Insights from a community-based palliative care course: a qualitative study.

BACKGROUND: The vast majority of medical students have no exposure to clinical palliative care encounters, especially in the community. Medical schools should respond to current challenges and needs of health systems by guaranteeing students adequate training that addresses palliative care needs of populations in different settings. The main purpose of this qualitative study was to capture the experiences of a select group of medical students' following a community-based PC course. METHODS: We carried out a qualitative study using two focus groups to capture the experience of medical students in a course that combined classroom teaching with community-based learning for undergraduate medical students in Germany. Discussions were transcribed and analyzed thematically. RESULTS: Fifteen female students in their 2nd to 5th year participated in the focus groups, which provided didactic teaching and experiential learning. Four areas were particularly relevant: (1) authenticity, (2) demystification of the concepts of palliative care through personal contact with patients, (3) translation of theoretical knowledge into practice, and (4) observation of a role model interacting with seriously ill patients and engaging in difficult conversations. CONCLUSION: Students whose encounters with patients and their families went beyond a review of their medical records had a better grasp of the holistic nature of PC than those who did not. Bringing students directly from the hospital to patients in their homes reinforced the benefits of an integrated healthcare system.

Association of social relationships with incident cardiovascular events and all-cause mortality.

OBJECTIVE: To examine how different aspects of social relationships are associated with incident cardiovascular events and all-cause mortality. METHODS: In 4139 participants from the population-based Heinz Nixdorf Recall study without previous cardiovascular disease (mean (SD) age 59.1 (7.7) years, 46.7% men), the association of self-reported instrumental, emotional and financial support and social integration at baseline with incident fatal and non-fatal cardiovascular events and all-cause mortality during 13.4-year follow-up was assessed in five different multivariable Cox proportional hazards regression models: minimally adjusted model (adjusting for age, sex, social integration or social support, respectively); biological model (minimally adjusted+systolic blood pressure, low-density and high-density lipoprotein cholesterol, glycated haemoglobin, body mass index, antihypertensive medication, lipid-lowering medication and antidiabetic medication); health behaviour model (minimally adjusted+alcohol consumption, smoking and physical activity); socioeconomic model (minimally adjusted+income, education and employment); and depression model (minimally adjusted+depression, antidepressants and anxiolytics). RESULTS: 339 cardiovascular events and 530 deaths occurred during follow-up. Lack of financial support was associated with an increased cardiovascular event risk (minimally adjusted HR=1.30(95% CI 1.01 to 1.67)). Lack of social integration (social isolation) was associated with increased mortality (minimally adjusted HR=1.47 (95% CI 1.09 to 1.97)). Effect estimates did not decrease to a relevant extent in any regression model. CONCLUSIONS: Perceiving a lack of financial support is associated with a higher cardiovascular event incidence, and being socially isolated is associated with increased all-cause mortality. Future studies should investigate how persons with deficient social relationships could benefit from targeted interventions.

[Social inequalities in nutrition: Evidence, causes and interventions]. / Soziale Ungleichheit im Ernährungsverhalten : Befundlage, Ursachen und Interventionen.

Malnutrition is unhealthy: obesity, type 2 diabetes, cardiovascular diseases, some cancers, and premature mortality are reliably associated with poor nutrition. However, literature reveals that some population groups are at higher risk of poor nutrition than others. More specifically, evidence shows that people with low social status are more likely to have poor nutrition than those with higher status, what may contribute to health inequalities. In this article, selected reviews and meta-analyses on social inequalities in nutrition are presented. By showing current data from the Second National Food Consumption Study, the situation in Germany is highlighted. Further, potential causes of social inequalities in nutrition are discussed, drawing on the results of current research. More specifically, socioeconomic and structural deprivation (e.g., poverty, living in deprived neighborhoods) in addition to unfavorable psychosocial (e.g., poor knowledge of nutrition, low levels of social support) and sociocultural factors (e.g., unfavorable nutritional traditions) might be associated with poor nutrition in people with low social status. Interventions promoting nutritional quality in disadvantaged groups should take into account the various influences on nutrition and meet good practice criteria for health promotion. Using three examples of interventions, conceivable concrete measures that can reduce social inequalities in nutrition are presented.

Poor social relations and adverse health behaviour: stronger associations in low socioeconomic groups?

OBJECTIVE: Poor social relations are supposed to contribute to adverse health behaviour. We examined this association and the role of low socio-economic position. METHODS: We regressed health behaviour on composite variables of the two exposures of social relations and socio-economic position (SEP). Social relations included networks and support; health behaviour was analysed in terms of smoking, poor nutrition and physical inactivity; socio-economic position comprised of income and education. Cross sectional data from a population based epidemiological study in German (4,814 men and women aged 45-75) was analysed. RESULTS: Among the indicators for social relations, social isolation was consistently associated with adverse health behaviour; social support showed modest effect. A combination of poor social relations and low SEP displayed stronger (additive) associations with adverse health behaviour than each factor alone. However, superadditivity was excluded. CONCLUSION: Given the important role of health adverse behaviour in chronic disease development, results underline the relevance of social environment and socio-economic structure in Public Health interventions.

Neighbourhood socioeconomic status and cardiovascular risk factors: a multilevel analysis of nine cities in the Czech Republic and Germany.

BACKGROUND: Previous studies have shown that deprived neighbourhoods have higher cardiovascular mortality and morbidity rates. Inequalities in the distribution of behaviour related risk factors are one possible explanation for this trend. In our study, we examined the association between cardiovascular risk factors and neighbourhood characteristics. To assess the consistency of associations the design is cross-national with data from nine industrial towns from the Czech Republic and Germany. METHODS: We combined datasets from two population based studies, one in Germany ('Heinz Nixdorf Recall (HNR) Study'), and one in the Czech Republic ('Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) Study'). Participation rates were 56% in the HNR and 55% in the HAPIEE study. The subsample for this particular analysis consists of 11,554 men and women from nine German and Czech towns. Census based information on social characteristics of 326 neighbourhoods were collected from local administrative authorities. We used unemployment rate and overcrowding as area-level markers of socioeconomic status (SES). The cardiovascular risk factors obesity, hypertension, smoking and physical inactivity were used as response variables. Regression models were complemented by individual-level social status (education) and relevant covariates. RESULTS: Smoking, obesity and low physical activity were more common in deprived neighbourhoods in Germany, even when personal characteristics including individual education were controlled for. For hypertension associations were weak. In the Czech Republic associations were observed for smoking and physical inactivity, but not for obesity and hypertension when individual-level covariates were adjusted for. The strongest association was found for smoking in both countries: in the fully adjusted model the odds ratio for 'high unemployment rate' was 1.30 [95% CI 1.02-1.66] in the Czech Republic and 1.60 [95% CI 1.29-1.98] in Germany. CONCLUSION: In this comparative study, the effects of neighbourhood deprivation varied by country and risk factor; the strongest and most consistent effects were found for smoking. Results indicate that area level SES is associated with health related lifestyles, which might be a possible pathway linking social status and cardiovascular disease. Individual-level education had a considerable influence on the association between neighbourhood characteristics and risk factors.