The role of sociodemographic, psychosocial, and behavioral factors in the use of preventive healthcare services in children and adolescents: results of the KiGGS Wave 2 study.

BACKGROUND: In Germany, various preventive services are offered to children and adolescents. These include regular standardized examinations (so called U/J examinations) and several vaccinations. Although strongly recommended, most of them are not mandatory. Our aim is to identify factors associated with the use of U/J examinations and vaccination against diphtheria, hepatitis B, Hib, pertussis, polio, and tetanus. While previous research has focused on sociodemographic factors, we also include socioeconomic, behavioral, and psychosocial factors. METHODS: We analyzed cross-sectional data from 15,023 participants (aged 0-17 years) of the nationwide representative KiGGS Wave 2 Survey. Participation in U/J examinations was assessed using a questionnaire, filled out by participants and/or their parents. Information on vaccination status was drawn from the participants' vaccination booklets. To identify relevant determinants for the use of preventive examinations and vaccinations, unadjusted and adjusted logistic regression models were employed with up to 16 different independent variables. RESULTS: Various independent variables showed an association with the use of preventive services. Higher socioeconomic status, absence of migration background, and lower household size were associated with significantly higher utilization of U examinations. Parents' marital status, area of residence, behavioral and psychosocial factors yielded insignificant results for most U/J examinations. Higher vaccination rates were found for children with no migration background, with residence in eastern Germany, lower household size, and with married parents. CONCLUSION: This study attempted to depict the influence of sociodemographic, psychosocial, and behavioral factors on the use of several preventive services. Our results indicate that predominantly sociodemographic variables influence the use of preventive services. Further efforts should be made to investigate the interplay of different determinants of healthcare use in children and adolescents.

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.

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

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

Social inequalities in early childhood language development during the COVID-19 pandemic: a descriptive study with data from three consecutive school entry surveys in Germany.

BACKGROUND: Social health inequalities are still of great public health importance in modern societies. The COVID-19 pandemic may have affected social inequalities in people's health due to containment measures. As these measures particularly affected children, they might have been particularly vulnerable to increased social inequalities. The aim of the study was to describe health inequalities during the pandemic based on language delay (LD) in children in order to inform public health interventions for a population at risk of long-term health and education inequalities. METHODS: Data of 5-7 year old children from three consecutive school entry surveys in the German federal state of Brandenburg were used, including data compulsorily collected before the pandemic (2018/2019: n = 19,299), at the beginning of the pandemic (2019/2020: n = 19,916) and during the pandemic (2020/2021: n = 19,698). Bivariate and multivariate binary regression analyses [OR, 95% CI] cross-sectionally examined the relationship between the prevalence of LD [yes/no] and social inequalities, operationalized by family socioeconomic position [SEP low/middle/high], migration background [native-German language/non-native German language] and length of kindergarten attendance [< 4 years/ ≥ 4 years]. Factors contributing to inequality in LD were examined by socioeconomic stratification. RESULTS: Cross-sectionally, LD prevalence has decreased overall (2018/2019: 21.1%, 2019/2020: 19.2%, 2020/2021: 18.8%), and among children from both high SEP and native German-speaking families. As LD prevalence increased among children from families with low SEP and remained stable among non-native German speakers, social inequalities in LD prevalence increased slightly during the pandemic i) by low SEP (2018/2019: OR = 4.41, 3.93-4.94; 2020/2021: OR = 5.12, 4.54-5.77) and ii) by non-German native language (2018/2019: OR = 2.22, 1.86-2.66; 2020/2021: OR = 2.54, 2.19-2.95). During the pandemic, both migration background and kindergarten attendance determined LD prevalence in the high and middle SEP strata. However, the measured factors did not contribute to LD prevalence in children from families with low SEP. CONCLUSION: Social inequalities in LD increased due to opposing trends in prevalence comparing low and high SEP families. To promote health equity across the life course, early childhood should be of interest for tailored public health actions (e.g. through targeted interventions for kindergarten groups). Further analytical studies should investigate determinants (e.g., parental investment).

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

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

[Life course epidemiology in migrant health research]. / Lebenslauforientierte Epidemiologie in der Migrationsforschung.

From free choice to forced flight, there are many reasons for migration. Accordingly, the backgrounds and living conditions of migrating people are also diverse. The different associated exposures affect the health of migrants and their children. To capture such a complex phenomenon, an approach is required that takes specific living conditions during the life course of migrants into account.An established methodological approach that can accomplish this is life course epidemiology. When applied to migrating populations, it examines exposures before, during, and after migration. In epidemiological research on the health of migrant populations, it is desirable to consider all three phases. This is countered by the fact that reliable data on the entire life course is not always available.A valid, timely collection and data protection-compliant linkage of longitudinal data from different sources can improve life course-related research on the health of migrants in Germany. In the future, corresponding data should also be included from the countries of origin of migrants.

Evaluating Interoperability in German Critical Incident Reporting Systems.

INTRODUCTION: In industrialised countries, one in ten patients suffers harm during hospitalization. Critical Incident Reporting Systems (CIRS) aim to minimize this by learning from errors and identifying potential risks. However, a lack of interoperability among the 16 CIRS in Germany hampers their effectiveness. METHODS: This study investigates reports' syntactic and semantic interoperability across seven different reporting systems. Syntactic interoperability was examined using WHO's Minimal Information Models (MIM), while semantic interoperability was evaluated with SNOMED concepts. RESULTS: The findings reveal a low structural overlap, with only two terms correctly represented in the SNOMED CT terminology. In addition, most systems showed no syntactic interoperability. CONCLUSION: Improving interoperability is essential for increasing the effectiveness and usability of CIRS. The study suggests a unified data model such as MIM or using Health Level 7 Fast Healthcare Interoperability Resources (HL7 FHIR) resources and expanding SNOMED CT with patient safety-relevant terms for semantic interoperability. Given the current lack of both syntactic and semantic interoperability in CIRS, developing a patient safety ontology is recommended for efficient critical incident analysis too.

Do family characteristics contribute to a socioeconomic gradient in overweight in early childhood? - Single mediation analyses of data from German preschool children.

Children's overweight is strongly associated with family socioeconomic position (SEP) and family characteristics (FC). There is limited research on the extent to which FC account for a socioeconomic gradient in childhood overweight. This study examined whether FC explain SEP differences in the prevalence of overweight. The study used baseline data of preschool-aged children from the German 'PReschool INtervention Study'. The sample (n = 872, 48% girls) was recruited at kindergartens in Baden-Württemberg, Germany. Data included children's measured weight status and parents' reports on socioeconomic indicators (e.g., school education, vocational education, income) and FC. Variables represent main determinants of overweight (nutrition: sweets consumption in front of TV, soft drink consumption, regular breakfast, child sets table; physical activity: outdoor sports; parental role model). In single mediation analyses indirect effects of SEP on overweight were analysed (OR[95%CI]). Preschool girls and boys with low parental education had higher odds for overweight than children with high parental education. Among boys, low levels of parental education contributed to the odds of overweight via indirect effects by both factors 'sweets consumption in front of TV' (OR = 1.31[1.05-1.59]) and 'no sports' (OR = 1.14[1.01-1.38]). Among girls, FC measured did not explain SEP differences in overweight. Family nutrition and parental/family physical activity contribute to inequalities in overweight among preschool boys, but not girls. Research is needed to identify FC that explain inequalities in overweight for both.

Self-rated health of university students in Germany-The importance of material, psychosocial, and behavioral factors and the parental socio-economic status.

Introduction: Health inequalities start early in life. The time of young adulthood, between late teens and early twenties, is especially interesting in this regard. This time of emerging adulthood, the transition from being a child to becoming an adult, is characterized by the detachment from parents and establishing of an own independent life. From a health inequality perspective, the question about the importance of the socio-economic background of parents is important. University students are an especially interesting group. Many students come from a privileged background and the question of health inequality among university students has not yet been properly studied. Methods: Based on the National Educational Panel Study (NEPS), we analyzed health inequalities among 9,000 students in Germany (∅ 20 years in the first year of their studies) over a period of 8 years. Results: We found that most university students (92%) in Germany reported a good and very good health. Yet, we still found substantial health inequalities. Students whose parents had a higher occupational status reported less health problems. Additionally, we observed that health inequalities had indirect impact on health via health behavior, psychosocial resources, and material conditions. Discussion: We believe our study is an important contribution to the understudied subject of students' health. We see the impact of social inequality on health among such a privileged group like university students as an important sign of the importance of health inequality.

[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.

Diurnal cortisol variation during pregnancy in Turkish origin and non-migrant women in a German birth cohort study.

BACKGROUND: Immigrants from Turkey experience health disadvantages relative to non-immigrant populations in Germany that are manifest from the earliest stages of the lifespan onwards and are perpetuated across generations. Chronic stress and perturbations of stress-responsive physiological systems, including the hypothalamus-pituitary-adrenal (HPA)-axis, are believed to in part mediate this relationship. Cortisol plays an important role in the association between maternal stress during pregnancy and many pregnancy-, birth- and offspring-related outcomes. We therefore examined whether maternal migrant background is associated with diurnal cortisol variation during pregnancy. METHODS: 109 pregnant women (incl. n = 32 Turkish origin women) that participated in a multi-site prospective cohort study in Germany collected saliva samples across the day on two consecutive days around 24 and 32 weeks gestation. Hierarchical linear models were applied to quantify associations between migrant background and diurnal cortisol variation across pregnancy. RESULTS: Women of Turkish origin exhibited a significantly lower cortisol awakening response (CAR) and a flatter diurnal cortisol slope (DCS) compared to non-migrant women after adjusting for household income. These relationships between migrant status and diurnal cortisol variation were mainly driven by 2nd generation migrants. DISCUSSION: A potential HPA axis dysregulation of Turkish-origin pregnant women may contribute to the intergenerational transmission of health disadvantages in this group.

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.

Association of regional socioeconomic deprivation and rurality with global developmental delay in early childhood: Data from mandatory school entry examinations in Germany.

BACKGROUND: From birth to young adulthood, health and development of young people are strongly linked to their living situation, including their family's socioeconomic position (SEP) and living environment. The impact of regional characteristics on development in early childhood beyond family SEP has been rarely investigated. This study aimed to identify regional predictors of global developmental delay at school entry taking family SEP into consideration. METHOD: We used representative, population-based data from mandatory school entry examinations of the German federal state of Brandenburg in 2018/2019 with n=22,801 preschool children. By applying binary multilevel models, we hierarchically analyzed the effect of regional deprivation defined by the German Index of Socioeconomic Deprivation (GISD) and rurality operationalized as inverted population density of the children's school district on global developmental delay (GDD) while adjusting for family SEP (low, medium and high). RESULTS: Family SEP was significantly and strongly linked to GDD. Children with the highest family SEP showed a lower odds for GDD compared to a medium SEP (female: OR=4.26, male: OR=3.46) and low SEP (female: OR=16.58, male: OR=12.79). Furthermore, we discovered a smaller, but additional and independent effect of regional socioeconomic deprivation on GDD, with a higher odds for children from a more deprived school district (female: OR=1.35, male: OR=1.20). However, rurality did not show a significant link to GDD in preschool children beyond family SEP and regional deprivation. CONCLUSION: Family SEP and regional deprivation are risk factors for child development and of particular interest to promote health of children in early childhood and over the life course.

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).

Moderating or mediating effects of family characteristics on socioeconomic inequalities in child health in high-income countries - a scoping review.

BACKGROUND: By explaining the development of health inequalities, eco-social theories highlight the importance of social environments that children are embedded in. The most important environment during early childhood is the family, as it profoundly influences children's health through various characteristics. These include family processes, family structure/size, and living conditions, and are closely linked to the socioeconomic position (SEP) of the family. Although it is known that the SEP contributes to health inequalities in early childhood, the effects of family characteristics on health inequalities remain unclear. The objective of this scoping review is to synthesise existing research on the mediating and moderating effects of family characteristics on socioeconomic health inequalities (HI) during early childhood in high-income countries. METHODS: This review followed the methodology of "Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews". To identify German and English scientific peer-reviewed literature published from January 1st, 2000, to December 19th, 2019, the following search term blocks were linked with the logical operator "AND": (1) family structure/size, processes, living conditions, (2) inequalities, disparities, diversities, (3) income, education, occupation, (4) health and (5) young children. The search covered the electronic databases PubMed, PsycINFO, and Scopus. RESULTS: The search yielded 7,089 records. After title/abstract and full-text screening, only ten peer-reviewed articles were included in the synthesis, which analysed the effects of family characteristics on HI in early childhood. Family processes (i.e., rules /descriptive norms, stress, parental screen time, parent-child conflicts) are identified to have mediating or moderating effects. While families' living conditions (i.e., TVs in children's bedrooms) are suggested as mediating factors, family structure/size (i.e., single parenthood, number of children in the household) appear to moderate health inequalities. CONCLUSION: Family characteristics contribute to health inequalities in early childhood. The results provide overall support of models of family stress and family investment. However, knowledge gaps remain regarding the role of family health literacy, regarding a wide range of children's health outcomes (e.g., oral health, inflammation parameters, weight, and height), and the development of health inequalities over the life course starting at birth.

Role of contextual and compositional characteristics of schools for health inequalities in childhood and adolescence: a scoping review.

OBJECTIVES: To synthesise the evidence on the role of compositional or contextual characteristics of schools in the association between students' socioeconomic position and their health in primary and secondary education in developed economies. DESIGN: Scoping review. We included studies examining the role of at least one school or class characteristic on students' health inequalities and was published since 1 January 2000, in English or German. We searched PubMed/Medline, Web of Science and Education Resources Information Center. We provided a narrative synthesis and an overview of findings. School characteristics were grouped into five broad categories: school composition, school climate, school policies and organisation, food environment and facilities. RESULTS: Of 8520 records identified, 26 studies were included. Twelve studies found a moderating and 3 a mediating effect. The strongest evidence came from studies examining the moderating effect of school composition, that is, the negative impact of a low individual socioeconomic position on mental health and well-being was aggravated by a low average socioeconomic position of schools. Evidence concerning the role of school climate, school stratification (eg, performance base tracking) and sponsorship, food environment and sport facilities and equipment was generally weak or very weak and mostly based on singular findings. Overall, favourable meso-level characteristics mitigated the negative impact of low individual socioeconomic position on health outcomes. CONCLUSIONS: School characteristics affect health inequalities in children and adolescents to some degree, but future research is necessary to strengthen the existing evidence and address under-represented aspects in school characteristics and health outcomes.

Health Inequalities in Children and Adolescents: A Scoping Review of the Mediating and Moderating Effects of Family Characteristics.

This scoping review systematically mapped evidence of the mediating and moderating effects of family characteristics on health inequalities in school-aged children and adolescents (6-18 years) in countries with developed economies in Europe and North America. We conducted a systematic scoping review following the PRISMA extension for Scoping Reviews recommendations. We searched the PubMed, PsycINFO and Scopus databases. Two reviewers independently screened titles, abstracts and full texts. Evidence was synthesized narratively. Of the 12,403 records initially identified, 50 articles were included in the synthesis. The included studies were conducted in the United States (n = 27), Europe (n = 18), Canada (n = 3), or in multiple countries combined (n = 2). We found that mental health was the most frequently assessed health outcome. The included studies reported that different family characteristics mediated or moderated health inequalities. Parental mental health, parenting practices, and parent-child-relationships were most frequently examined, and were found to be important mediating or moderating factors. In addition, family conflict and distress were relevant family characteristics. Future research should integrate additional health outcomes besides mental health, and attempt to integrate the complexity of families. The family characteristics identified in this review represent potential starting points for reducing health inequalities in childhood and adolescence.

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.

A method to define the relevant ego-centred spatial scale for the assessment of neighbourhood effects: the example of cardiovascular risk factors.

INTRODUCTION: The neighbourhood in which one lives affects health through complex pathways not yet fully understood. A way to move forward in assessing these pathways direction is to explore the spatial structure of health phenomena to generate hypotheses and examine whether the neighbourhood characteristics are able to explain this spatial structure. We compare the spatial structure of two cardiovascular disease risk factors in three European urban areas, thus assessing if a non-measured neighbourhood effect or spatial processes is present by either modelling the correlation structure at individual level or by estimating the intra-class correlation within administrative units. METHODS: Data from three independent studies (RECORD, DHS and BaBi), covering each a European urban area, are used. The characteristics of the spatial correlation structure of cardiovascular risk factors (BMI and systolic blood pressure) adjusted for age, sex, educational attainment and income are estimated by fitting an exponential model to the semi-variogram based on the geo-coordinates of places of residence. For comparison purposes, a random effect model is also fitted to estimate the intra-class correlation within administrative units. We then discuss the benefits of modelling the correlation structure to evaluate the presence of unmeasured spatial effects on health. RESULTS: BMI and blood pressure are consistently found to be spatially structured across the studies, the spatial correlation structures being stronger for BMI. Eight to 22% of the variability in BMI were spatially structured with radii ranging from 100 to 240 m (range). Only a small part of the correlation of residuals was explained by adjusting for the correlation within administrative units (from 0 to 4 percentage points). DISCUSSION: The individual spatial correlation approach provides much stronger evidence of spatial effects than the multilevel approach even for small administrative units. Spatial correlation structure offers new possibilities to assess the relevant spatial scale for health. Stronger correlation structure seen for BMI may be due to neighbourhood socioeconomic conditions and processes like social norms at work in the immediate neighbourhood.

Association of maternal migrant background with inflammation during pregnancy - Results of a birth cohort study in Germany.

BACKGROUND: Health disparities in children of immigrants are prevalent from birth and are hypothesized to - in part - emerge as a biological consequence of migration's unfavorable social and psychological sequelae. The aim of this study was to examine whether maternal migrant background is associated with inflammation during pregnancy - a key pathway by which maternal states and conditions during pregnancy may influence fetal development and subsequent pregnancy, birth, and child developmental and health outcomes. MATERIAL AND METHODS: Data was available from 126 pregnant women who participated in a population based multi-site prospective birth cohort study in Bielefeld and Berlin, Germany. The study included two study visits in mid- and late pregnancy. At each visit, a composite maternal pro-inflammatory score was derived from circulating levels of plasma inflammatory markers (IL-6, CRP). Migrant background was defined by country of origin of participants and their parents' (Turkey or other) and generation status (1st or 2nd generation). We applied hierarchical linear models (HLM) in order to quantify the relationship between different migrant background variables and inflammation during pregnancy after adjustment for potential confounders (including socioeconomic status). RESULTS: Migrant background was significantly associated with inflammation during pregnancy. When compared to women without migrant background, levels of inflammation were increased in 1) pregnant women with migrant background in general (B = 0.35, SE = 0.12, p < .01); 2) 1st (B = 0.28, SE = 0.15, p < .10) and 2nd generation (B = 0.40, SE = 0.15, p < .01); 3) women with a Turkish migrant background (B = 0.28, SE = 0.14, p < .10) and women with another migrant background (B = 0.42, SE = 0.15, p < .01); and 4) 2nd generation Turkish origin women (B = 0.38, SE = 0.20, p < .10), 1st generation women with other migrant background (B = 0.44, SE = 0.26, p < .10), and 2nd generation women with other migrant background (B = 0.43, SE = 0.17, p < .05). DISCUSSION: Our findings support a role for maternal inflammation as a pathway of intergenerational transmission of migration-related health inequalities, suggest that the effect seems to persist in 2nd generation immigrants, and highlight the need for future research and targeted interventions in this context.