Child health and development in the course of the COVID-19 pandemic: are there social inequalities?

COVID-19 pandemic lockdowns and closures have influenced all children's health and development (HAD). We aimed to examine whether this differs by social circumstances. We hypothesised that socially disadvantaged children experienced more pronounced deterioration in their HAD compared with better-off children. In our trend study, we included five cohorts of school enrolment medical screening (school entrance 2018-2022) in the city of Dusseldorf, Germany. To compensate for selection bias due to the limited number of examinations in pandemic months, we chose the first 800 examinations of each cohort. We computed predicted prevalences of overweight, coordination and language problems as indicators of HAD. Neighbourhood deprivation, single-parent families and non-German nationality were used as indicators of social disadvantage. All groups of children experienced a deterioration in their HAD. Its magnitude is comparable between children with different social circumstances. For instance, between 2018 and 2021, prevalence of overweight increased from 19.2 to 24.2% in children from deprived neighbourhoods, and from 8.1 to 16.5% in children from well-off neighbourhoods. Prevalence of language problems (prepositions) increased from 49.9 to 72.1% among non-German children, and from 14.4 to 39.1% among German children.   Conclusion: Results only partly confirmed our hypothesis. However, since the pre-pandemic prevalences of HAD problems among disadvantaged children were already higher, further deterioration - regardless of its magnitude - has led to their particularly poor situation. For those children, overweight and language development should be priorities of prevention. Generally, important settings for child HAD such as kindergartens or leisure facilities should remain open in future pandemics. What is known: • The COVID-19 pandemic has had a negative impact on general child health and development. • Before the pandemic, social inequalities in child health and development were a common phenomenon. What is new: • Children in all social groups experienced a deterioration in their health and development over the course of the pandemic. • Over the course of the pandemic, children from deprived neighbourhoods have demonstrated a particularly high prevalence of overweight. Language problems are particularly prevalent among non-German children.

Neighbourhood deprivation and obesity among 5656 pre-school children-findings from mandatory school enrollment examinations.

The risk of child obesity is strongly related to socioeconomic factors such as individual socioeconomic position (SEP) and neighbourhood deprivation. The present study analyses whether the relationship between neighbourhood deprivation and child obesity differs by child's individual SEP. Data from 5656 children (5-7 years) from the mandatory school enrollment examinations of the pre-school cohorts 2017/2018 in Düsseldorf were analysed. Obesity was determined by the age- and gender-specific body mass index (BMI); neighbourhood deprivation by using the socio-spatial degree of deprivation of the children's residential addresses; and individual SEP by the level of parental education. Using Poisson regression, we estimated prevalence ratios (PR with 95% confidence interval (CI)) of child obesity by neighbourhood deprivation and parental education. Interactions between neighbourhood deprivation and parental education were tested. The prevalence of child obesity increases with the degree of neighbourhood deprivation. Compared to children living in low deprivation neighbourhoods, the proportion of obese children was twice as high in high deprivation neighbourhoods (PR=2.02; CI=1.46-2.78). Likewise, children from families with medium and low education have twice the risk for obesity compared to children with high parental education (PR=2.05; CI=1.46-2.78). The relationship between neighbourhood deprivation and child obesity was significantly moderated by parental education; it was stronger for higher parental education than for medium and low parental education (p<.001).Conclusion: Our findings suggest that children from deprived neighbourhoods and families with lower education have a higher risk for child obesity. The identification of particularly deprived neighbourhoods with structural interventions in combination with the strengthening of parental health literacy seems reasonable. What is Known: • Studies show that children from disadvantaged neighbourhoods are more frequently obese. What is New: • The relationship between neighbourhood deprivation and child obesity is significantly moderated by parental education. It is stronger for children with higher parental education than for children with medium and low parental education.

Closing the gap between practice and science in school- and community-based participatory physical literacy promotion: study protocol of the StuPs project.

BACKGROUND: The role of physical activity in the promotion of children's well-being and health is widely known. However, research indicates that the time spent physically exercising and participating in organized sport activities is decreasing among children. Although there is currently no gold standard for promoting sustainable physical activity in children, community-based approaches, particularly those that are multicomponent, appear to be the most successful. The project StuPs: a school- and community-based participatory approach for promoting physical activity in children and their families aims to develop a community-based approach to promoting physical activity by increasing physical literacy among elementary school children and their household members. METHODS: The project is built upon the intervention mapping approach and consists of two periods with an overall duration of 3 years. Period I will last 9 months and include an assessment of needs, wants, strengths, and weaknesses regarding physical activity and health promotion at the community- and school-based level according to the keywords "capacity building" and "physical literacy." Based on the knowledge gained in this stage, measures for capacity building to promote healthy lifestyles and physical literacy in children will be developed using the community-based participatory research and capacity building approach. In Period II, the measures will be applicated, implemented and evaluated using a pre-/post-design to assess efficacy. DISCUSSION: Although the efficacy of using community-based and capacity building approaches to reach children is promising, there remains a gap regarding best practices for changing existing structures and habits over the long term and in the sense of promoting physical literacy.

Reminder system for health screening in early childhood - an analysis regarding different social circumstances.

BACKGROUND: Children with a low socio-economic position (SEP) participate in prevention and health examinations less often. In order to increase participation, reminder systems have been implemented in Germany since 2009. The aim of the study is to investigate whether this implementation is associated with an increased participation in health examination in early childhood for children in disadvantaged social circumstances. METHODS: We used data from the school enrolment examination from 2002 to 2017 from the city of Duesseldorf (n = 64,883 children). With a trend analysis we observed health examination over time and we compared rates of children after implementation of the reminder system (2010 or later) to those who were not exposed to the programme (earlier than 2010). Health examination was measured by participation in the last examination before school entry ("U9") documented by paediatricians. Social circumstances included neighbourhood deprivation (very high to very low), migration background (foreign first language vs. German) and family status (one-parent vs. two-parent families). Poisson regression estimated adjusted Prevalence Ratios (PR) with a 95% confidence interval (CI) of U9 participation by reminder system exposure, both for the total population and within groups of social circumstances. Based on that, we calculated adjusted participation rates (predictive margins) by reminder system exposure for the different social circumstances. RESULTS: Participation rates increased slightly, but gradually over time. The probability of U9 participation for children exposed to the reminder system is 1.04-fold (1.03-1.04 CI) compared to children who were not exposed to it. The association of the reminder system and U9 participation differs according to social circumstances. Adjusted prevalences increased the most in the group of children from very deprived neighbourhoods, ranging from 84.3 to 91.4% (PR = 1.07; 1.03-1.10 CI); in all language groups; more in children from one-parent families ranging from 82.4 to 88.9% (PR = 1.07; 1.05-1.09 CI). CONCLUSION: Our results suggest that reminder systems have a moderate impact on the participation in health examinations in early childhood in the general population. In vulnerable groups, however, they could make a difference. Reminder systems should be combined with further activities of tailored prevention.

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

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

Gendered work-family trajectories and depression at older age.

Objectives: The paper identifies types of work-family trajectories of men and women and investigates their links with depression at older age. Method: We use data from the Heinz Nixdorf Recall study, with retrospective information on employment histories and parenthood between age 20 and 50 (1482 men and 1537 women, born between 1925 and 1955). We apply sequence analysis and group trajectories into six clusters for each gender. We test their association with two alternative measures of depression: self-reported depressive symptoms and intake of antidepressant medication. Multivariate models exclude participants with early life depression and adjust for age, marital status, education, and income. Results: We find clear differences of work-family trajectories between men and women, where women's trajectories are generally more diverse, and include family leaves and returns into full or part-time work. For men, work-family trajectories are neither related to depressive symptoms nor to medication intake. In contrast, women who returned into full-time work after family leave show more depression than those who return part-time, both in terms of depressive symptoms and intake of antidepressant medication. Conclusion: Our findings show gender differences in terms of work-family trajectories and their health-related consequences. In particular, findings suggest that mothers who return to full-time work are a vulnerable group for depression at older age and should be the focus of further research attention.

[How Representative are Participants of a Parent Survey in the Context of School Entrance Examination]. / Wer macht mit? Zur Repräsentativität einer Elternbefragung im Rahmen der Schuleingangsuntersuchung.

AIM: In an evaluation study of preventive programmes, the recruitment success of families in difficult socio-economic circumstances was examined during the school entrance examination (SEE). METHOD: Using a 3-stage recruitment procedure, parents were motivated to participate in the survey. The response rate was calculated for the entire cohort and separately for the single recruitment stages. Non-participants and participants were compared on 4 indicators of difficult socio-economic circumstances. RESULTS: 52% of the parents participated in the study. The response rate reached 21% for the recruitment stage 'questionnaire with invitation to the SEE', 28% for stage 'personal delivery at the health department' and 4% for stage 'stamped addressed envelope'. Families with low education were more often non-participants (multivariate Odds Ratio (OR) 2.2; 95%-confidence interval (CI) 1.3-3.6). Marginal differences in study participation were present for unemployed families (OR 1.4; CI 0.6-3.2), single parents (OR 1.0; CI 0.6-1.8) and families with immigration background (OR 1.2; CI 0.7-1.5). CONCLUSION: The response rate was adequate. Personal delivery achieved the highest response rate compared to the other stages. A parent survey at the SEE is a promising approach to access families in difficult socio-economic circumstances. Nevertheless, families with low education are still underrepresented.

[Is the school entrance examination a door opener for health sciences research? : Analyzing study participation of hard-to-reach groups]. / Die Schuleingangsuntersuchung als Türöffner für die gesundheitswissenschaftliche Forschung? : Eine Analyse zur Studienteilnahme "schwer erreichbarer" Bevölkerungsgruppen.

BACKGROUND: Additional scientific surveys within the compulsory school entrance examination (SEE) have become increasingly popular, partly because the SEE potentially reaches all socioeconomic groups. However, it has not been sufficiently explored whether selective participation in voluntary supplementary surveys actually results in no selection bias along socioeconomic characteristics. Therefore, the aim of this study is to analyze the participation of potentially hard-to-reach families in a parent survey at the SEE. MATERIALS AND METHODS: The parent survey on the utilization of community prevention has been linked to the SEE in a community in North Rhine-Westphalia. We compared families with low and higher education (CASMIN classification), families with and without migration background (at least one parent was not born in Germany), as well as single-parent and two-parent families. Using logistic regression we analyzed whether survey participation (n = 3410) and non-participation (n = 346) was different along all three indicators. RESULTS: Families with low education were slightly more often among the group of participants compared to non-participants (11.2 vs. 8.8%; odds ratio (OR) 1.29; 95% confidence interval (CI) 0.85-1.95) and single-parent families slightly less often (14.1 vs. 17.7%; OR 0.75; 95% CI 0.55-1.02). Families with migration background participated significantly more often (52.9 vs. 46.1%; OR 1.27; 95% CI 1.01-1.60). CONCLUSIONS: Hard-to-reach families could be recruited for a voluntary parent survey in the SEE to a satisfying degree. This illustrates the potential of the SEE for population-based basic and evaluation research.

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

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

Child Motor Development before and after the COVID-19 Pandemic: Are There Social Inequalities?

BACKGROUND: COVID-19 pandemic has influenced all children's motor development. We examine whether this differs by social circumstances. We hypothesise that socially disadvantaged children experienced more pronounced motor problems compared with better-off children. METHODS: Our trend study includes three representative waves of preschoolers (school years 2018/19, 2019/20, 2023/24) from a German school enrolment medical screening. Based on logistic regressions, we computed predicted prevalences of motor problems separately for children in different social circumstances (neighbourhood, migration background, family status). RESULTS: Motor development of preschoolers slightly worsened by 2023 compared to pre-pandemic level (6.3 percent 2018 to 7.4 percent 2023). Results by neighbourhood highlight that preschoolers from well-off districts experienced a deterioration of motor development (4.9 percent 2018-6.4 percent 2023). The prevalence of motor problems is, however, below that of children from deprived neighbourhoods with consistently high prevalence (9.2-10 percent). Results by migration background show a worsening trend for children without migration background and the gap between the groups disappears in 2023. Results by family status do not indicate significant differences. CONCLUSION: Contrary to our hypothesis, socially disadvantaged children experienced smaller change in motor problems. However, our results highlight the potential of structured physical activities in daycare centres and sports facilities to enhance the motor development of these children.

Does the Association between Preschool Media Use and Language Difficulties at School Entry Vary by First Language of the Child and Parental Education?

BACKGROUND: Both media use and social background affect children's language development. The aim of this study was to explore the association between media use and different aspects of language difficulties (grammar, auditory memory, articulation) and social background (first language (FL), parental education (PE)) in more detail. METHODS: We analyzed data from 4015 children from the 2013/14 school entry examination in a Western German city. Media use, FL, and PE were assessed by social history, and language difficulties by sociopediatric screening. We calculated Prevalence Ratios with a 95% Confidence Interval for language difficulties by media use and FL/PE; compared models with and without interaction terms; and estimated the predicted prevalence of language difficulties by media use and FL/PE. RESULTS: Children with non-German FL/low PE had a higher media use and more language difficulties. However, the gradual association between media use and grammatical abilities/recommendation of training was more pronounced in children with German FL and medium/high PE. e.g., especially in the preposition subtest. CONCLUSIONS: The association between media use and language difficulties varies regarding different aspects of social background and language difficulties. Still, extensive media use is linked with language difficulties for all children. The media competence of young families remains crucial in times of digitalization.

Insomnia and urban neighbourhood contexts--are associations modified by individual social characteristics and change of residence? Results from a population-based study using residential histories.

BACKGROUND: Until now, insomnia has not been much of interest in epidemiological neighbourhood studies, although literature provides evidence enough for insomnia-related mechanisms being potentially dependent on neighbourhood contexts. Besides, studies have shown differences in sleep along individual social characteristics that might render residents more vulnerable to neighbourhood contextual exposures. Given the role of exposure duration and changes in the relationship between neighbourhoods and health, we studied associations of neighbourhood unemployment and months under residential turnover with insomnia by covering ten years of residential history of nearly 3,000 urban residents in the Ruhr Area, Germany. METHODS: Individual data were retrieved from the Heinz Nixdorf Recall Study, a population-based study of randomly chosen participants from adjacent cities, which contains self-rated insomnia symptoms and individual social characteristics. Participants' residential addresses were retrospectively assessed using public registries. We built individually derived exposure measures informing about mean neighbourhood unemployment rates and months under high residential turnover. These measures were major predictors in multivariate logistic regressions modelling the association between social neighbourhood characteristics and insomnia in the whole sample and subgroups defined by low income, low education, social isolation, and change of residence. Traffic-related noise, age, gender, economic activity, and education were considered as covariates. RESULTS: Nearly 12 per cent of the participants complained about insomnia. Associations of neighbourhood unemployment with insomnia were more consistent than those of residential turnover in the whole sample (adjusted OR 1.42, 95% CI 1.00-2.03 for neighbourhood unemployment and OR 1.33, 95% CI 0.78-2.25 for residential turnover in the highest exposure categories). In low-income and socially isolated participants, neighbourhood unemployment odds of reporting insomnia were particularly elevated (adjusted OR 2.90, 95% CI 1.39-6.02 and OR 3.32, 95% CI 1.11-9.96, respectively). Less educated participants displayed relatively high odds of reporting insomnia throughout all upper neighbourhood unemployment exposure categories. Change of residence weakened associations, whereas undisrupted exposure sharpened them by trend. CONCLUSIONS: Our findings hint at multiple stressors being effective in both the neighbourhood context and individual resident, possibly reflecting precarious life situations undermining residents' sleep and health chances. Moreover, our results suggest a temporal dependency in the association between neighbourhood and insomnia.

Is the Level of Motor Development at School Entry Related to the Use of Municipal Exercise Programs? A Social-Differential Analysis.

Children's motor development is socially unevenly distributed despite many municipal exercise programs (EXP). It has not been sufficiently investigated whether and how they appeal to children from different social backgrounds. This study investigates the use of municipal EXP in preschool age and the association between participation and motor development considering social circumstances. In school entry health examinations, parents were asked about participating in various EXP (response = 65.5%; n = 6480). Motor development, i.e., body coordination and visual-motor coordination, were assessed by a social pediatric development screening, and social circumstances by migration background (MB) and parental education (PE). Poisson regression estimated adjusted Incidence Rate Ratios (IRR; 95% confidence interval, 95%-CI) for relationships between social circumstances and participation in programs and participation and body coordination/visual-motor coordination. Children with MB (IRR 0.73; 95%-CI 0.71-0.75) and low PE (IRR 0.45; 95%-CI 0.40-0.50) used EXP less often. Children participating less often have a finding in body- (IRR 0.76; 95%-CI 0.63-0.90) and visual-motor coordination (IRR 0.47; 95%-CI 0.35-0.62). Significant effects were found for children with and without MB and higher PE. Municipalities should make EXP more attractive for families with MB and low PE.

Effects of the Population-Based "10,000 Steps Duesseldorf" Intervention for Promoting Physical Activity in Community-Dwelling Adults: Protocol for a Nonrandomized Controlled Trial.

BACKGROUND: The World Health Organization recommends 150 minutes of moderate to vigorous physical activity (PA), which translates to approximately 7000 to 10,000 steps per day for adults. In Germany, less than half of the population in this age range meets this recommendation, highlighting the need for population-based intervention approaches for promoting daily PA. OBJECTIVE: The complex community-based PA intervention "10,000 Steps Ghent," which was originally developed in Belgium and was shown to be effective for PA promotion, has been adapted for implementation and evaluation in 2 German cities. The original Belgian study is currently being replicated, and we aim to examine the effectiveness of the adapted intervention among adults living in intervention city districts in Duesseldorf when compared with those living in control city districts in Wuppertal, over the course of 1 year. METHODS: A controlled intervention trial examining the effects of an intervention addressing multiple levels (eg, individual level: website; organizational level: PA promotion in companies; community level: media campaigns and environmental changes) is being conducted. PA and various secondary outcomes will be assessed in 2 random samples of adults aged 25 to 75 years (n=399 in each city) at baseline and after 1 year. RESULTS: Funding for this study was obtained in March 2020. Recruitment for this study and baseline data collection were conducted from May 2021 to March 2022 (as of March 2022, 626 participants were enrolled in the study). The intervention will be implemented in Duesseldorf for 1 year from April 2022 onward, and follow-up assessments will be conducted, starting in May 2023 (until September 2023). Data analysis will be performed in fall 2023, and the results will be published in spring 2024. CONCLUSIONS: To our knowledge, this is the first research project (currently underway in Germany) that is aimed at replicating the effects of a complex intervention for PA promotion that was previously shown to be effective in another European country. TRIAL REGISTRATION: German Clinical Trials Register DRKS00024873; https://tinyurl.com/4c9e8azh. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39175.

Does socioeconomic status affect the association of social relationships and health? A moderator analysis.

BACKGROUND: Social relations have repeatedly been found to be an important determinant of health. However, it is unclear whether the association between social relations and health is consistent throughout different status groups. It is likely that health effects of social relations vary in different status groups, as stated in the hypothesis of differential vulnerability. In this analysis we explore whether socioeconomic status (SES) moderates the association between social relations and health. METHODS: In the baseline examination of the Heinz Nixdorf Recall study, conducted in a dense populated Western German region (N = 4,814, response rate 56%), SES was measured by income and education. Social relations were classified by using both structural as well as functional measures. The Social Integration Index was used as a structural measure, whilst functional aspects were assessed by emotional and instrumental support. Health was indicated by self-rated health (1 item) and a short version of the CES-D scale measuring the frequency of depressive symptoms. Based on logistic regression models we calculated the relative excess risk due to interaction (RERI) which indicates existing moderator effects. RESULTS: Our findings show highest odds ratios (ORs) for both poor self-rated health and more frequent depressive symptoms when respondents have a low SES as well as inappropriate social relations. For example, respondents with low income and a low level of social integration have an OR for a high depression score of 2.85 (95% CI 2.32-4.49), compared to an OR of 1.44 (95% CI 1.12-1.86) amongst those with a low income but a high level of social integration and an OR of 1.72 (95% CI 1.45-2.03) amongst respondents with high income but a low level of social integration. As reference group those reporting high income and a high level of social integration were used. CONCLUSIONS: The analyses indicate that the association of social relations and subjective health differs across SES groups as we find moderating effects of SES. However, results are inconsistent as nearly all RERI scores are positive but do not reach a significant level. Also moderating effects vary between women and men and depending on the indicators of SES and social relations used. Thus, the hypothesis of differential vulnerability can only partially be supported. In terms of practical implications, psychosocial and health interventions aiming towards the enhancement of social relations should especially consider the situation of the socially deprived.

Linked work lives: The interrelation of own and partner's employment history and their relationship with mental health in older European couples.

INTRODUCTION: There is strong evidence for the importance of previous employment for mental health at older age but little is known about the role of partner's employment history in this. Life course theory suggests that individual trajectories are linked and evidence from cross-sectional studies suggest that there are cross-over effects within couples. Therefore, the present study tests the interdependence of own and partner's employment history and their relationship with depressive symptoms. METHODS: Analyses are based on retrospective data from the SHARE survey for 5664 long-term couples aged 50 or older, with employment information for each age between 30 and 50 (full-time, part-time, domestic work or non-employed). We use sequence analysis to group similar employment histories and relate own and partner's employment histories with depressive symptoms (EURO-D) using regression models. RESULTS: Results show that own and partner's employment history are interdependent and mainly follow traditional divisions of paid work, with the majority of men working full-time and women often working part-time or not working. We find increased depressive symptoms after longer episodes of non-employment for men but not for women, regardless of partner's employment situation. CONCLUSION: The study shows that mental health later in life is related to own employment history and that this relationship is not moderated by partner's employment history. The results need to be interpreted against cultural and gender role norms at the time.

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

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

Subclinical coronary atherosclerosis and neighbourhood deprivation in an urban region.

Inhabitants of deprived neighbourhoods are at higher risk of coronary heart disease. In this study we investigate the hypothesis that social inequalities at neighbourhood level become already manifest in subclinical coronary atherosclerosis, as defined by electron-beam computed tomography derived measures. Coronary artery calcification was assessed as a marker of atherosclerosis in a population based sample of 4301 men and women (45-75 years) without a history of coronary heart disease. Participants lived in three adjacent cities in Germany and were examined between 2000 and 2003 as part of the Heinz Nixdorf Recall Study. Individual level data was combined with neighbourhood level information about unemployment, welfare and living space per inhabitant. This dataset was analysed with descriptive and multilevel regression methods. An association between neighbourhood deprivation and subclinical coronary calcification was observed. After adjustment for age and individual socioeconomic status male inhabitants of high unemployment neighbourhoods had an odds ratio of 1.45 (1.11, 1.96) of exhibiting a high calcification score (>75th percentile) compared to men living in low unemployment areas. The respective odds for women was 1.29 (0.97, 1.70). Additional explorative analyses suggest that clustering of unhealthy lifestyles in deprived neighbourhoods contributes to the observed association. In conclusion, findings suggest that certain neighbourhood characteristics promote the emergence of coronary atherosclerosis. This might point to a pathway from neighbourhood deprivation to manifest coronary heart disease.

Low socio-economic position is associated with poor social networks and social support: results from the Heinz Nixdorf Recall Study.

BACKGROUND: Social networks and social support are supposed to contribute to the development of unequal health within populations. However, little is known about their socio-economic distribution. In this study, we explore this distribution. METHODS: This study analyses the association of two indicators of socio-economic position, education and income, with different measures of social networks and support. Cross-sectional data have been derived from the baseline examination of an epidemiological cohort study of 4.814 middle aged urban inhabitants in Germany (Heinz Nixdorf Recall Study). Bivariate and multivariate logistic regression analysis were carried out to estimate the risk of having poor social networks and support across socio-economic groups. RESULTS: Socially disadvantaged persons more often report poor social networks and social support. In multivariate analyses, based on education, odds ratios range from 1.0 (highest education) to 4.9 (lowest education) in a graded way. Findings based on income show similar effects, ranging from 1.0 to 2.5. There is one exception: no association of SEP with close ties living nearby and regularly seen was observed. CONCLUSION: Poor social networks and low social support are more frequent among socio-economically disadvantaged people. To some extent, this finding varies according to the indicator chosen to measure these social constructs.

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

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