A longitudinal analysis of health inequalities from adolescence to young adulthood and their underlying causes.

Research suggests that children of low-educated parents face greater health burdens during the passage from adolescence to young adulthood, as they are more likely to become low-educated themselves, establish behavioural and psychosocial disadvantages, or being exposed to unhealthy working conditions. However, studies examining the development and drivers of health inequalities during this particular life stage are limited in number and have produced varied results. This study investigates trajectories of self-rated health and overweight from 14 to 25 years of age, stratified by parental education, and explores the role of potential mediators (educational achievement, health behaviours, psychosocial factors, working conditions). We rely on prospective cohort data from the National Educational Panel Study (NEPS), a representative sample of 14,981 German ninth graders interviewed yearly from 2011 to 2021 (n = 90,096 person-years). First, we estimated random-effects growth curves for self-rated health and overweight over participants' age and calculated the average marginal effect of high versus low parental education. Second, a series of simulation-based mediation analyses were performed to test how much of health inequalities were explained by children's educational attainment (years of school education, years in university), health behaviours (smoking, alcohol, physical inactivity), psychosocial factors (number of grade repetitions, years in unemployment, chronic stress, self-esteem) and working conditions (physical and psychosocial job demands). We accounted for potential confounding by controlling for age, sex, migration background, residential area, household composition, and interview mode. Results show that higher parental education was related to higher self-rated health and lower probabilities of being overweight. Interaction between parental education and age indicated that, after some equalisation in late adolescence, health inequalities increased in young adulthood. Furthermore, educational attainment, health behaviours, psychosocial factors, and early-career working conditions played a significant role in mediating health inequalities. Of the variables examined, the level of school education and years spent in university were particular strong mediating factors. School education accounted for around one-third of the inequalities in self-rated health and one-fifth of the differences in overweight among individuals. Results support the idea that the transition to adulthood is a sensitive period in life and that early socio-economic adversity increases the likelihood to accumulate health disadvantages in multiple dimensions. In Germany, a country with comparatively low educational mobility, intergenerational continuities in class location seem to play a key role in the explanation of health inequalities in youth.

[Living Actively with Cancer - Recommendations for a Healthy Life Style: Needs Assessment and Design of Multimedia Patient Information]. / "Aktiv leben mit Krebs ­ Tipps für einen gesunden Lebensstil" ­ Bedarfserfassung und Entwicklung einer multimedialen Patienteninformation.

The positive effects of a healthy lifestyle on the holistic physical condition and quality of life of cancer survivors is scientifically proven. The National Comprehensive Cancer Network (NCCN) Guidelines for Survivorship specifically highlight the need for support in these areas. The lack of specialised offers for cancer patients in predominantly rural areas, however, represents a high level of assistance needed in terms of the development and implementation of a healthy lifestyle. Following a needs assessment, our aim was to conceptualise and design an easily accessible multi-media patient information system on the basis of a social-cognitive process model on health behaviour (Health Action Process Approach - HAPA). A higher level of health literacy represents, inter alia, the basis for informed choice and, as such, forms an important resource for the aftercare of cancer patients. Further studies are recommended on the acceptance, use and effects of patient information with regard to intended longer-term changes of health behaviour.

Predictors and prevalence of hazardous alcohol use in middle-late to late adulthood in Europe.

Objectives: Even low to moderate levels of alcohol consumption can have detrimental health consequences, especially in older adults (OA). Although many studies report an increase in the proportion of drinkers among OA, there are regional variations. Therefore, we examined alcohol consumption and the prevalence of hazardous alcohol use (HAU) among men and women aged 50+ years in four European regions and investigated predictors of HAU.Methods: We analyzed data of N = 35,042 participants of the European SHARE study. We investigated differences in alcohol consumption (units last week) according to gender, age and EU-region using ANOVAs. Furthermore, logistic regression models were used to examine the effect of income, education, marital status, history of a low-quality parent-child relationship and smoking on HAU, also stratified for gender and EU-region. HAU was operationalized as binge drinking or risky drinking (<12.5 units of 10 ml alcohol/week).Results: Overall, past week alcohol consumption was 5.0 units (±7.8), prevalence of HAU was 25.4% within our sample of European adults aged 50+ years. Male gender, younger age and living in Western Europe were linked to both higher alcohol consumption and higher risks of HAU. Income, education, smoking, a low-quality parent-child relationship, living in Northern and especially Eastern Europe were positively associated with HAU. Stratified analyses revealed differences by region and gender.Conclusions: HAU was highly prevalent within this European sample of OA. Alcohol consumption and determinants of HAU differed between EU-regions, hinting to a necessity of risk-stratified population-level strategies to prevent HAU and subsequent alcohol use disorders.

Referral criteria for chronic kidney disease: implications for disease management and healthcare expenditure-analysis of a population-based sample.

BACKGROUND: Clinical practice guidelines recommend specialist referral according to different criteria. The aim was to assess recommended and observed referral rate and health care expenditure according to recommendations from: • Kidney Disease Improving Global Outcomes (KDIGO,2012) • National Institute for Health and Care Excellence (NICE,2014) • German Society of Nephrology/German Society of Internal Medicine (DGfN/DGIM,2015) • German College of General Practitioners and Family Physicians (DEGAM,2019) • Kidney failure risk equation (NICE,2021) METHODS: Data of the population-based cohort Study of Health in Pomerania were matched with claims data. Proportion of subjects meeting referral criteria and corresponding health care expenditures were calculated and projected to the population of Mecklenburg-Vorpommern. RESULTS: Data from 1927 subjects were analysed. Overall proportion of subjects meeting referral criteria ranged from 4.9% (DEGAM) to 8.3% (DGfN/DGIM). The majority of patients eligible for referral were ≥ 60 years. In subjects older than 60 years, differences were even more pronounced, and rates ranged from 9.7% (DEGAM) to 16.5% (DGfN/DGIM). Estimated population level costs varied between €1,432,440 (DEGAM) and €2,386,186 (DGfN/DGIM). From 190 patients with eGFR < 60 ml/min, 15 had a risk of end stage renal disease > 5% within the next 5 years. CONCLUSIONS: Applying different referral criteria results in different referral rates and costs. Referral rates exceed actually observed consultation rates. Criteria need to be evaluated in terms of available workforce, resources and regarding over- and underutilization of nephrology services.

Socioeconomic position and self-rated health among female and male adolescents: The role of familial determinants in explaining health inequalities. Results of the German KiGGS study.

OBJECTIVE: Although health inequalities in adolescence are well documented, the underlying mechanisms remain unclear. Few studies have examined the role of the family in explaining the association between the family's socioeconomic position and adolescents' self-rated health. The current study aimed to explore whether the association between socioeconomic position and self-rated health was mediated by familial determinants. METHODS: Using data from wave 2 of the"German Health Interview and Examination Survey for Children and Adolescents" (KiGGS) (1,838 female and 1,718 male 11- to 17-year-olds), linear regression analyses were conducted to decompose the total effects of income, education, occupational status, socioeconomic position index and adolescents' subjective social status on self-rated health into direct effects and indirect effects through familial determinants (family cohesion, parental well-being, parental stress, parenting styles, parental obesity, smoking and sporting activity). RESULTS: A significant total effect of all socioeconomic position indicators on self-rated health was found, except for income in male adolescents. In female adolescents, more than 70% of the total effects of each socioeconomic position indicator were explained by familial mediators, whereas no significant direct effects remained. The most important mediator was parental well-being, followed by family cohesion, parental smoking and sporting activity. In male adolescents, the associations between income, parental education, the socioeconomic position index and subjective social status were also mediated by familial determinants (family cohesion, parental smoking, obesity and living in a single-mother family). However, a significant direct effect of subjective social status remained. CONCLUSION: The analysis revealed how a family's position of socioeconomic disadvantage can lead to poorer health in adolescents through different family practices. The family appears to play an important role in explaining health inequalities, particularly in female adolescents. Reducing health inequalities in adolescence requires policy interventions (macro-level), community-based strategies (meso-level) and programs to improve parenting and family functioning (micro-level).

The role of education and migration background in explaining differences in folic acid supplementation intake in pregnancy: results from a German birth cohort study.

OBJECTIVE: Official German recommendations advise women to start taking folic acid supplementation (FAS) before conception and continue during the first pregnancy trimester to lower the risk of birth defects. Women from lower socio-economic background and ethnic minorities tend to be less likely to take FAS in other European countries. As little is known about the determinants of FAS in Germany, we aimed to investigate the association between FAS and formal education and migration background, adjusting for demographic factors. DESIGN: We used data (2013-2016) on nutrition and socio-economic and migration background from the baseline questionnaire of the BaBi cohort study. We performed multivariate regressions and mediation analyses. SETTING: Bielefeld, Germany. PARTICIPANTS: Nine-hundred forty-seven women (pregnant or who had given birth in the past 2 months). RESULTS: 16.7% of the participants (158/947) did not use FAS. Migration-related variables (e.g. language, length of stay) were not associated with FAS in the adjusted models. FAS was lower in women with lower level of formal education and in unplanned pregnancies. Reasons given by women for not taking FAS were unplanned pregnancy and lack of knowledge of FAS. CONCLUSIONS: Health practitioners may be inclined to see migrant women as an inherently at-risk group for failed intake of FAS. However, it is primarily women who did not plan their pregnancy, and women of lower formal education level, who are at risk. Different public health strategies to counter low supplementation rates should be supported, those addressing the social determinants of health (i.e. education) and those more focused on family planning.

Correlation of mesolevel characteristics of the healthcare system and socioeconomic inequality in healthcare use: a scoping review protocol.

INTRODUCTION: Although the impact of macrolevel characteristics of health systems on socioeconomic inequity in health has been studied extensively, the impact of access characteristics on a smaller scale of health systems has received less attention. These mesolevel characteristics can influence access to healthcare and might have the potential to moderate or aggravate socioeconomic inequity in healthcare use. This scoping review aims to map the existing evidence of the association of socioeconomic inequity in healthcare use and mesolevel access characteristics of the health system. METHODS AND ANALYSIS: In conducting the scoping review, we follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols Extension for Scoping Reviews. The search will be carried out in four scientific databases: MEDLINE (via PubMed), Web of Science, Scopus and PsycINFO. Main eligibility criteria are inclusion in the analysis of a measure of socioeconomic position, a measure of individual healthcare use and a mesolevel determinant of access to healthcare services. The selection process consists of two consecutive screening stages (first: title/abstract; second: full text). At both stages, two reviewers independently assess the eligibility of studies. In case of disagreement, a third reviewer will be involved. Cohen's kappa will be calculated to report inter-rater agreement between reviewers. Results are synthesised narratively, as a high heterogeneity of studies is expected. ETHICS AND DISSEMINATION: No primary data are collected for the presented scoping review. Therefore, ethical approval is not necessary. The scoping review will be published in an international peer-reviewed journal, and findings will be presented on national and international conferences.

Study on E-Cigarettes and Pregnancy (STEP) - Results of a Mixed Methods Study on Risk Perception of E-Cigarette Use During Pregnancy.

Introduction E-cigarette use during pregnancy is a risk factor for maternal and fetal health. Early studies on animals showed that in utero exposure to e-cigarettes can have negative health outcomes for the fetus. There has been only limited research into the risk perceptions of e-cigarette use during pregnancy. This study was conducted to comprehensively characterize the constructs of risk perceptions with regard to e-cigarette use during pregnancy using an I ntegrated H ealth B elief M odel (IHBM). Methods Our ST udy on E -cigarettes and P regnancy (STEP) used a mixed methods approach, with the study divided into an initial qualitative part and a quantitative part. A netnographic approach was used for the first part, which consisted of the analysis of 1552 posts from 25 German-language online discussion threads on e-cigarette use during pregnancy. Using these qualitative results, a quantitative questionnaire was developed to explore risk perception constructs about e-cigarette use during pregnancy. This questionnaire was subsequently administered to pregnant women (n = 575) in one hospital in Hamburg, Germany. Descriptive and bivariate analysis was used to examine differences in risk perception according to participants' tobacco and e-cigarette user status before and during pregnancy. While the study design, methods and sample have been extensively described in our recently published study protocol in the January 2020 issue of Geburtshilfe und Frauenheilkunde , this paper is devoted to a presentation of the results of our mixed methods study. Results Themes related to perceived threats identified in the qualitative study part were nicotine-related health risks and potential health risks of additional ingredients . Perceived benefits were possibility and facilitation of smoking cessation and a presumed potential to reduce harm . The subsequent quantitative part showed that nearly all participants (99.3%) perceived e-cigarettes which contained nicotine as constituting a threat to the health of the unborn child. The most commonly perceived barrier was health-related (96.6%), while the most commonly perceived benefit was a reduction in the amount of tobacco cigarettes consumed (31.8%). We found that particularly perceived benefits varied depending on the participant's tobacco and e-cigarette user status. Conclusion When considering future prevention strategies, the potential health risks and disputed effectiveness of e-cigarettes as a tool for smoking cessation need to be taken into account and critically discussed.

Active and Passive Exposure to Tobacco and e-Cigarettes During Pregnancy.

OBJECTIVES: Active and passive exposure to tobacco cigarettes during pregnancy is associated with multiple negative health outcomes for the fetus. In addition, exposure to e-cigarettes has been progressively discussed as a new threat to fetal health. Until now, there has been a lack of studies examining active and passive exposure to tobacco and e-cigarettes among pregnant women. The objective of our current STudy on E-cigarettes and Pregnancy (STEP) was to advance and complement the current knowledge regarding active and passive exposure to tobacco and e-cigarettes before pregnancy and during early and late pregnancy. METHODS: One element of the STEP study was a quantitative cross-sectional design: A sample of 540 pregnant women recruited at an obstetrician clinic in Hamburg from April 2018 to January 2019 were surveyed once via a standardized questionnaire and provided complete information regarding their consumption of tobacco and e-cigarettes. We performed a descriptive analysis of tobacco and e-cigarette use before pregnancy and during early and late pregnancy, as well as bivariate analysis of these variables with sociodemographic determinants. Passive exposure was assessed by asking the participating pregnant women about the consumption of tobacco and e-cigarettes by their partners, in general, and in their homes. RESULTS: Before pregnancy, 20.0% of the participants used tobacco cigarettes exclusively, 1.3% used e-cigarettes exclusively, and 6.5% were dual users. Educational level was significantly associated with tobacco cigarette use (p < 0.001) and dual use (p = 0.047) before pregnancy. During early (late) pregnancy, 8.7% (2.8%) used tobacco cigarettes and 0.4% (0.0%) used e-cigarettes exclusively. Twenty-point nine percent of women's partners consumed tobacco cigarettes exclusively, 2.7% consumed e-cigarettes exclusively, and 2.7% consumed both. A total of 8.5% (16.7%) of the partners who consumed tobacco cigarettes exclusively (e-cigarettes exclusively) did so in the women's homes. CONCLUSIONS FOR PRACTICE: Among pregnant women, the use of tobacco cigarettes remains prominent before and during pregnancy, while e-cigarette use predominately occurs before pregnancy. Our study shows that pregnant women are frequently exposed to their partners' tobacco and e-cigarette use within their homes. Strategies to reduce such exposure should be further intensified.

Breast cancer incidence and mammography screening among resettlers in Germany.

BACKGROUND: European studies showed that women with a migration background are less likely to participate in mammography screenings than autochthonous women. However, the participation in the German mammography screening programme (MSP) among ethnic German migrants from countries of the former Soviet Union (called resettlers) is unclear so far. The aim of this study was to identify possible differences regarding MSP participation between resettlers from the FSU and the general German population. METHODS: Data from two independent, complementary studies from North Rhine-Westphalia, Germany (a retrospective cohort study 1994-2013; a cross-sectional study 2013/14) were used for comparisons between resettlers and the general population: Odds Ratios (ORs) for MSP participation utilizing the cross-sectional data and time trends of breast cancer incidence rates as well as Chi-Square tests for breast cancer stages utilizing the cohort data. RESULTS: Resettlers showed higher Odds to participate in the MSP than the general population (OR 2.42, 95% CI 1.08-5.42). Among resettlers, a large increase in incidence rates was observed during the MSP implementation (2005-2009), resulting in stable and comparable incidence rates after the implementation. Furthermore, pre-MSP implementation, the proportion of advanced breast cancer stages was higher among resettlers than in the German population, post-MSP implementation the proportion was comparable. CONCLUSIONS: MSP participating seems surprisingly high among resettlers. An explanation for the increased willingness to participate might be the structured invitation procedure of the MSP. However, the exact reasons remain unclear and future research is needed to confirm this hypothesis and rule out the possibility of selection bias in the cross-sectional study.

STudy on E-Cigarettes and Pregnancy (STEP) - Study Protocol of a Mixed Methods Study on Risk Perception of E-Cigarette Use During Pregnancy and Sample Description.

Introduction During pregnancy, the mother's healthy lifestyle is crucial for the health of the fetus. Potential risk factors for maternal and child health should therefore be identified and reduced as early as possible. The consumption of e-cigarettes represents one of these potential risk factors. Exploring risk perceptions about e-cigarette use during pregnancy can provide early indications of possible user motives. Therefore, our mixed methods ST udy on E -cigarettes and P regnancy (STEP) aimed to comprehensively analyze risk perceptions about e-cigarette use during pregnancy based on an I ntegrated H ealth B elief M odel (IHBM). This paper describes the study design, methods, sample population and limitations of STEP. Methods Our sequential mixed methods study combined qualitative and quantitative approaches. In the qualitative section of the study which preceded the quantitative part of the study, we aimed to characterize risk perceptions about e-cigarette use during pregnancy. We used a netnographic research approach which analyzed discussion threads in online forums dealing with e-cigarette use during pregnancy. The analysis was based on an IHBM. Identified themes were incorporated in the questionnaire which was developed for the quantitative part of the study. The quantitative section aimed to quantify, among other things, perceived threats, barriers and benefits and to explore differences in risk perception according to sociodemographic characteristics and tobacco and e-cigarette usage. Results In the qualitative section, 1552 posts in 25 online discussion threads dealing, inter alia, with e-cigarette use during pregnancy were identified. The quantitative part looked at the responses in the questionnaires handed in by 575 pregnant women who attended a hospital in Hamburg (Germany) from April 2018 to January 2019 (response rate: 27.5%). Conclusion Data collection was successful for both the qualitative and quantitative parts of the study. When interpreting the results of STEP, different limitations should be taken into account. The results of STEP provide starting points for the development of tailored preventive measures for pregnant women.

Perceived threats, benefits and barriers of e-cigarette use during pregnancy. A qualitative analysis of risk perception within existing threads in online discussion forums.

OBJECTIVE: Previous studies have shown that e-cigarettes are perceived as being less harmful than tobacco cigarettes by pregnant women and might be used to quit smoking during pregnancy. Our aim was to further explore and characterise perceived threats, benefits and barriers of e-cigarette use during pregnancy. METHODS: Our STudy on E-cigarettes and Pregnancy (STEP) was, among others, based on a netnographic approach of analysing existing threads in German-speaking online discussion forums dealing with perceived threats and benefits of e-cigarette use during pregnancy. For the analysis, we used an inductive-deductive qualitative content analysis. FINDINGS: Based on 25 online discussion threads containing 1552 posts, we identified perceived threats, perceived benefits and perceived barriers to e-cigarette use during pregnancy, among others, as main themes. Subthemes identified within the main theme perceived threats were severe nicotine related health risks, potential health risks of additional ingredients, relative risks and lack of knowledge and research studies. As perceived benefits, we identified possibility and facilitation of smoking cessation, harm reduction and financial benefits. Perceived barriers were lack of satisfaction and social stigma. CONCLUSION: Our qualitative results suggest that the perception of the health threats related to e-cigarette use during pregnancy varies according to the nicotine content and the perception of relative risks compared with tobacco cigarettes. In addition to this, risk perception is defined through further health and non-health related barriers and benefits (e.g. suitability of e-cigarettes as a smoking cessation aid, social stigma).

Development of the Informed Choice in Mammography Screening Questionnaire (IMQ): factor structure, reliability, and validity.

BACKGROUND: Informed choice is of ethical and practical importance in mammography screening. To assess the level to which decisions regarding such screening are informed is thus imperative, but no specific instrument has been available to measure informed choice in the German mammography screening programme. The aims of this study were to develop the Informed Choice in Mammography Screening Questionnaire (IMQ) and to find first evidence for the factor structure, reliability and validity of its different components. METHODS: The IMQ was sent to 17.349 women aged 50 in Westphalia-Lippe, Germany. The instrument has been developed after consideration of (1) the results of qualitative interviews on decision making in the mammography screening programme, (2) relevant literature on other informed choice instruments and (3) a qualitative study on influencing factors. The IMQ comprises 3 scales (attitude, norms, and barriers), 1 index (knowledge) and singular items covering intention to participate and sociodemographic variables. To assess the psychometric properties of the components of the IMQ, confirmatory factor and item response theory analyses were conducted. Additionally, reliability, validity and item statistics were assessed. RESULTS: 5.847 questionnaires were returned (response rate 33.7%). For attitude, the confirmatory factor analysis supported a one-factor structure. For norms, the model fit was not acceptable. Reliability levels were good with a Cronbach's α of.793 for attitude (4 items) and.795 for norms (5 items). For barriers, 9 items were deleted because of low discrimination indices; 6 items remained. The hypothesised assumption-subscale and the importance-subscale were confirmed, but these subscales showed poor reliabilities with Cronbach's α=.525 (4 items) and.583 (2 items). For the knowledge index, item response theory analysis showed that 6 out of 7 items were suitable. Hypotheses concerning the correlations between the different components were confirmed, which supported their convergent and divergent validity. CONCLUSION: The results of this study demonstrated that the IMQ is a multidimensional instrument. Further development of the barriers and norms scales is necessary. The IMQ can be utilised to assess the level of informed choices as well as influencing factors.

Uptake of Gynecological Cancer Screening and Performance of Breast Self-Examination Among 50-Year-Old Migrant and Non-migrant Women in Germany: Results of a Cross-Sectional Study (InEMa).

Our aim was to provide data regarding uptake of gynecological early detection measures and performance of breast self-examinations among migrant women in Germany. Cross-sectional self-reported data were collected using paper-and-pencil questionnaires. Descriptive analyses, Chi square-tests, and logistic regression were applied. Results were adjusted for educational level. Of 5387 women, 89.9% were autochthonous, 4.1% German resettlers, 2.8% Turkish, 3.1% other migrants. Participation rates regarding cancer screening differed significantly, with the lowest proportion in Turkish migrants (65.0%), resettlers (67.8%), other migrants (68.2%) and autochthonous population (78.2%). No differences in performance of breast self-examinations were detected. When adjusted for education, results indicated only slight changes in the odds to participate in screening irregularly or not at all. Results support existing evidence by showing lower participation rates in cancer screening among migrant women, but there were no differences regarding breast self-examinations. Migrant women form a potential high-risk group for late-stage diagnosis of cervical or breast cancer.

Knowledge about mammography screening in Germany by education and migrant status ­ results of a cross-sectional study (InEMa)

Background: The population-based mammography screening program (MSP) is aimed to reduce breast cancer mortality, to detect breast cancer at an early stage, and to allow for less invasive treatment. However, it also has some potential harms, such as overdiagnosis and overtreatment. Therefore, it is necessary that women receive sufficient and balanced information to enable informed decision-making. We examined knowledge about benefits and harms of the MSP in Germany among first-time invitees of different socio-demographic backgrounds. Methods: This observational study assessed knowledge about benefits and harms of the MSP among women who were invited to the MSP for the first time by six multiple choice items, using a postal survey. We investigated (i) single items of knowledge, (ii) the distribution of sufficient knowledge stratified by education, migration status and invitation, and (iii) possible determinants of sufficient knowledge by analyzing Odds Ratios (ORs) using bivariate and multivariate logistic regression. Results: In total, 5397 women included in the analyses. 46.1% of the study population had sufficient knowledge about benefits and harms of the MSP. However, women with low educational level and migration background had higher proportions of insufficient knowledge and used most frequently the option "don't know". Women had the most difficulties answering the numeric question and the question about the target group correctly. Results from the logistic regression showed that the odds of having sufficient knowledge were higher among well-educated women (OR 3.84, 95%CI 3.24­4.55), among women who already received the MSP invitation (OR 1.38, 95%CI 1.20­1.59) and lowest among Turkish women (OR 0.14, 95%CI 0.07­0.25). Conclusions: Women with low education and migration background need adapted information regarding benefits and harms of the MSP and are important target groups for further developing the information material about mammography screening to reduce disparities in knowledge and enable informed decision-making (AU)

Informed Choice in the German Mammography Screening Program by Education and Migrant Status: Survey among First-Time Invitees.

Breast cancer is the most prevalent cancer among women and mammography screening programs are seen as a key strategy to reduce breast cancer mortality. In Germany, women are invited to the population-based mammography screening program between ages 50 to 69. It is still discussed whether the benefits of mammography screening outweigh its harms. Therefore, the concept of informed choice comprising knowledge, attitude and intention has gained importance. The objective of this observational study was to assess the proportion of informed choices among women invited to the German mammography screening program for the first time. A representative sample of 17,349 women aged 50 years from a sub-region of North Rhine Westphalia was invited to participate in a postal survey. Turkish immigrant women were oversampled. The effects of education level and migration status on informed choice and its components were assessed. 5,847 (33.7%) women responded to the postal questionnaire of which 4,113 were used for analyses. 31.5% of the women had sufficient knowledge. The proportion of sufficient knowledge was lower among immigrants and among women with low education levels. The proportion of women making informed choices was low (27.1%), with similar associations with education level and migration status. Women of low (OR 2.75; 95% CI 2.18-3.46) and medium education level (OR 1.49; 95% CI 1.27-1.75) were more likely to make an uninformed choice than women of high education level. Turkish immigrant women had the greatest odds for making an uninformed choice (OR 5.30, 95% CI 1.92-14.66) compared to non-immigrant women. Other immigrant women only had slightly greater odds for making an uninformed choice than non-immigrant women. As immigrant populations and women with low education level have been shown to have poor knowledge, they need special attention in measures to increase knowledge and thus informed choices.

A cross-sectional study on informed choice in the mammography screening programme in Germany (InEMa): a study protocol.

INTRODUCTION: Breast cancer is the most prevalent cancer among women. In Germany, women are invited to a population-based mammography screening programme for the first time at the age of 50. Since it is still discussed whether the benefits of mammography screening outweigh its harms, the concept of informed choice has gained importance. The objective of this cross-sectional study is to assess the proportion of informed choices in the mammography screening programme. A special focus is on the examination of the impact of Turkish migration background and educational level on informed choices. METHODS AND ANALYSIS: The proportion of informed choices is evaluated in a cross-sectional study with 3-month follow-up for behavioural implementation of the screening intention. A randomly selected sample of 17,000 women aged 50 years living in Westphalia-Lippe, a region in the Federal State of North-Rhine Westphalia, is invited to participate in this study. To reach adequate numbers of Turkish women, all possibly Turkish women in the sample are identified through a name algorithm and contacted. The sample is drawn from women registered in the study area for which the registration offices consented to supply data for the study (88% of all towns/cities in the study region). Women identified through the Turkish name algorithm received all materials in German and Turkish. The primary outcome is informed choice. Data are collected on informed choice components (knowledge, attitude, decision/implementation) as well as on its possible determinants (eg, health behaviour, perceived behavioural control, subjective norms, invitation status, migration background and other demographic variables). Data are collected before the screening appointment and at 3 months follow-up. ETHICS AND DISSEMINATION: The study was approved by the ethical committee of the Medical Faculty of Muenster University. Results will be published in a relevant scientific journal and communicated to respondents and relevant institutions.

How immigrants adapt their smoking behaviour: comparative analysis among Turkish immigrants in Germany and the Netherlands.

BACKGROUND: Smoking behaviour among immigrants is assumed to converge to that of the host country's majority population with increasing duration of stay. We compared smoking prevalence among Turkish immigrants residing in two different countries (Germany (DE)/the Netherlands (NL)) between and within countries by time spent in Turkey and DE/NL. METHODS: The German 2009 micro-census and the Dutch POLS database (national survey, 1997-2004) were analysed. An interaction variable with dichotomised length of stay (LOS) in Turkey (age: 0-17; 18+) and categorised LOS in the host country (immigration year: 1979 and earlier, 1980-1999, 2000-2009; the latter only for Germany) was generated. Age standardised smoking prevalences and sex-specific logistic regression models were calculated. RESULTS: 6,517 Turkish participants were identified in Germany, 2,106 in the Netherlands. Age-standardised smoking prevalences were higher among Turkish immigrants in the Netherlands compared to those in Germany: 62.3% vs. 53.1% (men/lower education); 30.6% vs. 23.0% (women/lower education). A similar trend was observed for the majority population of both countries. The chance of being a smoker was lower among Turkish men with short LOS in Turkey and middle LOS in Germany/the Netherlands compared to those with short LOS in Turkey and long LOS in Germany/the Netherlands (NL: OR = 0.57[95% CI = 0.36-0.89]; DE: OR = 0.73[95% CI = 0.56-0.95]). Contrary to that, the chance of being a smoker was higher among Turkish men with long LOS in Turkey and middle LOS in Germany/the Netherlands compared to those with long LOS in Turkey and long LOS in Germany/the Netherlands (NL: OR = 1.35[95% CI = 0.79-2.33]; DE: OR = 1.44[95% CI = 1.03-2.02]). The effects for Turkish women were similar, but smaller and often non-significant. CONCLUSION: Turkish immigrants adapt their smoking behaviour towards that of the Dutch/German majority population with increasing duration of stay. This was particularly obvious among those who left Turkey before the age of 18 years - a group that needs tailored interventions to prevent further increases in smoking. Those who left Turkey as adults and spent a short time in the host countries show 'imported' smoking patterns. A limitation of this study is the use of cross-sectional data: a cohort effect cannot be ruled out. Our findings have to be confirmed with longitudinal data.

Participation in breast cancer screening among women of Turkish origin in Germany - a register-based study.

BACKGROUND: Population-based breast cancer screening programs were implemented to reduce breast cancer mortality and to improve recovery chances. Breast cancer screening participation among migrant women differs from that of autochthonous populations in several European countries. Here we investigate for the first time participation among women of Turkish origin in Germany. METHODS: Data of five screening units covering 2010 and 2011 as well as associated population registries were analysed. Women of Turkish origin were identified using a name-based algorithm. Participation ratios among women of Turkish origin and odds ratios compared to women of non-Turkish origin were calculated. Analyses were stratified and adjusted for age-groups and screening unit. RESULTS: A total of 208,500 participants in the five breast screening units were included, out of 423,649 eligible women in the catchment areas (participation 49.2%). Women of Turkish origin have a slightly higher chance to participate in breast cancer screening than women without Turkish origin (OR 1.17; 95% CI: 1.14-1.21). Only women of Turkish origin aged 65-69 years have a lower chance to participate than women without Turkish origin (OR: 0.71; 95% CI: 0.66-0.75). CONCLUSION: In spite of low participation in preventive measures among migrant populations, the overall breast cancer screening participation among women of Turkish origin in Germany seems to be higher compared to women of non-Turkish origin. Turkish women aged 65 years and above have a lower chance of participation than younger Turkish women. There is need for further research to study factors affecting participation in screening among migrant and non-migrant populations in Germany.

Perinatal outcomes of immigrant women of Turkish, Middle Eastern and North African origin in Berlin, Germany: a comparison of two time periods.

PURPOSE: Publications based on data from perinatal health registries reported worse perinatal health outcomes among women of Turkish origin. The aim of this study was to compare the perinatal outcomes of women of German and Turkish origin in Berlin in two time periods and to analyze if the situation among the women of Turkish origin has improved over time. METHODS: Datasets of all singleton deliveries from Berlin hospitals for the time periods 1993-1997 (n = 144,600) and 2003-2007 (n = 147,559) were used. Incidence rates resp. prevalences of perinatal health outcomes were computed for women of German and a group of immigrant women mostly of Turkish origin stratified for 'parity' and 'having a partner'. Logistic regression models were computed to test for a change in the odds for adverse perinatal outcomes over time. RESULTS: The chances for adverse perinatal outcomes were decreasing in the later time period for most measures. For stillbirth, preterm birth and congenital malformations, no differences between women of Turkish and German origin could be found. Differences exist in the utilization of perinatal health care and in the risk for anemia. Among women of Turkish origin, the chance for being anemic is even higher in 2003-2007 compared to 1993-1997. CONCLUSIONS: The perinatal health measures of women of Turkish origin have improved over time. The lower utilization rates of antenatal health care could be the expression of barriers to access the health care for pregnant women with migration background as offered in Germany. A risk group which needs a special focus by health care providers are women without a partner, irrespective of their origin.