Childhood and adolescence factors and multiple sclerosis: results from the German National Cohort (NAKO).

BACKGROUND: Multiple Sclerosis (MS) represents the most common inflammatory neurological disease causing disability in early adulthood. Childhood and adolescence factors might be of relevance in the development of MS. We aimed to investigate the association between various factors (e.g., prematurity, breastfeeding, daycare attendance, weight history) and MS risk. METHODS: Data from the baseline assessment of the German National Cohort (NAKO) were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the association between childhood and adolescence factors and risk of MS. Analyses stratified by sex were conducted. RESULTS: Among a total of 204,273 participants, 858 reported an MS diagnosis. Male sex was associated with a decreased MS risk (HR 0.48; 95% CI 0.41-0.56), while overweight (HR 2.03; 95% CI 1.41-2.94) and obesity (HR 1.89; 95% CI 1.02-3.48) at 18 years of age compared to normal weight were associated with increased MS risk. Having been breastfed for ≤ 4 months was associated with a decreased MS risk in men (HR 0.59; 95% CI 0.40-0.86) compared to no breastfeeding. No association with MS risk was observed for the remaining factors. CONCLUSIONS: Apart from overweight and obesity at the age of 18 years, we did not observe considerable associations with MS risk. The proportion of cases that can be explained by childhood and adolescence factors examined in this study was low. Further investigations of the association between the onset of overweight and obesity in childhood and adolescence and its interaction with physical activity and MS risk seem worthwhile.

Compassionate Othering: the construction of refugee patients in medical students' narratives - a qualitative study using story completion.

BACKGROUND: Refugees remain a marginalized population and are exposed to a variety of discriminatory processes, among them Othering which categorizes people as belonging or not-belonging according to certain ascribed characteristics. We explored how the narrative construction of refugee patients by medical students constitutes a form of Othering. METHODS: Using story completion, 124 5th year medical students at the Martin- Luther- University Halle-Wittenberg in October 2019 wrote a fictional story in response to a story stem situated in a medical practice. In a comparative approach, one patient presenting with abdominal pain lacks further characterization (version A) and the other is a refugee (version B). The stories were coded using qualitative content analysis by Mayring with a focus on content and narrative strategies (plot structure and perspective). RESULTS: We identified four themes: characters, medical condition, access to care and provision of substandard care. The stories were predominantly framed with a medical or an interaction-based plot structure and written from a process-oriented perspective. The themes in version B, supported by their use of narrative strategies, were largely contextualized within the patients' history of migration. An empathic depiction of patient B and the students' compassion for the patients facing substandard care were key motifs as well. CONCLUSION: The perception of the version B patients predominantly as refugees establishes their construction as an Other. The students' compassion acts as a representation of societal inequalities and remains an inept response without the tools to counter underlying discriminatory structures. Based on a discourse of deservingness, compassion alone therefore perpetuates Othering and highlights the need for structural competency training in medical school.

[Management Of Covid-19 Pandemic In Shelters For Asylum Seekers: Results From A Mixed Methods Study.] / Pandemie-Management in Unterkünften für Geflüchtete ­ Ergebnisse einer mixed methods-Studie während der COVID-19-Pandemie.

BACKGROUND: Refugees in Germany are often housed in shelters, where their influence on the organization of everyday life is severely limited. During the COVID-19 pandemic, these shelters therefore had a special responsibility to take measures to protect the health of their residents. The aim of this research project was to examine how this task was managed and how the pandemic affected daily life in refugee shelters, with the aim to formulate recommendations for practice. METHODS: Using a mixed-methods study, the first step was a scoping review of the literature on the management of infectious disease outbreaks in refugee shelters. Building on the findings of the review, management of the pandemic was then explored in an online survey and in interviews with experts and residents of shelters. In a third step, the results of the preceding steps were summarized and discussed with a panel of experts. Recommendations for practice were developed with the expert panel in two discussion rounds two months apart. RESULTS: The refugee shelters included in the study were inadequately prepared for the pandemic and often did not develop contingency plans until the pandemic was underway. In many cases, the contingency plans included the establishment of crisis teams, but the interests and perspectives of facility residents were generally not represented by these teams. This subsequently led to problems: Pandemic measures were often not communicated in a timely or sufficiently understandable manner, gaps in care resulting from measures were not identified or addressed, and psychosocial stresses associated with the pandemic and quarantine measures were not adequately mitigated. CONCLUSION: • Refugee shelters should establish mechanisms to integrate residents' interests and perspectives into decision-making processes in a structured manner, regardless of the pandemic.• Depending on the type of shelter, this should be realized through resident involvement in decision-making bodies or other appropriate representation of interests. • Measures introduced during the pandemic that may have a negative impact on the psychosocial situation of residents should be terminated as soon as the epidemic justification for the measures no longer applies.

Increasing social disparities in obesity among 15 000 pre-schoolers in a German district from 2009 to 2019.

BACKGROUND: Although childhood obesity prevalence has stagnated in many high-income regions after decades of increase, it continues to be a major public health problem with adverse effects. The objective was to examine obesity trends as a function of parental social status to identify obesity disparities among children. METHODS: Data from school entry examinations from 2009 to 2019 of 14 952 pre-schoolers in one German district were used. Logistic regression models (obesity/overweight as dependent variable) and a linear regression [BMI z-score (BMIz) as dependent variable] were performed adjusted for social status and sex to investigate time trends in overweight and obesity. RESULTS: Overall, we found an increase of obesity over time [odds ratio (ORs): 1.03 per year, 95% CI: 1.01-1.06]. Children with low social status had an OR of 1.08 per year (95% CI: 1.03-1.13), while the trend was less expressed in children with high social status (OR: 1.03 per year, 95% CI: 0.98-1.08). The mean BMIz decreased per year (regression coefficient -0.005 per year, 95% CI: -0.01 to 0.0) when considering all children. This decrease was more pronounced in children with high social status (regression coefficient: -0.011 per year, 95% CI: -0.019 to -0.004), compared with a slight increase of 0.014 (95% CI: -0.003 to 0.03) per year among children with low social status. Also, children with low parental social status were heavier and smaller than their peers with high social status. CONCLUSIONS: Although the mean BMIz decreased among pre-schoolers, obesity prevalence and status-related inequity in obesity prevalence increased from 2009 to 2019 in the region studied.

[Determinants of asylum seekers' health and medical care in Germany]. / Determinanten der Gesundheit und medizinischen Versorgung von Asylsuchenden in Deutschland.

Asylum seekers in Germany are exposed to a variety of health-related stressors, while their access to medical care is impaired. This review explains some of the determinants that structure this situation, for example by elaborating on how the Asylum Seekers' Benefits Act (ASBA), billing via treatment vouchers, and accommodation in refugee shelters affect asylum seekers' health and healthcare utilization. Hereby, it becomes clear that the exclusion of asylum seekers from the welfare system is detrimental to their health, is expensive, and raises ethical and legal questions. In particular, the huge discretionary scope of the social welfare offices in the assumption of costs as well as the different models for billing medical services for asylum seekers are potentially unjust and lead to a plurality of care, which lacks legal and ethical justification.The second part of the article shows that asylum seekers generally suffer from the same health problems as people with statutory health insurance-with the exception of mental illnesses, which are substantially more common among asylum seekers, but are often undiagnosed and frequently inadequately treated.This leads to three practical conclusions: (1) asylum seekers should be integrated into statutory health insurance, (2) from a public health point of view, accommodation in refugee shelters should be avoided in favor of decentralized accommodation, and (3) to ensure diversity-sensitive care for all patients, the healthcare system must make adjustments to its structures and practices.

[The Migration and Health Teaching Network: consolidating and developing education and training]. / Das Lehrnetzwerk Migration und Gesundheit: Aus- und Weiterbildung konsolidieren und weiterentwickeln.

Patients with migration history often encounter barriers to accessing healthcare in Germany, which lowers the quality of care available to them and can affect their overall health. These barriers in access to healthcare are due to both adverse health policies and a lack of migration-related - and diversity-sensitive - content in medical and other health profession teaching. Although most healthcare professionals regularly care for patients with individual or generational migration experience in Germany, teaching content relevant to the healthcare of these patients has not yet been anchored in the curriculum. At best, it is taught in the form of electives or other optional courses.To address this gap, the Teaching Network Migration and Health was created with the goal of promoting the development of human rights-based, diversity-sensitive, and equity-oriented curricula at medical and healthcare professions schools. It aims to (1) connect individuals active in teaching and promote the exchange and collaborative development of teaching materials, (2) use this collective knowledge and experience to develop a model course on migration and health, and (3) develop strategies for the longitudinal implementation of this course into the regular medical and other health professional school curricula. These efforts are flanked by evaluative accompanying research. Anyone interested in joining the network is invited to join and strengthen the network by contacting the authors.

Breast cancer morbidity and mortality in rural Ethiopia: data from 788 verbal autopsies.

INTRODUCTION: In Ethiopia, breast cancer is the leading cause of cancer among women. Little is known about the duration of disease and symptoms of patients who died from breast cancer in rural Ethiopia. The objective of this study was to assess breast cancer mortality with a particular focus on the self-reported duration of illness including suffering of symptoms, and need for medical care. METHODS: The cause of death was determined among randomly selected Ethiopian women residing in western Ethiopia. A modified standard verbal autopsy (VA) questionnaire was completed by women whose sisters had died. The questionnaires were reviewed by two independent local physicians to assign a cause of death. We analyzed pattern of cause of deaths, duration of suffering, symptoms, and treatment received. RESULT: In our study, the age at death was very similar to other population-based data from Ethiopia. We found 32% of 788 deaths were caused by communicable diseases, 12.1% by neoplasms, and 9.4% by pregnancy/maternal mortality. Breast cancer was the second leading neoplasm, responsible for 21 (2.7%) of all deaths (95% CI 1.5-3.7%), and was among the top five causes of non-communicable deaths. The median age of breast cancer death was 37 years, younger than for other causes of death. The median duration of illness with breast cancer was around 1 year. This was substantially more compared to the duration of infectious diseases, but less than the duration of reproductive neoplasms, diabetes, and epilepsy. DISCUSSION/CONCLUSION: Breast cancer deaths are common causes of death in women of rural Ethiopia. When assessing the total duration of illness according to specific causes of death, breast and other cancers accounted for a large share of the burden. This has practical implications and highlights the need for palliative care for cancer patients. Substantial efforts are necessary to improve early detection and treatment for breast cancer to reduce premature death in women.

[The Importance of Language Interpretation in the Health Care System]. / Die Relevanz des Dolmetschens im Gesundheitssystem.

BACKGROUND: Many people in German-speaking countries have a limited proficiency in the German language. In the health care system, this may result in barriers to accessing and utilization of health services. The aim of this review was to present the current state of research on the relevance of language barriers in medical care and to explain strategies used to address language-related communication problems. METHODS: The review is based on a synthesis of German- and English-language systematic reviews on the topic of 'language interpretation in the health care sector', including also all original papers from Germany published since 2015. RESULTS: The most common method used in hospitals for language problems was interpretation by relatives of patients or by bilingual staff of the hospital. The quality of this language mediation by untrained laypersons was often limited, which can affect health care outcomes. Using professional interpreters was associated with significantly better health care outcomes and, particularly in the form of interpretation via telephone, was a flexible and cost-effective approach. CONCLUSION: Language-based communication is an important prerequisite for patient-centered care and must be ensured by the health care system for ethical, social and legal reasons. In this context, professional interpretation solutions should be used, for which the required financial resources and infrastructure must also be made available.

[The Asylum Seekers' Benefit Act in the German Medical Literature: A Scoping Review]. / Das Asylbewerberleistungsgesetz in der medizinischen Fachliteratur: Ein Scoping Review.

BACKGROUND: Medical care of asylum seekers in Germany is complicated by laws -predominantly the Asylum Seekers' Benefit Act (ASBA) - that regulate the billing of services. Physicians need to be familiar with these regulations to ensure that these regulations do not hamper the medical care this vulnerable group of patients receives. This article investigates how the ASBA is presented in the medical literature and to what extent the descriptions in the literature meet physicians' information needs. METHODS: A scoping review of the German language medical literature published between 01.01.2015 and 14.04.2020 on asylum seekers' medical care in Germany was carried out. RESULTS: The analysis included a total of 55 articles. The majority of articles (80%, n=44) mentioned the ASBA as an important determinant of asylum seekers' medical care. The definition of the ASBA's recipients and the benefit period was mostly correct, while explanations concerning the scope of benefits covered by ASBA were correct and complete in only 16% (n=9) of the articles. The administrative details connected with the ASBA were mentioned only rarely; 23% (n=10) of the articles falsely portrayed the ASBA as a normative guide for medical practice. CONCLUSIONS: Often, the presentation of the ASBA in the medical literature seems to be unsuitable to guide physicians through the practical problems that often come up when treating asylum seekers. To achieve this, a more nuanced engagement with the topic would be necessary that also pays attention to the legal literature.

[Reasons and Influencing Factors for the Willingness to Document Preferences Regarding Organ Donation: Results of an Online Survey]. / Gründe und Einflussfaktoren für die Bereitschaft zur Dokumentation von Präferenzen bezüglich Organspende. Ergebnisse einer Online-Umfrage.

OBJECTIVE: Different options to regulate decisions about organ transplantation were subjected to discussions prior to parliamentary decision on 16.01.2020. The goal of this study was the description of citizens' attitudes towards organ donation and investigation of predictors of (documentation of) willingness to donate. METHODS: Cross sectional online survey in Berlin and Saxony-Anhalt between 25.11.2019 till 16.01.2020. Descriptive, statistical analysis. We report absolute and relative frequencies. We conducted logistic regression analysis for the influence of age, income and gender on knowledge, willingness to donate and possession of an organ donor card. RESULTS: Of 20 020 invited citizens, 676 (3.4%) participated in the online survey; 54.9% were in favour of an opt-out regulation, 49.4% supported an opt-in regulation, 63.3% of respondents were willing or rather willing to donate an organ and 43.2% possessed an organ donor card. Willingness to donate and possession of an organ donor card decreased with increasing age. A Higher educational level was associated with having an organ donor card. Gender, income, education and knowledge about organ donation were not associated with the willingness to donate an organ. Of those who were willing to donate but who had not a donor card, 45.7% had communicated their will to relatives. Reasons indicated for lack of documentation included practical reasons as also fears related to medical care in case of critical health state. DISCUSSION: None of the discussed legislative regulations on organ donation has been supported by a clear majority of respondents. Distinct population-based surveys can serve as starting point for developing targeted initiatives to increase the documentation of citizens' will regarding organ donation following brain death.

Outpatient health care utilization and health expenditures of asylum seekers in Halle (Saale), Germany - an analysis of claims data.

BACKGROUND: Asylum seekers are a vulnerable group with special needs in health care due to their migration history and pre-, peri- and postmigratory social determinants of health. However, in Germany access to health care is restricted for asylum seekers by law and administrative regulations. METHODS: Using claims data generated in the billing process of health care services provided to asylum seekers, we explore their utilization of health care services in the outpatient sector. We describe the utilization of outpatient specialties, prevalences of diagnoses, prescribed drugs and other health care services, as well as total costs of health care provision. RESULTS: The estimated prevalence for visiting an ambulatory physician at least once per year was 67.5% [95%-Confidence-Interval (CI): 65.1-69.9%], with a notably higher prevalence for women than men. The diagnoses with the highest one-year prevalence were "Acute upper respiratory infections" (16.1% [14.5-18.0%]), "Abdominal and pelvic pain" (15.6% [13.9-17.4%]) and "Dorsalgia" (13.8% [12.2-15.5%]). A total of 21% of all prescriptions were for common pain killers. Women received more diagnoses across most diagnosis groups and prescribed drugs from all types than men. Less than half (45.3%) of all health care costs were generated in the outpatient sector. CONCLUSION: The analysis of claims data held in a municipal social services office is a novel approach to gain better insight into asylum seekers' utilization of health services on an individual level. Compared to regularly insured patients, four characteristics in health care utilization by asylum seekers were identified: low utilization of ambulatory physicians; a gender gap in almost all services, with higher utilization by women; frequent prescription of pain killers; and a low proportion of overall health care costs generated in the outpatient sector. Further research is needed to describe structural and individual factors producing these anomalies.

["Someone else has to take care of that" - Asylum-seekers' Health Care as a Challenge for Biopsychosocial Medicine]. / "Da muss sich jemand anders kümmern" ­ Die medizinische Versorgung von Asylsuchenden als Herausforderung für eine bio-psycho-soziale Medizin.

AIM OF THE STUDY: Medicine has been criticized for over-emphasizing biological aspects of health and disease while neglecting social determinants. However, the last decades witnessed the rise of a strand of medical theorizing that proposed a biopsychosocial perspective on health and disease. This article investigates from ethnographic perspectives the extent to which contemporary biopsychosocial medicine succeeds in providing medical care to asylum-seekers in order to grasp societal influences on health and illness. METHODS: A mix of ethnographic methods including narrative interviews, semi-structured interviews and participant observation was used. RESULTS: Using examples of legal restrictions in patients' access to care and language barriers, the ethnographic material showed that physicians regularly failed to take asylum seekers' health-related life-world scientifically into account. Instead, they routinely improvised solutions or deferred responsibility for finding solutions to other agents. CONCLUSIONS: Approaches employed in the social sciences - especially in medical anthropology - could help alleviate these difficulties that result in sub-standard care, and should therefore be integrated into medical teaching and postgraduate education. Concurrently, theoretical and methodological gaps that might also concern other groups of patients might be closed.

[Persons with migration background in the German National Cohort (NAKO)-sociodemographic characteristics and comparisons with the German autochthonous population]. / Personen mit Migrationshintergrund in der NAKO Gesundheitsstudie ­ soziodemografische Merkmale und Vergleiche mit der autochthonen deutschen Bevölkerung.

BACKGROUND: Persons with a migration background (PmM) as a population group usually differ from the autochthonous population in terms of morbidity, mortality, and use of the health care system, but they participate less frequently in health studies. The PmM group is very heterogeneous, which has hardly been taken into account in studies so far. OBJECTIVES: Sociodemographic characteristics of PmM in the NAKO health study (age, sex, time since migration, education) are presented. In addition, it is examined through an example whether migration background is related to the use of cancer screening for colorectal cancer (hemoccult test). METHODS: Data of the first 101,816 persons of the NAKO were analyzed descriptively and cartographically. The migration background was assigned on the basis of the definition of the Federal Statistical Office, based on nationality, country of birth, year of entry, and country of birth of the parents. RESULTS: Overall, the PmM proportion is 16.0%. The distribution across the 18 study centers varies considerably between 6% (Neubrandenburg) and 33% (Düsseldorf). With 153 countries of origin, most countries are represented in the NAKO. All variables show clear differences between the different regions of origin. In the hemoccult test, persons of Turkish origin (OR = 0.67) and resettlers (OR = 0.60) have a lower participation rate. PmM born in Germany do not differ in this respect from the autochthonous population (OR = 0.99). CONCLUSION: PmM in the NAKO are a very heterogeneous group. However, due to the sample size, individual subgroups of migrants can be studied separately with respect to region of origin.

Risk-based approach to school entry examinations in Germany - a validation study.

BACKGROUND: In Germany, all preschoolers undergo a school entry examination (SEE). While most children are sufficiently served with standardized developmental tests only, for a small group of otherwise underserved children, the SEE should also include a subsidiary health checkup. The aim of the study was to validate selection criteria to differentiate these two groups of children. METHODS: Secondary data from the SEEs of 2016 and 2017 that contained information on 3513 children were analyzed. Of these children, a subset was selected in which no severe developmental disorders were diagnosed prior to the SEE (n = 2744). The selection criteria identified in an earlier study (low or medium social status, missed the last pediatric routine check-up, migration background, three or more siblings, and raised by a single mother) were then applied to this subset to estimate their effectiveness in finding children at risk for a newly diagnosed severe developmental disorder. The sensitivity, specificity and positive and negative predictive values of the selection criteria were calculated. RESULTS: The tested selection criteria identified children who would likely benefit from a subsidiary checkup in the context of SEEs with a sensitivity of 96% (95% CI: 94.5-98.9%). The negative predictive value and specificity of the criteria were 99% (98.6-99.7%) and 34% (32.1-35.8%), respectively. By using this approach, the number of children seen by a physician could be reduced to 53% of the age cohorts. CONCLUSION: The tested selection criteria are a viable way to differentiate children for whom SEEs should include a subsidiary health checkup from those who do not need it. Therefore, the time that physicians spend with SEEs could be reduced. Using the selection criteria to establish a stepped procedure in SEEs therefore offers a valid way to focus physicians' resources on the children who need them most.

Morbidity of asylum seekers in a medium-sized German city.

Asylum seekers constitute a particularly vulnerable group. Not only is their physical and mental health exposed to multiple stresses, but also their access to health care in Germany is legally restricted. Up to now, there is very limited scientific literature investigating the health-outcomes of asylum seekers in Germany. The aim of this study was to provide prevalence data on the morbidity and vaccination status of asylum seekers in a medium-sized German city. We used a structured questionnaire in a cross-sectional study on 214 adult asylum seekers (182 males, 24 females, 8 unknown) in Halle, Germany, 2015. The questionnaire inquired about the respondent's self-reported physical health and vaccination status and assessed their mental health using the Hopkins-Symptom-Checklist-25 and the Harvard Trauma Questionnaire. Pain (37.9 %) and psychological illness (depression: 54.7 %, anxiety disorder: 40.2 %; post-traumatic stress disorder: 18.2 %) were the most prevalent complaints. Among asylum seekers with psychological complaints, co-morbidity was high (64.2 % had more than one psychological disease). 5.6 % of the respondents mentioned suicidal thoughts. The prevalence of chronic diseases was low. We suggest interventions to improve asylum seekers' health on two levels: first, the obligatory initial medical examination after the refugees' arrival at the reception centre should be complemented with questions related to the vaccination status and the most common complaints including pain and psychological diseases. Second, medical infrastructure should be expanded to better serve the needs of culturally and linguistically diverse patient populations, so that those screened positive can be referred for early diagnosis and treatment.

Health Service Use Among Migrants in the German National Cohort-The Role of Birth Region and Language Skills.

Objective: To compare health service use (HSU) between migrants and non-migrants in Germany. Methods: Using data from the population-based German National Cohort (NAKO), we compared the HSU of general practitioners, medical specialists, and psychologists/psychiatrists between six migrant groups of different origins with the utilization of non-migrants. A latent profile analysis (LPA) with a subsequent multinomial regression analysis was conducted to characterize the HSU of different groups. Additionally, separate regression models were calculated. Both analyses aimed to estimate the direct effect of migration background on HSU. Results: In the LPA, the migrant groups showed no relevant differences compared to non-migrants regarding HSU. In separate analyses, general practitioners and medical specialists were used comparably to slightly more often by first-generation migrants from Eastern Europe, Turkey, and resettlers. In contrast, the use of psychologists/psychiatrists was substantially lower among those groups. Second-generation migrants and migrants from Western countries showed no differences in their HSU compared to non-migrants. Conclusion: We observed a low mental HSU among specific migrant groups in Germany. This indicates the existence of barriers among those groups that need to be addressed.

Childhood Trauma and Somatic and Mental Illness in Adulthood.

BACKGROUND: Childhood trauma is associated with somatic and mental illness in adulthood. The strength of the association varies as a function of age, sex, and type of trauma. Pertinent studies to date have mainly focused on individual diseases. In this study, we investigate the association between childhood trauma and a multiplicity of somatic and mental illnesses in adulthood. METHODS: Data from 156 807 NAKO Health Study participants were analyzed by means of logistic regressions, with adjustment for age, sex, years of education, and study site. The Childhood Trauma Screener differentiated between no/minor (n = 115 891) and moderate/severe childhood trauma (n = 40 916). The outcome variables were medical diagnoses of five somatic and two mental health conditions as stated in the clinical history. RESULTS: Persons with childhood trauma were more likely to bear a diagnosis of all of the studied conditions: cancer (odds ratio [OR] = 1.10; 95% confidence interval: [1.05; 1.15]), myocardial infarction (OR = 1.13 [1.03; 1.24]), diabetes (OR = 1.16, [1.10; 1.23]), stroke (OR = 1.35 [1.23; 1.48]), chronic obstructive pulmonary disease (OR = 1.45 [1.38; 1.52]), depression (OR = 2.36 [2.29; 2.43]), and anxiety disorders (OR = 2.08 [2.00; 2.17]). All of these associations were stronger in younger persons, regardless of the nature of childhood trauma. Differences between the sexes were observed only for some of these associations. CONCLUSION: Childhood trauma was associated with a higher probability of developing mental as well as somatic illness in adulthood. As childhood trauma is an element of individual history that the victim has little to no control over, and because the illnesses that can arise in adulthood in association with it are a heavy burden on the affected persons and on society, there is a need for research on these associations and for the development of preventive measures.

Barriers to and Facilitators of Hepatitis B Vaccination among the Adult Population in Indonesia: A Mixed Methods Study.

To reach the goals of the Global Hepatitis Elimination 2030 program, Indonesia is now preparing a new regulation for hepatitis B vaccinations for adult population. This study aimed to determine the factors influencing vaccine uptake for hepatitis B in the adult population, and identify barriers to, and facilitators of, hepatitis B vaccination programmes. An explanatory sequential mixed methods design was implemented in this study. We conducted a survey involving 893 participants in the general population followed by 14 in-depth interviews with health providers. The survey found that only 15% (95% confidence interval 13-18%) of participants received at least one dose of the hepatitis B vaccine. Factors associated with vaccine uptake were, living in Yogyakarta compared to living in Aceh, having secondary and higher education compared to primary education, working as a health worker compared to working in other sectors, and having health insurance that covered hepatitis B vaccination compared to not having such health insurance. Our qualitative study also identified several barriers to the adult hepatitis B vaccination programme in Indonesia such as the high cost of vaccination, lack of vaccine availability in certain areas, limited human resources to implement the hepatitis B vaccination programme, and the ineffective dissemination of hepatitis B vaccination. This study highlights that accessibility and affordability of vaccinations are important determinants of vaccination uptake that should be taken into account when planning vaccination campaigns.

Segregated by Wealth, Health, and Development: An Analysis of Pre-School Child Health in a Medium-Sized German City.

The School Entry Examination (SEE) can be used to identify children with current health issues, developmental delays, and risk factors for later diseases. This study analyzes the health status of preschool children in a German city with considerable socio-economic differences among its quarters. We used secondary data from SEEs 2016-2019 from the entire city (8417 children), which we divided into quarters with low (LSEB), medium (MSEB), and high socioeconomic burden (HSEB). In HSEB quarters, 11.3% of children were overweight as opposed to 5.3% in LSEB quarters. In HSEB quarters, 17.2% of children had sub-par cognitive development in contrast to 1.5% in LSEB quarters. For overall sub-par development, LSEB quarters had a prevalence of 3.3%, whereas, in HSEB quarters, 35.8% of children received this result. Logistic regression was used to determine the influence of the city quarter on the outcome of overall sub-par development. Here, considerable disparities among HSEB and LSEB quarters remained after adjustment for parents' employment status and education. Pre-school children in HSEB quarters showed a higher risk for later disease than children in LSEB quarters. The city quarter had an association with child health and development that should be considered in the formulation of interventions.

Associations of Migration, Socioeconomic Position and Social Relations With Depressive Symptoms - Analyses of the German National Cohort Baseline Data.

Objectives: We analyze whether the prevalence of depressive symptoms differs among various migrant and non-migrant populations in Germany and to what extent these differences can be attributed to socioeconomic position (SEP) and social relations. Methods: The German National Cohort health study (NAKO) is a prospective multicenter cohort study (N = 204,878). Migration background (assessed based on citizenship and country of birth of both participant and parents) was used as independent variable, age, sex, Social Network Index, the availability of emotional support, SEP (relative income position and educational status) and employment status were introduced as covariates and depressive symptoms (PHQ-9) as dependent variable in logistic regression models. Results: Increased odds ratios of depressive symptoms were found in all migrant subgroups compared to non-migrants and varied regarding regions of origins. Elevated odds ratios decreased when SEP and social relations were included. Attenuations varied across migrant subgroups. Conclusion: The gap in depressive symptoms can partly be attributed to SEP and social relations, with variations between migrant subgroups. The integration paradox is likely to contribute to the explanation of the results. Future studies need to consider heterogeneity among migrant subgroups whenever possible.