[Regional Deprivation in Germany: Nation-wide Analysis of its Association with Mortality Using the German Index of Multiple Deprivation (GIMD)]. / Regionale Deprivation in Deutschland: Bundesweite Analyse des Zusammenhangs mit Mortalität unter Verwendung des 'German Index of Multiple Deprivation (GIMD)'.

BACKGROUND: Deprivation indices are increasingly being used to assess the effects of contextual factors on health. In Germany, the recently developed 'German Index of Multiple Deprivation (GIMD)' integrates various dimensions of regional deprivation. We aim to assess the validity of the GIMD through a recalculation using more recent rural and urban district level data and by analysing its association with mortality at the national level. METHODS: We calculated a new version of the GIMD based on data from 2007 to 2010 for all 412 rural and urban districts in Germany. Mortality was quantified using indirectly standardised mortality ratios (SMRs). Correlation analyses and Poisson regression analyses were used to assess the association between the GIMD scores and total mortality, as well as premature mortality (< 65 years). RESULTS: Correlation analyses showed a positive association between the GIMD and both total mortality (p<0.001) and premature mortality (p<0.001). In the Poisson regression analyses, rural and urban districts in the quintile with the highest deprivation showed a significantly elevated risk of total mortality (RR: 1.29; 95% CI: 1.28-1.30) as well as premature mortality (RR: 1.50; 95% CI: 1.47-1.53), compared to the districts in the lowest quintile. CONCLUSION: The association between regional deprivation and mortality has already been shown for the federal state of Bavaria. Using more recent data, this relationship could be confirmed here for Germany as a whole. The GIMD has been shown to be able to effectively assess regional deprivation. Concerning public health policy, the significant, positive and stable association between regional deprivation and mortality indicates an increased need for health care provision particularly in the most deprived districts. Further studies should examine, for example, whether and how the allocation of districts to quintiles of regional deprivation changes over time, and how this affects mortality.

[Social Differences in Physical Activity among Adolescents in Germany: Analyses Based on Information Concerning the Metabolic Equivalent of Task (MET)]. / Soziale Unterschiede in der körperlich-sportlichen Aktivität bei Jugendlichen: Analyse der MoMo-Daten mithilfe der metabolischen Äquivalente (MET).

Introduction: Energy consumption, i. e., the metabolic equivalent of task (MET), provides a precise assessment of physical activity (PA). Studies on social inequalities of PA have hardly used this possibility, however. Methods: The analyses are based on the 'Motorik-Modul (MoMo) of the KiGGS study (German Health Interview and Examination Survey for Children and Adolescents) conducted between 2003 and 2006 (n=1 757; age group 11-17 years). PA has been assessed in 3 settings (sport club in school, other sport club, leisure time). 3 dependent variables were distinguished by combining the following criteria: at least 21 MET-hours per week, intensity between 3 and 6 METs, at least 7 hours a week. The main independent variables are: type of school and socioeconomic status (SES) of the parents. 'Two part models' have been used to assess social difference in PA among those who are physically active. Results: PA is much more common in the higher SES groups. Looking at the MET-hours, though, there are just little differences among those who are physically active (regressions coefficient for low vs. high SES: 1.15; 95% conf. interv. 0.99-1.33). Conclusion: Social differences can be seen mainly for the proportion of adolescents being physically active, not for the extent of PA among those who are physically active. Therefore, the central request should be to increase the proportion of adolescents performing any PA in the low SES group.

[Health Status of Persons without Health Insurance and of Undocumented Migrants: Analysis of Data from the Malteser Migranten Medizin (MMM) in Munich, Germany]. / Gesundheitszustand von Menschen ohne Krankenversicherung und von Menschen ohne legalen Aufenthaltsstatus: Analyse von Daten der Malteser Migranten Medizin (MMM) in München.

INTRODUCTION: It is estimated that more than 100,000 persons are without health insurance in Germany. The number of undocumented migrants is roughly estimated to be about 40,000. There are hardly any empirical studies looking at health care provision for these population groups, it is even rarely stressed that more empirical studies are needed. There seems to be a major gap concerning perception and research. The present study aims at promoting this discussion by presenting analyses based on data from an institution providing health care for these population groups, i. e., the Malteser Migranten Medizin (MMM) in Munich. METHODS: Data were available from all patients coming to MMM between January 2009 and October 2012 (i. e., from 2,352 visits altogether). The following information is available for each visit: date, sex, age group, country of origin, residence permit status (3 groups), diagnosis (ICD-10 chapter), type of health care (4 broad groups). Multivariate analyses have been conducted for simultaneous control of these variables. In order to compare these data with information from the general population, data from a large statutory sickness fund have been included as well. RESULTS: Focusing first on the MMM patients, the analyses showed large differences concerning diagnoses by country of origin and by residence permit status. We were not able, however, to confirm the hypothesis that mental health problems are especially common among undocumented migrants. The comparison with the general population indicated, surprisingly, that MMM patients showed a very similar spectrum of diagnoses as compared with the general population. CONCLUSION: The data from MMM do not allow a precise assessment of health care need, they still indicate, though, how different the patients are who seek help. MMM offers a broad range of health care, but it is hardly possible to meet the manifold demands of all the patients; there is no psychotherapist, for example. The resources available at MMM will always just allow a very limited provision of health care. It would be important to promote the integration of persons without health insurance and for undocumented migrants into the general system of statutory sickness funds.

[Health inequalities and cost-effectiveness: what do important health policy actors say about this potential conflict situation?]. / Gesundheitliche Chancengleichheit und Kosten-Effektivität: Was sagen wichtige gesundheitspolitische Akteure zu diesem potentiellen Zielkonflikt?

The German statutory health-care system is based on the principle of solidarity and thus it is committed to the objective of 'equal chances'. From an economic perspective it is also important to emphasise that scarcity of resources continuously pushes the services towards cost control and towards increasing cost-effect-iveness. There could be conflicts between the 2 objectives 'equal chances' and 'cost-effectiveness', of course, for example if measures for increasing cost-effectiveness lead to increased financial burdens of the insured. To date it has not been studied if and how this potential conflict is discussed in Germany.In a first step we searched for German publications discussing this potential conflict focusing on 3 major public health journals (Das Gesundheitswesen, Bundesgesundheitsblatt, Ethik in der Medizin) and on the internet portal "gerechte-gesundheit.de". For the main part of the paper, we looked for publications from 4 major health policy actors (Bundesärztekammer, Zentrale Ethikkommission bei der Bundesärztekammer, Deutscher Ethikrat, Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen). All papers published since the year 2000 were included in the system-atic qualitative analysis.The analyses show that the potential conflict between 'equal chances' and 'cost-effectiveness' is rarely discussed in any detail, at most in an implicit way. It would be important, though, to have an explicit discussion, supported by scientifically based analyses and recommendations. One step towards this objective could be, for example, a closer cooperation between social-epidemiologists and health--economists.

[Are health inequalities increasing with time? Results of a literature review and recommendations for further research]. / Nimmt die gesundheitliche Ungleichheit zu? Ergebnisse eines Literaturreviews und Empfehlungen für die weitere Forschung.

It has been shown that socio-economic status (SES) and health are closely linked to one another. Now we focus on further questions, and one of the most important ones is whether these "health inequalities" increase with time. In Germany, there is little discussion about this question and no review summarising the empirical evidence is available.This review focuses on 4 dimensions: time trends of health inequalities concerning mortality (or, respectively, life expectancy), self-rated health, smoking and obesity. First we included all empirical analyses from Germany, and all analyses from other European countries published between 2008 and 2012. Then, step-wise, 44 studies (including 5 from Germany) were selected by predefined criteria for a detailed -description of empirical results and methods.The number of publications has strong-ly increased in recent years, illustrating the growing interest in time trends of health inequalities. The empirical results of the 44 studies could be summarised in the following way: All in all, 184 empirical results are reported about time trends in health inequalities and 112 of them show increasing inequalities; decreasing inequalities are shown in 13 reports. The studies from Germany point in the same direction (i. e., most results indicate increasing health inequalities). It is also important to stress that there is great -heterogeneity concerning the methodical approaches. Some studies analyse health inequalities by individual socio-economic status (e. g., educational level), others by regional deprivation. Sometimes changes in the extent of health inequalities over time are not calculated explicitly. Some papers do not include absolute and relative measures of inequalities, but just one of them.In Germany, there is a need for more empirical studies looking at time trends of health inequalities; the available datasets should be used more often for this type of analysis. If possible, further studies should include individual SES and regional deprivation, measures of absolute and relative inequality (stratified by sex, with significance tests for time trend), and they should cover as many points in time as possible. Also, it would be important to relate the chang-es in health inequalities to the other changes in the society.

[Widening health inequalities? Time trends concerning self-rated health, smoking and obesity between 1984/1985 and 1999/2000 among adults in Augsburg]. / Nimmt die gesundheitliche Ungleichheit zu? : Trends beim subjektiven Gesundheitszustand, beim Rauchen und bei Adipositas zwischen 1984/85 und 1999/2000 bei Erwachsenen in Augsburg.

The analyses focused on time trends in health inequalities in the 25 to 64-year-old population of Augsburg. The analyses are based on four independent cross-sectional surveys from the MONICA/KORA study covering 15 years: 1984/1985 (n = 4,022), 1989/1990 (n = 3,966), 1994/1995 (n = 3,916) and 1999/2000 (n = 3,492). Socioeconomic status (SES) was assessed by educational level and per capita household income with separate analyses for each of these two variables. Both absolute and relative health inequalities were calculated. The results showed that inequalities in self-rated health did not change very much (with some indications for increasing inequalities). However, concerning smoking the results clearly pointed towards increasing health inequalities (for example concerning relative inequalities among women by educational level: significant increase from survey to survey of about 20 %). The prevalence of obesity was increased in all SES groups but the inequalities did not change very much. These time trends show that the efforts aimed at reducing health inequalities should be intensified.

[Direct costs of diabetes mellitus in Germany: first estimation of the differences related to educational level]. / Direkte Krankheitskosten von Diabetes mellitus in Deutschland: erste Abschätzung der Unterschiede zwischen Bildungsgruppen.

OBJECTIVE: There are many studies on health inequalities, but these are rarely combined with cost-of-illness analyses. If the cost-of-illness were to be calculated for the individual status groups, it would be possible to assess the economic potential of preventive measures aimed specifically at people from low status groups. The objective of this article is to demonstrate for the first time the preventive potential by taking the example of diabetes mellitus (DM) from an economic perspective. METHODS: Based on a systematic literature review, the average direct costs per patient with DM were assessed. Then, the prevalence of DM among adults with different educational levels was estimated based on the nationwide survey 'German Health Update' (GEDA), conducted by the Robert Koch-Institute in Germany in 2009. Finally, the cost and prevalence data were used to calculate the direct costs for each educational level. RESULTS: The direct costs of DM amount to about 13.1 billion € per year; about 35% of these costs can be attributed to patients with a low educational level. Thus, their share of the total costs is about 67% higher than their share of the total population. If the prevalence in the group with 'low educational level' (14.8%) could be reduced to the prevalence in the group with 'middle educational level' (7.9%), this would save about 2.2 billion (about 16.5%) € of direct costs. DISCUSSION: The analysis provides a first estimate of the potential savings from an effective status specific prevention programme. However, the direct costs per patient used were only an average for all people with DM, as a breakdown by educational level was not available. Since education can also affect health behaviour and compliance, which are also determinants of cost, the analyses presented here are probably conservative.

[Identification of city areas with an urgent need for early help in Munich: presentation of a new procedure on the basis of data on regional social structures and on the health risks of newborn babies]. / Ermittlung von Stadtgebieten mit hohem Bedarf an Frühen Hilfen in München: Vorstellung eines neuen Verfahrens auf Basis von Daten zur regionalen Sozialstruktur und zum gesundheitlichen Risiko von Neugeborenen.

BACKGROUND: In Germany, it is forbidden by law to physically punish children or to harm them mentally. Breaking these rules can result in severe health problems for the children. Home visiting programmes for families with young children are aimed at supporting young families who are facing large social problems, and at enhancing the chances of their children to grow up in a healthy way. Maps showing the regional distribution of the need for these home visiting programmes could be an important tool for local health policy planning. They could help to focus the resources on those families who are in greatest need. METHODS: The method proposed here for developing such a regional map is based on the following steps: (a) search for data that indicate the potential for child neglect, maltreatment or abuse, and that are available for each zip code in the city of Munich, Germany; (b) based on these data, calculation of a summary score that could indicate high need for these home visits; (c) grouping of the zip code areas according to this score; (d) presentation of the regional distribution in a map. RESULTS: After inspecting different data sources, we could identify 5 variables that could indicate the need for these home visits and that are available for each zip code: index of purchasing power, percentage of the population with low education, percentage of the population with migration background, percentage of single mothers, percentage of new-borns with low birth weight (<2 500 g). If 'high need' is defined as 'upper quintile of at least 3 among the 5 variables listed above, about 1 087 newborn babies would have to be visited per year (i. e., 10% of all newborn infants in Munich). CONCLUSION: These home visits should be as little stigmatising as possible, and especially those families should be reached that are in greatest need. If it is not possible to reach all families in the community, it can be recommended to focus on city districts with a high percentage of families in greatest need. As far as we know, this is the first scientifically based method for such a definition of city districts. The method proposed here could serve as starting point, and it would be important to develop it further. It is very flexible, though, and it can easily be transferred to other cities or districts.

The impact of regional deprivation and individual socio-economic status on the prevalence of Type 2 diabetes in Germany. A pooled analysis of five population-based studies.

AIM: Our objective was to test the hypothesis that the prevalence of Type 2 diabetes increases with increasing regional deprivation even after controlling for individual socio-economic status. METHODS: We pooled cross-sectional data from five German population-based studies. The data set contained information on n = 11,688 study participants (men 50.1%) aged 45-74 years, of whom 1008 people had prevalent Type 2 diabetes (men 56.2%). Logistic multilevel regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI) for diabetes prevalence. We controlled for sex, age and lifestyle risk factors, individual socio-economic status and regional deprivation, based on a new small-area deprivation measure, the German Index of Multiple Deprivation. RESULTS: Adjusted for sex, age, body mass index (BMI), physical activity, smoking status and alcohol consumption, the prevalence of Type 2 diabetes showed a stepwise increase in risk with increasing area deprivation [OR 1.88 (95% CI 1.16-3.04) in quintile 4 and OR 2.14 (95% CI 1.29-3.55) in quintile 5 compared with the least deprived quintile 1], even after controlling for individual socio-economic status. Focusing on individual socio-economic status alone, the risk of having diabetes was significantly higher for low compared with medium or high educational level [OR 1.46 (95% CI 1.24-1.71)] and for the lowest compared with the highest income group [OR 1.53 (95% CI 1.18-1.99)]. CONCLUSION: Regional deprivation plays a significant part in the explanation of diabetes prevalence in Germany independently of individual socio-economic status. The results of the present study could help to target public health measures in deprived regions.

[Inequalities in health risks, morbidity and health care of children by health insurance of their parents (statutory vs. private health insurance): results of the German KiGGS study]. / Unterschiede bei Gesundheitsrisiken, Morbidität und gesundheitlicher Versorgung zwischen Kindern GKV- bzw. PKV-versicherter Eltern: Ergebnisse aus dem Kinder- und Jugendgesundheitssurvey (KiGGS).

AIM OF THE STUDY: In Germany, differences in health risks, morbidity and health care between children whose parents are insured either in the statutory or in the private health insurance (in German: GKV or PKV respectively) have rarely been studied. Recent studies have shown that adults who are insured in the GKV tend to be less healthy and tend to seek primary health care more frequently than those who are insured in the PKV. The study presented here focuses on the hypothesis that similar inequalities also exist between their children. METHODS: The analyses are based on data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), i.e., a large and representative study (n=17,641; response rate: 66.6%) conducted 2003/2006. 3 groups of outcome variables are distinguished: health risks (e.g., smoking, breast-feeding), morbidity (e.g., self-rated health, psychological well-being) and health care (e.g., utilization of primary care physicians and of preventive services). First, bivariate associations between health insurance (GKV vs. PKV) and outcomes were analysed by chi-square tests. Then, the significant associations were tested further in logistic regression models including other variables such as age, sex, national origin and socioeconomic status (SES). We also included analyses stratified by sex and SES. RESULTS: The bivariate analyses show that there are many significant differences between GKV- and PKV-insured children in terms of health risks, morbidity and health care. After controlling for the other variables in the logistic regression, most of these associations become statistically insignificant. Some remain significant, though, for example: Reduced breast-feeding is more common in the GKV group (OR=1.17; 95% CI 1.03 - 1.34), smoking is more prevalent in this group as well (OR=1.41; 95% CI 1.04 - 1.91), and GKV-insured children seek primary health care more frequently than PKV-insured (OR=1.27; 95% CI 1.05 - 1.54). CONCLUSION: Health risks are usually greater among GKV-insured children as compared with PKV-insured. Concerning morbidity, these differences can mainly be explained by differences in national origin and SES. Efforts aimed at reducing these health differences should therefore focus on risks associated with migration and low SES. In addition, differences concerning risk factors such as smoking could not be explained by differences in national origin and SES. Thus, there seems to be a general need for more preventive measures in the GKV (i.e., independent of national origin and SES).

[Impact of small-area context on health: proposing a conceptual model]. / Die Bedeutung des kleinräumigen Kontexts für Gesundheit: Entwurf eines Erklärungsmodells.

BACKGROUND: Recent empirical studies stress the impact of features related to the small-area context on individual health. However, so far there exists no standard explanatory model that integrates the different kinds of such features and that conceptualises their relation to individual characteristics of social inequality. METHODS: A review of theoretical publications on the relationship between social position and health as well as existing conceptual models for the impact of features related to the small-area context on health was undertaken. RESULTS: In the present article we propose a conceptual model for the health impact of the small-area context. This model conceptualises the location of residence as one dimension of social inequality that affects health through the resources as well as stressors which are inherent in the small-area context. CONCLUSION: The proposed conceptual model offers an orientation for future empirical studies and can serve as a basis for further discussions concerning the health relevance of the small-area context.

[Relevance of 'subjective social status' for health risks and health status - results from the KORA-F4-study]. / Einfluss des subjektiven Sozialstatus auf gesundheitliche Risiken und Gesundheitszustand - Ergebnisse der KORA-F4-Studie.

OBJECTIVES: In public health research, social status is usually assessed by objective indicators such as educational level and income. Recent studies have shown the importance of including 'subjective social status (SSS)'. The aim of this study is to analyse the influence of SSS on health for the first time in Germany, and to find out if there is an effect over and above the objective indicators of social status. METHODS: The KORA F4 study took place in 2006-2008 in the region of Augsburg, Southern Germany, with a study population of 3 080 men and women aged 32-81 years. SSS was assessed by a single question with 6 possible responses. For the analyses, 3 SSS categories were differentiated: low, middle and high. The following dependent variables were included: self-rated health (SRH), hypertension (uncontrolled), diabetes, metabolic syndrome, hay fever, no participation in medical cancer prevention, obesity (assessed by body mass index and waist-hip-ratio), smoking, physical inactivity. Logistic regression models were used to estimate the influence of SSS (e. g. adjusted for educational level and income). RESULTS: About 25% of the participants group themselves into the lowest SSS-category. Without adjustment for educational level and income, SSS is negatively associated with SRH, hypertension, diabetes, metabolic syndrome, obesity, no participation in medical cancer prevention, smoking and physical inactivity; as expected the association with hay fever is positive. After adjustment for educational level and income, not all of these associations remain significant. Some of the adjusted odds ratios (OR) for SSS differ considerably when stratified by gender, for example concerning the variable 'physical inactivity': The comparison of 'SSS low' vs. 'SSS high' shows for men OR 2.35 (95% confidence interval (CI) 1.57-3.50) and for women OR 3.58 (95% CI 2.34-5.47). CONCLUSION: The results from this study strongly suggest that SSS is an important indicator of social status (to date largely disregarded in public health research). Thus, SSS should be applied in addition to other indicators of social status such as educational level and income. The associations with SSS depend on the health indicator studied. Also, sometimes there are large differences when stratified by gender. Further research is needed to fully understand the determinants of SSS and its impact on health.

[Regional concentration of social disadvantage and of risks for lung cancer and colon cancer: systematic review and recommendations for research]. / Regionale Konzentration von sozialer Benachteiligung und von Risiken für Lungen- und Darmkrebs: Systematischer Review und Ableitung von Empfehlungen.

OBJECTIVES: Individual health status is influenced by individual social characteristics (age, gender, income usw.) and by the social characteristics of the regional environment in which the person lives. This is true also for lung cancer and colon cancer, two of the most common cancer sites in Germany. No systematic review about the social and regional distribution of lung cancer and colon cancer has been published in German-speaking countries yet. However, it could allow us to deepen the discussion regarding explanations of cancer risks and potential interventions. METHODS: Lung cancer and colon cancer have been selected because they are the two most common gender-independent cancer sites in Germany. A systematic literature search has been conducted via the Medline database using PubMed. 2 groups of regional differences have been distinguished, first by socio-economic characteristics (e. g., average household income) and second by urban vs. rural characteristics. The publications have then been analysed in a systematic way. RESULTS: 17 publications could be found, just 2 of them are from a German-speaking country (one each from Germany and Switzerland). The results concerning incidence and mortality can be summarised in the following way: The risks for lung cancer increase with decreasing socio-economic status of the region, but no clear association could be found for colon cancer. Some studies include information on urban-rural differences. They show that the risks for lung cancer are higher in urban as compared to rural areas; for colon cancer, again, no clear associations could be found. CONCLUSION: The review shows that some studies have already looked at social and regional differences in lung cancer and colon cancer, and that these associations have hardly been discussed in German-speaking countries as yet. We still do not know why lung cancer risks are especially high in low status regions, even if individual smoking is accounted for. The answer could probably be provided by risks such as air pollution. Therefore, a balanced strategy for reducing health inequalities should not just focus on improving individual health behaviour, but also on reducing the regional risks factors.

[Morbidity and healthcare differences between insured in the statutory ("GKV") and private health insurance ("PKV") in Germany. Review of empirical studies]. / Morbidität und Gesundheitsversorgung bei GKV- und PKV-Versicherten. Forschungsstand empirischer Studien.

BACKGROUND: It has rarely been analyzed whether there are differences in Germany concerning morbidity and healthcare between insured by statutory health insurance (Gesetzliche Krankenversicherung, GKV) and insured by private health insurance (Private Krankenversicherung, PKV). In addition, the available studies are very scattered and no review has been published yet. The study presented here aims at closing this gap and at discussing recommendations for future analyses. METHODS: By searching for publications in the Medline and PubMed databanks, only a very few studies could be identified in this manner Thus, our search was extended to include a number of German institutes and organizations working in the field of public health and health systems research. In addition, we checked all references listed in the relevant publications. RESULTS: A total of 18 relevant publications could be identified; however, just four of them were found via Medline and PubMed. The empirical analyses show that the GKV insured are often less healthy than the PKV insured, and that they more often go to primary care physicians. A potential disadvantage of GKV insured concerning healthcare can be seen in regard to new, innovative drugs, organ transplantations, financial burden due to co-payments, waiting times, and communication between patient and physician. CONCLUSION: Most studies show that there are large differences between GKV-insured and PKV-insured, concerning health status as well as healthcare. However, due to methodological weaknesses, some of these results are difficult to interpret. More studies focusing on specific age groups (e.g., children) are needed, and the methodological standard (e.g., statistical control for other factors such as income, distinction between different subgroups of insured) must also be raised. Finally, systematic differences between GKV and PKV should be considered in all analyses comparing these two schemes, such as differences in the availability of data concerning healthcare.

[Health status of adults in Germany: results from a representative survey using the EuroQol 5D (EQ-5D)]. / Gesundheitszustand bei Erwachsenen in Deutschland: Ergebnisse einer repräsentativen Befragung mit dem EuroQol 5D (EQ-5D).

OBJECTIVE OF THE STUDY: Over the past few years, the discussion on health-related quality of life (HRQL) has increased considerably in Germany as well. HRQL can be assessed by different dimensions of health, and it can be summarised by a single numerical value. This study intends to describe the HRQL of German adults based on individual valuations, to compare the results with those of an earlier study, to investigate the impact of using valuations based on given health states, and as an example of use to analyse socioeconomic differences using the EQ-5D. METHODS: The analyses are based on a representative survey in Germany, conducted by the Wort und Bild Verlag in 2006. HRQL has been assessed by the EuroQol 5D (EQ-5D). In the descriptive part, health was assessed by five descriptive questions. Next, valuations of overall health were elicitated from survey participants using a visual analogue scale (VAS) and, alternatively, taken from a different sample based on the time trade off (TTO) method. Five independent variables were included in the analysis: age, sex, educational level, per capita income, employment status. The results are compared with previous German evidence from the ESEMeD study. RESULTS: Data were retrieved from 1 966 persons (aged 20 years or above); the response rate was 73%. In the descriptive part of the EQ-5D, the prevalence of some problems was especially high in the dimension pain/discomfort (31.9%). In contrast, the prevalence of extreme problems was very low in all five dimensions. The mean VAS value was 79.2. Considering the five dimensions, the VAS values and the TTO score, HRQL was mostly higher for men than for women, and mostly higher for the upper educational groups (as compared with the lower educational groups). Very similar associations were found when the independent variables are mutually controlled for, in logistic regressions (dependent variables: five dimensions) as well as in linear regressions (dependent variables: VAS value or TTO score). The linear regressions also showed that HRQL increases with increasing per capita income. DISCUSSION: The EQ-5D provides a simple instrument for assessing HRQL. It can well detect health inequalities, and the results can be replicated in different studies. More research is needed on the techniques to valuate HRQL in population studies. The EQ-5D provides a tool to assess the HRQL of the German population. New reference figures have been presented for this, and it has been shown how health economic tools and research on health inequalities can be integrated.

[Social inequality in health care--a plea for systematic research]. / Soziale Ungleichheit in der gesundheitlichen Versorgung--Ein Plädoyer für systematische Forschung.

Inequalities in health care are often discussed in an undifferentiated way in Germany. Against this background, this article presents an analysis scheme for a classification of relevant studies and an identification of research needs. To this aim, areas of health care are differentiated (ambulant and inpatient care, prevention and health promotion) and a difference is made between access, utilization and quality of care. According to this scheme, research regarding inequalities in health care can be conducted in nine fields. For each field, exemplary results of a recent study from Germany are summarized. It becomes apparent that there is a substantial lack of systematic research in inequalities in health care in Germany.

[Social inequality and health care among the aged]. / Soziale Ungleichheit und gesundheitliche Versorgung im höheren Lebensalter.

In this article the association between social inequality and selected aspects of health care among the aged is analysed. Analyses are based on German data (release 1) of the 'Survey of Health, Ageing and Retirement in Europe' (SHARE) in 2004. Data from 1921 respondents aged 50 years or more are analysed. Three indicators of social inequality are used (education, income, and financial assets). In terms of health care, indicators of geriatric assessment by the general practitioner of the respondent (questions about balance, physical exercise, and drugs as well as examination of balance and weight control) and secondary prevention (mammogram, endoscopic examination of colon, eye examination) are included. Results of cross-tabs and logistic regression analyses show that geriatric assessment is less comprehensive among people in a comparatively high socioeconomic position. On the other hand, people in a higher socioeconomic position use screening examinations more often than those in a lower position. Inconsistency of results indicates the necessity to distinguish different areas of health care when analysing social inequalities. Moreover, results indicate that no simple answer can be given to the question whether and to what extent social inequalities in health among older people can be explained by inequalities in medical care.

[Cancer screening for women is less frequently visited in regions with lower household income--analysis of data from health insurances in Bavaria]. / Die Krebsfrüherkennungsuntersuchung für Frauen wird in Regionen mit niedrigerem Haushaltseinkommen seltener in Anspruch genommen--Analyse von Daten der Kassenärztlichen Vereinigung Bayerns.

AIM OF THE STUDY: Differences in health care in Germany have rarely been analysed. Recent research, however, indicates that subjects of the lower social class participate in cancer screening less frequently. METHODS: Participation in screening for cervical cancer among women older than 20 years has been analysed using billing information of the KVB (Kassenärztlichen Vereinigung Bayern) for the period from 2002-2005. Women were assigned to one of the 96 Bavarian districts based on their postal code. The following variables were used: Participation rate in cervical cancer screening; age; average household income; gynaecologists per 10,000 women. Multivariate analyses were based on age-stratified linear regressions. RESULTS: There are considerable regional differences in participation in screening for cancer among older women. Participation rates are lower in districts with lower average household income. The correlation between participation rates and average household income shows an almost linear dependence on the level of districts. This association could not be explained by the variable "gynaecologists per 10,000 women". CONCLUSION: In order to provide social equality in health care, regional differences in cancer screening participation should be targeted. This is especially important in districts with lower average household incomes.

[Health inequalities in Germany: the international perspective]. / Soziale Ungleichheit und Gesundheit in Deutschland : Die internationale Perspektive.

In recent years, a lively discussion has developed in Germany concerning health inequalities. The international perspective has however been largely neglected. Two questions are important: Are health inequalities in Germany as large as in the other Western European countries? What topics and initiatives are of major importance if the scope is expanded to countries outside of Western Europe? Some studies have been published that could contribute to an answer to the first question. This information is very scattered, though, and it has not been reviewed yet in a systematic manner. The overview presented here shows that health inequalities in Germany are about as large as in the other Western European countries. Looking at health inequalities on a more global scale, it can be seen, for example, how the scientific community is trying to place more emphasis on the large differences between rich and poor countries.