[Analysis of factors influencing outpatient paediatric antibiotic prescriptions in Bielefeld from 2015 to 2018]. / Analyse von Einflussfaktoren auf ambulante pädiatrische Antibiotikaverordnungen in Bielefeld 2015­2018.

BACKGROUND: There are significant regional differences in antibiotic prescribing behaviour. The reasons for this are still largely unknown. Beneath demographic and morbidity-related factors, doctor-specific or "cultural" factors may also play a role. A differentiated analysis including diagnostic data is needed to put these data into context. METHODS: A data analysis with secondary data available via the Westphalia-Lippe Association of Statutory Health Insurance Physicians (KVWL) was conducted on infection diagnoses and antibiotic prescriptions of outpatient paediatricians in the KV district of Bielefeld from 2015 to 2018. In addition, algorithmized 1:1 connections between diagnoses and prescriptions were performed. RESULTS: For 262,969 "medication patients" (AMP), 28,248 antibiotic prescriptions and 90,044 infection diagnoses were evaluated, from which 11,131 1:1 connections could be generated. Concerning the prescribing behaviour of individual paediatric GP offices, after adjusting for the denominator AMP and despite a comparable age and gender structure, there were some significant differences. This affected both the frequency of prescriptions and the qualitative composition of the substance groups prescribed. DISCUSSION: The differences in antibiotic prescribing behaviour, even at GP office level, cannot be adequately explained by the demographic composition or different morbidities of the respective clientele. Individual attitudes and local prescribing cultures are likely to play a relevant role. To address these offers an important approach for antibiotic stewardship (ABS). In addition to the area of outpatient paediatrics presented here, the methodology described can also be used as a model for more detailed analysis in other outpatient speciality groups.

Socioeconomic factors associated with suicidal behaviors in South Korea: systematic review on the current state of evidence.

BACKGROUND: The economic and human costs of suicide to individuals, families, communities, and society make suicide a major public health problem around the world. Suicide rates in South Korea are among the highest in the world. This paper is the first systematic review investigating socioeconomic risk factors for suicidal behaviors (suicidal ideation, attempted suicides, and completed suicides) in South Korea. METHODS: We performed a systematic review in Medline and Web of Science. Empirical studies and peer-reviewed articles on the association between individual socioeconomic factors and suicidal behaviors have been included. A total of 53 studies were included in a descriptive synthesis. RESULTS: Overall, 35 studies focused on the association between individual socioeconomic factors and suicidal ideation, 16 were related to suicide attempts, while 10 addressed completed suicides. Low income, unemployment, and financial difficulties were identified as risk factors for all suicidal behaviors. Working in precarious conditions, long working hours, self-employment, changes in employment status, shift work/night-time work, and occupational stress were associated with an increased risk for suicidal ideation. Low educational attainment appears to increase the risk for suicide attempts and completed suicide, but the significance of educational attainment on the reporting of suicidal ideation could not be verified. The primary studies were unable to ascertain whether the place of residence impacts on suicidal behaviors. CONCLUSIONS: The results highlight the relevance of socioeconomic factors for suicidal behaviors in South Korea. Governmental social spending must be increased and redirected more efficiently so that the economically most vulnerable groups are financially protected and income inequality does not widen. Furthermore, comprehensive prevention strategies at the community level are needed. Future research needs to focus on identifying vulnerable groups for whom the effects of low socioeconomic status may have particularly serious consequences with regard to suicidal behaviors.

[Supra-regional public health actors in Germany-an overview and categorization]. / Überregionale Public-Health-Akteure in Deutschland ­ eine Bestandsaufnahme und Kategorisierung.

BACKGROUND: Public health actors contribute significantly to health protection, promotion, and prevention at the population level. An overview of the public health landscape can facilitate collaboration among the stakeholders and increase transparency of career paths for young professionals. OBJECTIVES: This study aims to develop an overview and category system of supra-regional public health actors in Germany. METHODS: Based on a list of institutional actors that participated in the national conference Future Forum Public Health ("Zukunftsforum Public Health") and a targeted online search by the authors, supra-regional institutions and organizations with a public health focus were identified. All actors were screened independently by ≥ 2 authors. Community-level actors as well as those without a direct public health focus were excluded. Additional actors were identified via a snowballing process. In order to cluster the actors thematically, a category system was formed inductively. RESULTS: Out of a total of 645 screened actors, 307 (47.6%) were included and subsequently assigned to 12 main and 30 subcategories. Professional associations (n = 60) made up the largest category, followed by civil society (n = 49) and state actors (n = 40). In addition to a tabular and graphical overview, an interactive visualization of the actors was created ( www.noeg.org ). CONCLUSIONS: This study provides a comprehensive overview of supra-regional institutional public health actors in Germany and highlights the breadth of the German public health landscape. The results of this work offer new opportunities for collaboration and can support young professionals in their career paths. Building on this work, further research on public health actors is recommended.

[Covid-19 in Refugee Shelters: The German Public Health Service Needs Strengthening Now]. / Covid-19 in Flüchtlingsunterkünften: ÖGD jetzt weiter stärken.

The Covid-19 pandemic poses a major challenge for the management of collective accommodation centres for refugees. The often-overcrowded facilities hinder satisfactory implementation of social distancing and hygiene practices. Adequate information policies as well as a rapid, efficient management of suspected and confirmed Covid-19 cases are essential. However, scientific evidence on this is largely lacking. Besides partially implemented approaches, such as isolation areas or cluster quarantine, plans to evacuate overcrowded facilities should also be considered. The German Public Health Service (ÖGD) plays a vital role in the current Covid-19 pandemic. In order to fulfil their routine tasks of infection control and support health services management for refugee accommodation centres, the ÖGD urgently needs to be strengthened in terms of personnel and material. Additionally, means for a rapid exchange of best practice examples of Covid-19 interventions across federal states as well as collaborative structures and capacity within the ÖGD for accompanying operational research are needed. Refugees, their housing situation and their access to health care need to be included in pandemic plans. Only an integrative health care system can achieve regional and international targets for the control of Covid-19 and other infectious diseases.

[Public Health in Germany From The Perspective of Young Professionals]. / Öffentliche Gesundheit in Deutschland: Eine Perspektive des Nachwuchses.

The current reform process of Germany's public health system has opened a window of opportunity for strengthening this field in research, policy and practice in Germany. The present article discusses challenges and necessary measures from the perspective of young professionals. The authors argue that public health education and training in Germany needs to be strengthened and reformed. Moreover, Germany's public health community must create and strengthen structures and processes needed to make its voice heard more strongly in politics and society, including an effective professional organization. Discussions on these challenges have begun in a number of fora and should be translated into concrete actions soon.

[Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]. / Systematische Übersicht und "Mapping" empirischer Studien des Gesundheitszustands und der medizinischen Versorgung von Flüchtlingen und Asylsuchenden in Deutschland (1990-2014).

BACKGROUND: Owing to a lack of routine statistics on the health status and medical care of asylum seekers, empirical studies play a major role in the mapping of these aspects. OBJECTIVES: The aim of this review is to provide a comprehensive overview of the research landscape in this area, synthesizing knowledge from empirical studies and identifying evidence gaps. METHODS: A three-tiered search strategy included searching for empirical studies in national/international databases and on the internet, screening reference lists, and contacting experts. Studies meeting predefined inclusion criteria were thematically organized and described in a narrative synthesis. RESULTS: The searches generated 1,190 hits; 52 articles met the inclusion criteria. Of these, 41 were quantitative studies (78.9 %), 10 qualitative (19.2 %), and 1 was a review (1.9 %). A total of 30 primary articles (58.9 %) analyzed mental health aspects, followed by infectious diseases (n = 12, 23.5 %). Qualitative studies, mainly ethnographies and case studies, explored mental health and social determinants of health, providing evidence for the impact of living conditions on health and medical care. Few studies analyzed chronic diseases (n = 3) or childhood illnesses (n = 6). No studies analyzed the health needs or medical care of asylum-seeking women during pregnancy and child birth. In 62.7 % of the primary studies, a single sampling point was used to recruit asylum seekers. Nationwide external validity was given in two quantitative studies. CONCLUSION: The priority research areas identified are chronic diseases and childhood and maternal health. The divergency and heterogeneity of the studies hamper a comprehensive and comparable acquisition of knowledgeand emphasize the  need for collaborative research to close the existing evidence gaps.

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: A cross-sectional, population-based, multi-level analysis in a German federal state.

Asylum seekers and refugees (ASR) in Germany are dispersed quasi-randomly to state-provided, collective accommodation centres. We aimed to analyse contextual effects of post-migration housing environment on their mental health. We drew a balanced random sample of 54 from 1 938 accommodation centres with 70 634 ASR in Germany's 3rd largest federal state. Individual-level data on depression and anxiety as well as sociodemographic- and asylum-related covariates, were collected and linked to contextual geo-referenced data on housing environment ('Small-area Housing Environment Deterioration' index, number of residents, remoteness, urbanity, and German Index of Multiple Deprivation). We fitted two-level random-intercept models to exploratively estimate adjusted contextual effects. Of 411 surveyed participants, 45.53% and 44.83%, respectively, reported symptoms of depression or anxiety. 52.8% lived in centres with highest deterioration, 46.2% in centres with > = 50 residents, 76.9% in urban, and 56% in deprived districts. 7.4% of centres were remote. We found statistically significant clustering in reporting anxiety on the level of accommodation centres. The model resulted in an intraclass correlation of 0.16 which translated into a median odds ratio of 2.10 for the accommodation-level effects. No significant clustering was found for symptoms of depression. The highest degree of deterioration, large accommodation size, remoteness, and district urbanity showed higher, but statistically not significant, odds for reporting anxiety or depression. District deprivation demonstrated higher odds for anxiety and lower odds for depression yet remained statistically insignificant for both. Evidence for contextual effects of housing environment on mental health of ASR could not be established but residual confounding by length of stay in the accommodation centre cannot be ruled out. Confirmatory analyses with prior power calculations are needed to complement these exploratory estimates.

Type of Refugee Accommodation and Health of Residents: A Cross-Sectional, Population-Based Cluster Analysis in South-West Germany.

Objectives: Few studies have assessed whether refugees' health is associated with accommodation characteristics. We aimed to devise a typology of refugee accommodation based on variables on the accommodation and its physical context before assessing its association with health in multivariate analyses. Methods: We performed a cluster analysis based on a hierarchal, agglomerative clustering algorithm using Euclidean Distance and Ward's method. We analysed accommodation clusters based on number of inhabitants, degree of housing deterioration, urbanity of location (urban/rural distinction), and remoteness (walking distance to shops, medical or administrative services). In total, we analysed health and accommodation data of 412 refugees and asylum seekers from 58 different accommodation facilities in the federal state of Baden-Württemberg in the south-west of Germany. Results: Accommodations with a moderate occupation, lowest levels of deterioration, and a central urban location showed the best health outcomes in terms of subjective general health status, depression, and generalized anxiety disorder (GAD). Associations were strongest for GAD and weakest for depression. Conclusion: Our findings inform policymakers on layout and location of refugee collective accommodation centres.

How to Increase the Attractiveness of the Public Health Service in Germany as a Prospective Employer? Part II of the OeGD-Studisurvey.

The Public Health Service (PHS) in Germany has had difficulties in recruiting enough qualified staff for years, but there is limited research on what factors drive decisions to (not) join the PHS workforce. We explored reasons for this perceived (lack of) attractiveness. We conducted two cross-sectional surveys among medical students (MS), public health students and students from other PHS-relevant fields (PH&ONM) in Germany before (2019/2020) and during the COVID-19 pandemic (2021). Both waves surveyed self-reported reasons for why students did (not) consider working in the PHS as attractive and how this could be improved, using open-question items. Qualitative and quantitative content analyses were conducted according to Mayring. In total, 948 MS and 445 PH&ONM provided valid written responses. Reasons for considering the PHS as attractive were, among others, the perception of a good work-life balance, high impact, population health focus, and generally interesting occupations. Suggestions to increase attractiveness included reducing bureaucracy, modernization/digitalization, and more acknowledgement of non-medical professionals. Among MS, reasons against were too little clinical/patient-related activities, low salary, and occupations regarded as boring. Our findings indicate areas for improvement for image, working conditions in, and institutional structures of the PHS in Germany to increase its attractiveness as an employer among young professionals.

What Factors Influence the Interest in Working in the Public Health Service in Germany? Part I of the OeGD-Studisurvey.

As in many European countries, the Public Health Service (PHS) in Germany has had considerable difficulties in attracting well-qualified personnel for decades. Despite ongoing political and societal debate, limited empirical research on possible causes and explanations is available. To identify areas of action, we explored reasons for the (lack of) interest in working in the PHS by conducting two cross-sectional surveys among 3019 medical students (MS), public health students, and students from other PHS-relevant fields (PH&ONM) in Germany right before (wave 1, 2019/2020) and during the COVID-19 pandemic (wave 2, 2021). While interest in working in the PHS among MS was low, it was considerably higher among PH&ONM. The prevalent underestimation of the importance of public health and low levels of knowledge about the PHS were identified as potential barriers. Although core activities of the PHS were often considered attractive, they were repeatedly not attributed to the PHS. A negative perception of the PHS (e.g., it being too bureaucratic) was prevalent among students with and without PHS interest, indicating that both a negative image and potentially structural deficits need to be overcome to increase attractiveness. Based on the findings, we propose approaches on how to sustainably attract and retain qualified personnel.

Measuring deterioration of small-area housing environment: Construction of a multi-dimensional assessment index and validation in shared refugee accommodation.

Housing is an important health determinant, in particular for asylum seekers and refugees (ASR) living in state-provided accommodation and struggling for residential autonomy. However, few validated objective measurement tools exist to measure housing quality in the sense of the deterioration of the housing environment. We aimed to construct and validate an instrument to enable resource-efficient monitoring of and health research on such housing quality. After considering existing theoretical frameworks on housing effects on health, we constructed an easily applicable tool measuring the degree of "Small-area Housing Environment Deterioration" (SHED), based on the "Broken Windows" - index. In a validation study, we tested SHED index's objectivity and reliability, measuring inter-/intra-rater reliability and internal consistency and discussed its strengths and limitations by means of cognitive testing. We ran a field-test as part of a population-based, cross-sectional refugee health survey in a random sample of 58 shared accommodation centers across 44 districts of the German federal state of Baden-Wuerttemberg, enabling us to test index applicability and convergence with ASR's satisfaction with their living place. The new SHED index provides a validated and field-tested measure of deterioration of small-area housing environment with substantial reliability. Serving both researchers and policy-makers, SHED offers an easily applicable index to support epidemiological analyses on housing as a contextual and social determinant of health as well as evidence-informed decision making in questions of housing policies.

Monitoring the health and healthcare provision for refugees in collective accommodation centres: Results of the population-based survey RESPOND.

To date, the integration of refugees in German health surveys is insufficient. The survey RESPOND (Improving regional health system responses to the challenges of forced migration) aimed to collect valid epidemiological data on refugee health status and healthcare provision. The core elements of the survey consisted of a population-based sampling procedure in Baden-Württemberg, multilingual questionnaires and a face-to-face approach of recruitment and data collection in collective accommodation centres with multilingual field teams. In addition, data on the geographical locations of accommodation centres and their structural quality were obtained. The results indicate a high overall health burden. The prevalence of depression (44.3%) and anxiety symptoms (43.0%) was high. At the same time, high unmet needs were reported for primary (30.5%) and specialist (30.9%) care. Despite sufficient geographical accessibility of primary care services, frequent ambulatory care sensitive hospitalisations, i.e. hospitalisations that could potentially have been avoided through primary care (25.3%), as well as subjective deficits in the quality of care, suggest barriers to accessing healthcare services. Almost half of all refugees (45.3%) live in accommodation facilities of poor structural quality. Collecting valid data on the health situation of refugees is possible through a combination of targeted sampling, multilingual recruitment and survey instruments as well as personal recruitment. The presented approach could complement established procedures for conducting health surveys and be extended to other federal states.

SARS-Cov-2 prevalence, transmission, health-related outcomes and control strategies in homeless shelters: Systematic review and meta-analysis.

BACKGROUND: People experiencing homelessness (PEH) may be at risk for COVID19. We synthesised evidence on SARS-Cov-2 infection, transmission, outcomes of disease, effects of non-pharmaceutical interventions (NPI), and the effectiveness of strategies for infection prevention and control (IPC). METHODS: Systematic review of articles, indexed in electronic databases (EMBASE, WHO-Covid19, Web of Science), institutional websites and the Norwegian Institute of Public Health's live map of COVID-19 evidence, and published from December 1st, 2019, to March 3rd, 2021. Empirical papers of any study design addressing Covid-19 and health(-related) outcomes in PEH or shelters' staff were included. (PROSPERO-2020-CRD42020187033). FINDINGS: Of 536 publications, 37 studies were included (two modelling, 31 observational, four qualitative studies). Random-effect meta-analysis yields a baseline SARS-Cov-2 prevalence of 2•32% (95% Confidence-Interval, 95%CI=1•30-3•34) in PEH and 1•55% (95%CI=0•79-2•31) in staff. In outbreaks, the pooled prevalence increases to 31•59% (95%CI=20•48-42•71) in PEH and 14•80% (95%CI=10•73-18•87) in staff. Main IPC strategies were universal rapid testing, expansion of non-congregate housing, and in-shelter measures (bed spacing, limited staff rotation, reduction in number of residents). INTERPRETATION: 32% of PEH and 15% staff are infected during outbreaks of SARS-Cov-2 in homeless shelters. Most studies were conducted in the USA. No studies were found quantifying health-related outcomes of NPI. Overview and evaluation of IPC strategies for PEH, a better understanding of disease transmission, and reliable data on PEH within Covid-19 notification systems are needed. Qualitative studies may serve to voice PEH and shelter staff experiences, and guide future evaluations and IPC strategies. FUNDING: None.

Covid-19 pandemic policy monitor (COV-PPM) - European level tracking data of non-pharmaceutical interventions.

The Covid-19 Pandemic Policy Monitor (COV-PPM) dataset prospectively documents non-pharmaceutical interventions (NPIs) taken to contain SARS-Cov-2 transmission across countries in EU27, EEA and UK. In Germany, measures have also been recorded at the federal state and, partially, at the district levels. NPIs implemented since January 2020 have been retrieved and updated weekly from March 2020, from official governments webpages, Ministries of Health, National (Public) Health Institutes or Administrations. NPI categories collected refer to restrictions, closures or changes in functioning implemented in 13 domains: public events (gatherings in indoor or outdoor spaces); public institutions (kindergartens, schools, universities); public spaces (shops, bars, restaurants); public transport (trains, buses, trams, metro); citizens movement/mobility (e.g. pedestrians, cars, ships); border closures (air, land or sea, all incoming travels, from high-risk regions, only non-nationals); measures to improve the healthcare system (e.g. human resources or technical reinforcement, redistribution, material or infrastructural); measures for risk/vulnerable groups (e.g. elderly, chronically ill, pregnant); economic measures (e.g. lay-off rules establishment, actions to avoid job-loss, tax relaxation); testing policies (e.g. testing criteria changes); nose and mouth protection rules, vaccination and others/miscellaneous measures.

How Do Countries' Health Information Systems Perform in Assessing Asylum Seekers' Health Situation? Developing a Health Information Assessment Tool on Asylum Seekers (HIATUS) and Piloting It in Two European Countries.

Background: Accurate data on the health status, health behaviour and access to health care of asylum seekers is essential, but such data is lacking in many European countries. We hence aimed to: (a) develop and pilot-test an instrument that can be used to compare and benchmark the country health information systems (HIS) with respect to the ability to assess the health status and health care situation of asylum seekers and (b) present the results of that pilot for The Netherlands (NL) and Germany (DE). Materials and Methods: Reviewing and adapting existing tools, we developed a Health Information Assessment Tool on Asylum Seekers (HIATUS) with 50 items to assess HIS performance across three dimensions: (1) availability and detail of data across potential data sources; (2) HIS resources and monitoring capacity; (3) general coverage and timeliness of publications on selected indicators. We piloted HIATUS by applying the tool to the HIS in DE and NL. Two raters per country independently assessed the performance of country HIS and the inter-rater reliability was analysed by Pearson's rho and the intra-class correlation (ICC). We then applied a consensus-based group rating to obtain the final ratings which were transformed into a weighted summary score (range: 0-97). We assessed HIS performance by calculating total and domain-specific HIATUS scores by country as well as absolute and relative gaps in scores within and between countries. Results: In the independent rating, Pearson's rho was 0.14 (NL) and 0.30 (DE), the ICC yielded an estimated reliability of 0.29 (NL) and 0.83 (DE) respectively. In the final consensus-based rating, the total HIATUS score was 47 in NL and 15 in DE, translating into a relative gap in HIS capacity of 52% (NL) and 85% (DE) respectively. Shortfalls in HIS capacity in both countries relate to the areas of HIS coordination, planning and policies, and to limited coverage of specific indicators such as self-reported health, mental health, socio-economic status and health behaviour. The relative gap in the HIATUS component "data sources and availability" was much higher in Germany (92%) than in NL (28%). Conclusions: The standardised tool (HIATUS) proved useful for assessment of country HIS performance in two countries by consensus-based rating. HIATUS revealed substantial limitations in HIS capacity to assess the health situation of asylum seekers in both countries. The tool allowed for between-country comparisons, revealing that capacities were lower in DE relative to NL. Monitoring and benchmarking gaps in HIS capacity in further European countries can help to strengthen HIS in the future.

Health status of and health-care provision to asylum seekers in Germany: protocol for a systematic review and evidence mapping of empirical studies.

BACKGROUND: There are more than 100,000 asylum seekers registered in Germany, who are granted limited access to health services. This study aims to provide a systematic overview of the empirical literature on the health status of and health-care provision to asylum seekers in Germany in order to consolidate knowledge, avoid scientific redundance, and identify research gaps. METHODS/DESIGN: A systematic review and evidence mapping of empirical literature on the health status of and health-care provision to asylum seekers in Germany will be performed. We will apply a three-tiered search strategy: 1. search in databases (PubMed/MEDLINE, Web of Science, IBSS, Sociological Abstracts, Worldwide Political Science Abstracts, CINAHL, Sowiport, Social Sciences Citation Index, ASSIA, MedPilot, DNB), dissertation and theses databases, and the internet (Google); 2. screening references of included studies; 3. contacting authors and civil society organizations for grey literature. Included will be studies which report quantitative and/or qualitative data or review articles on asylum seekers in Germany, published in German or English language. Outcome measures will include physical, mental, or social well-being, and all aspects of health-care provision (access, availability, affordability, and quality). Search results will be screened for eligibility by screening titles, abstracts and full texts. Data extraction comprises information on study characteristics, research aims, and domains of health or health-care services analyzed. The quality of studies will be appraised and documented by appropriate assessment tools. A descriptive evidence map will be drawn by categorizing all included articles by research design and the health conditions and/or domains of health-care provision analyzed. The body of evidence will be evaluated, and a narrative evidence synthesis will be performed by means of a multi-level approach, whereby quantitative and qualitative evidence are analyzed as separate streams and the product of each stream is configured in a final summary. DISCUSSION: This systematic review will provide an evidence map and synthesis of available research findings on the health status of and health-care provision to asylum seekers in Germany. In anticipation of identifying areas which are amenable to health-care interventions, deserve immediate action, or further exploration, this review will be of major importance for policy-makers, health-care providers, as well as researchers. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2014: CRD42014013043.