower risk of developing skin cancer than other people of the same age and sex. Younger individuals were more likely to be optimistic. Individuals with an increased risk of skin cancer were more likely to perceive this higher risk. CONCLUSION: While it is realistic for those who actually have a higher risk of skin cancer to perceive it that way, the findings for the general population (and specifically for younger individuals) are concerning. It seems important to explain to people that their perception of their own risk of skin cancer is unrealistic, as this may affect their individual screening and prevention behavior.

Are tanning salons in compliance with German law? An evaluation based on a nationwide representative survey.

BACKGROUND: Given the evidence for increased skin cancer risk due to the sunbed use, a regulation of hazardous artificial ultraviolet radiation (UVR regulation) was passed in Germany in 2012. The aim of this study was to explore the advisory services in tanning studios as reported by sunbed users and to evaluate the information provided by the personnel of tanning salons after the UVR regulation was enacted. METHODS: The first wave of the representative National Cancer Aid Monitoring on Sunbed Use included a subgroup of 357 German citizens between 14 and 45 years who had used sunbeds since the UVR regulation was implemented. The participants provided data on sunbed use and related issues in telephone interviews. RESULTS: Although sunbed operators are mandated to offer their customers certain services at least once since the implementation of the UVR regulation, 15.4% of sunbed users were never advised to use protective eyewear during tanning and 13.1% were not provided with eyewear during their last sunbed use. Overall, 66.0% were never offered to develop a tanning schedule, 56.9% were never advised on the risks of UVR, 43.4% were never offered a determination of their skin type and 40.0% of users were never advised on how to use a sunbed safely. CONCLUSIONS: The data showed that 3 years after the UVR regulation was enacted, compliance with this legislation is still not optimal. Binding wording in the legal text and making them applicable to unsupervised sunbeds as well is necessary to extend the impact of this legislation.

Effort-reward imbalance among students at German universities: associations with self-rated health and mental health.

PURPOSE: Although psychosocial stress has been associated with adverse health parameters, little is known about this topic among the variety of university students. We thus examined associations of psychosocial stress due to academic education with self-rated health, and symptoms of depression and anxiety among students from various study disciplines. METHODS: We used data from the Nutrition and Physical Activity (NuPhA) Study, a cross-sectional online survey among students enrolled across German universities (n = 698). Academic stress was assessed by a newly developed and validated student version of the Effort-Reward Imbalance (ERI-Student) Questionnaire. Depressive and anxiety symptoms were measured by applying the Patient Health Questionnaire-4 (PHQ-4) and using validated cut-offs. RESULTS: Separate multivariate logistic regression analyses run for the different ERI components, the ERI-ratio revealed that high effort, low reward, high over-commitment, and a high ERI-ratio were associated with poor self-rated health, and depressive and anxiety symptoms (odds ratios ≥ 2.43). Separate analyses for medical students and non-medical students largely confirmed these findings for both groups. Associations between all ERI components, the ERI ratio, and both mental health measures were, however, more pronounced among medical students. CONCLUSIONS: We were able to show consistent associations between the ERI-Student Questionnaire and self-rated health and mental health across students from different study disciplines. Further research on associations between academic stress and health parameters is necessary to develop effective strategies that prevent students from adverse health outcomes during their academic education.