Do health literacy, physical health and past rehabilitation utilization explain educational differences in the subjective need for medical rehabilitation? Results of the lidA cohort study.

BACKGROUND: Medical rehabilitation can be helpful for maintaining workers' health and work ability. Its contribution to longer working lives is of high economic relevance in aging populations. In Germany, individuals must apply for rehabilitative measures themselves. Therefore, the subjective need for rehabilitation (SNR) is a prerequisite for rehabilitation access. A low education level is associated with poor health, lower health literacy and more frequent utilization of health services. In the present study, we investigated whether lower educational levels are also associated with a greater SNR and whether health literacy, past rehabilitation utilization and physical health play a mediating role in this path in older employees. METHODS: 3,130 socially insured older employees (born in 1959 or 1965) who participated in the German prospective lidA (leben in der Arbeit) cohort-study in 2011, 2014 and 2018 were included. A causal mediation analysis with an inverse odds weighting approach was performed with the SNR as the dependent variable; educational level as the independent variable; and health, health literacy and past rehabilitation utilization as the mediating variables. Sociodemographic variables were adjusted for. RESULTS: The SNR was significantly greater in subjects with a low education level, poor physical health, inadequate health literacy and those who had utilized rehabilitation in the past. For health literacy, past rehabilitation utilization and physical health, a significant partial mediating effect on the SNR was found for employees with low compared to those with high education levels. However, the combined mediating effect of all the mediators was lower than the sum of their individual effects. Among those with medium or high education levels, none of the variables constituted a significant mediator. CONCLUSIONS: The path between a low education level and a high SNR is mediated by inadequate health literacy, past rehabilitation utilization and poor physical health; these factors do not act independently of each other. Promoting health education may lower the SNR by improving physical health and health literacy. While improving physical health is beneficial for individuals, improved health literacy can be economically advantageous for the health system by reducing inappropriate expectations of rehabilitation benefits and subsequent applications for rehabilitation.

[Workload and Rehabilitation Needs of Older Workers with and without Migrant Background - Results of the lidA Cohort Study]. / Arbeitsbelastungen und Rehabilitationsbedarf bei älteren Erwerbstätigen mit und ohne Migrationshintergrund ­ Ergebnisse der lidA Kohortenstudie.

BACKGROUND: The need for rehabilitation measures will increase in the future due to increasing retirement age and demographic changes. In addition, the need for rehabilitation measures is determined, among other things, by the strenuousness of work. The aim of the present study was to investigate whether employees with a migrant background (EmM) are exposed to strenuous work more often and have a higher need for rehabilitation than employees without a migrant background (EoM). MATERIAL AND METHODS: The lidA study is a nationwide, prospective cohort study focusing on work, age, health and labour force participation. Study subjects (2443 female, 2281 male) were socially secured employees, born in 1959 or 1965. They were personally interviewed with computer assistance. Data from the first study wave (2011) were used. Multiple logistic regression analyses adjusted for socio-demographic factors (age, gender, education and household equivalent income) were carried out to estimate the influence of migrant background, nationality and high workloads on the need for rehabilitation. RESULTS: First generation EmMs were particularly affected by high workloads compared to EoM. The subjectively experienced workloads of EoM and EmM of the second generation were on a comparable level. In contrast, there were no differences between EmM with German and foreign citizenship. After adjustment for sociodemographic and workload-related factors, a higher need for rehabilitation was shown for the first-generation EmM (not significant) in comparison with the second-generation EoM and EmM, but not for EmM with foreign citizenship in comparison with EmM with German citizenship. DISCUSSION: First-generation EmMs are exposed to strenuous work significantly more often and have a higher need for rehabilitation. However, the migrant background itself is not a determinant for increased rehabilitation needs. The significantly higher need for rehabilitation can rather be explained by the strenuousness of work and socio-demographic characteristics that are more frequent in first-generation EmM. Differentiated considerations of the subgroups of EmM are important to identify special needs and to avoid undersupply (e. g. due to access barriers).

[Utilization of Medical Rehabilitation and Access Barriers for Persons with a Migrant Background - Results of the lidA Cohort Study]. / Inanspruchnahme medizinischer Rehabilitation und Zugangsbarrieren bei Personen mit Migrationshintergrund ­ Ergebnisse der lidA-Kohortenstudie.

INTRODUCTION: Rehabilitation services are considerably less used by persons with a migration background of working age in Germany than by persons without migration background. One reason could be access barriers. They can arise both from the structures of the health/rehabilitation system as well as from influences of the personal environment, e. g. financial burdens incurred through the use of rehabilitation or cultural expectations. In addition to the migration status, other factors such as country of origin, reasons for immigration, length of stay as well as the religious affiliation and social status could influence the utilization of medical rehabilitation. It was examined to what extent differences in utilisation are due to the migration background and to migration-independent personal barriers to access. METHODS: The lidA-study is a nationwide, representative prospective cohort study among employees with insurable employment born in 1959 and 1965 with a focus on work, age, health and employment. Data from the first (2011) and the second wave (2014) were combined for the analyses. In addition to bivariate analyses to describe the sample according to migration status, logistic regression analyses were carried out to estimate the odds ratios for the influence of migration background or nationality and other factors on the use of a medical rehabilitation measure. RESULTS: The chance of receiving medical rehabilitation is increased for migrants of the 1st generation (odds ratio (OR) 1.56, 95% confidence interval (CI): 1.09-2.25). If predominantly or exclusively no German is spoken at home, this could be associated with a comparatively much lower chance of utilisation (OR: 0.56, 95% CI: 0.28-1.15). Because only nationality is often available in routine data to determine the status of migration, another model only considers migrants and 2nd generation nationals and examines the influence of nationality on utilisation. A foreign nationality was not associated with a higher utilisation (OR: 1.07, 95% CI: 0.55-2.08). DISCUSSION: Results of previous studies on the use of medical rehabilitation for people with a migration background are inconsistent. This could be due to different examined population groups, different indications for rehabilitation, a temporal change in utilisation and the various study designs as well as data sources. We found a higher use of medical rehabilitation services by persons with a migrant background (1st generation) compared to non-migrant persons. One reason could be our more precise definition of the migration background compared to analyses of routine data. If predominantly or exclusively another language than German is spoken at home, the utilisation tends to be lower. The finding coincides with a lack of German language skills described as an access barrier in the literature.

Utilisation of rehabilitation services for non-migrant and migrant groups of higher working age in Germany - results of the lidA cohort study.

BACKGROUND: An ageing and a shrinking labour force implies that the prevention of a premature exit from work due to poor health will become more relevant in the future. Medical rehabilitation is a health service that aims at active participation in working life. The provision of this service will be relevant for an increasing part of the ageing labour force, namely, employees with a migrant background and their different subgroups. Thus, this study examines whether first- and second-generation employees with migrant background differ from non-migrants in their utilisation of rehabilitation services and whether within the subsample of migrant employees, those persons with foreign nationality differ from those with German nationality. METHODS: Socially insured employees born in 1959 or 1965 were surveyed nationwide in 2011 as part of the lidA cohort study (n=6303). Survey data of the first study wave were used to identify the dependent variable of the utilisation of rehabilitation (in- and outpatient), the independent variable of migrant status and the covariates of sociodemographic, work- and non-work-related factors. Applying bivariate statistics with tests of independence and block-wise logistic regressions, differences between the groups were investigated. Additionally, average marginal effects were computed to directly compare the adjusted models. RESULTS: The study showed that first-generation migrants had a significantly lower likelihood of utilising outpatient rehabilitation than non-migrants (fully adj. OR 0.42, 95% CI 0.22-0.82) and that average marginal effects indicated higher differences in the full model than in the null model. No significant differences were found between the first- or second-generation migrants and non-migrants when comparing the utilisation of inpatient rehabilitation or any rehabilitation or when analysing German and foreign employees with migrant background (n=1148). CONCLUSIONS: Significant differences in the utilisation of outpatient rehabilitation between first-generation migrants and non-migrants were found, which could not be explained by sociodemographic, work- and non-work-related factors. Thus, further factors might play a role. The second-generation migrants resemble the non-migrants rather than their parent generation (first-generation migrants). This detailed investigation shows the heterogeneity in the utilisation of health services such as medical rehabilitation, which is why service sensitive to diversity should be considered.

Survival of patients with hepatobiliary tract and duodenal cancer sites in Germany and the United States in the early 21st century.

Hepatobiliary tract cancers (HBTCs) are a heterogeneous group of cancers with high mortality. Because most of these cancers, with the exception of hepatocellular carcinoma (HCC), are rare, few data are available concerning the population level survival expectations of patients with HBTC. Here, we describe survival of patients with HBTC in Germany with comparison to survival in the US. Therefore, data were extracted from 12 databases in Germany and the Surveillance, Epidemiology and End Results (SEER13) database in the US. Period analysis and modeled period analysis were used to calculate 5-year relative survival estimates for patients with HBTC diagnosed from 1997 to 2013. HCC was the most common HBTC in each database, accounting for over 1/3 of HBTC in Germany and about half of cases in the US. Overall age adjusted 5-year relative survival for HBTC in 2006-2013 was 19.1% in Germany and 20.6% in the US. Five-year relative survival increased by 3.8% units in Germany and 4.5% units in the US between 2002-2005 and 2010-2013. Five-year relative survival for individual types of HBTC ranged from 9.8% in Germany and 2.9% in the US for not otherwise specified biliary tract cancers to 44.4% and 50.1%, respectively, in Germany and the US for duodenal cancers. In conclusion, survival for HBTC remains poor in both Germany and the US, although a small increase in survival in the past decade was observed. Further work to find better treatment options for HBTC is needed to improve survival.

Correction: Medical rehabilitation of older employees with migrant background in Germany: Does the utilization meet the needs?

[This corrects the article DOI: 10.1371/journal.pone.0263643.].

Medical rehabilitation of older employees with migrant background in Germany: Does the utilization meet the needs?

Due to demographic change with an ageing workforce, the proportion of employees with poor health and a need for medical rehabilitation is increasing. The aim was to investigate if older employees with migrant background have a different need for and utilization of medical rehabilitation than employees without migrant background. To investigate this, self-reported data from older German employees born in 1959 or 1965 of the first and second study wave of the lidA cohort study were exploratory analyzed (n = 3897). Subgroups of employees with migrant background were separated as first-generation, which had either German or foreign nationality, and second-generation vs. the rest as non-migrants. All subgroups were examined for their need for and utilization of medical rehabilitation with descriptive and bivariate statistics (chi-square, F- and post-hoc tests). Furthermore, multiple logistic regressions and average marginal effects were calculated for each migrant group separately to assess the effect of need for utilization of rehabilitation. According to our operationalizations, the foreign and German first-generation migrants had the highest need for medical rehabilitation while the German first- and second-generation migrants had the highest utilization in the bivariate analysis. However, the multiple logistic model showed significant positive associations between their needs and utilization of rehabilitation for all subgroups. Further in-depth analysis of the need showed that something like under- and oversupply co-exist in migrant groups, while the foreign first-generation migrants with lower need were the only ones without rehabilitation usage. However, undersupply exists in all groups independent of migrant status. Concluding, all subgroups showed suitable use of rehabilitation according to their needs at first sight. Nevertheless, the utilization does not appear to have met all needs, and therefore, the need-oriented utilization of rehabilitation should be increased among all employees, e.g. by providing more information, removing barriers or identifying official need with uniform standards.

Subjective employment perspective among older workers with and without migrant background in Germany-Results of the lidA cohort study.

OBJECTIVES: The aim of this study was to investigate the subjective employment perspective in higher working age for different employee groups with migrant background (EMB) and without (non-EMB), meaning willing, being able, and planning to work until the individual state pension age (iSPA). METHODS: A representative sample of socially insured employees born in 1959 or 1965 was surveyed in 2011, 2014, and 2018 with computer-assisted personal interviews. The current cross-sectional analysis is based on data from the third study wave (n = 3286) of the lidA cohort study. EMB were differentiated via generation (first generation, G1, vs second generation, G2) or nationality (German vs foreign). Applying bivariate statistics with the tests of independence and block-wise logistic regressions, group differences were investigated. Sex, age, educational level, net household income, health, and work factors were considered as covariates. RESULTS: When comparing subgroups of EMB, significant differences appeared in bivariate analyses for willing and planning to work. G1 were to a higher degree planning to work longer than G2 and those with foreign nationality were more willing and planning than those with German nationality. Multivariate analyses revealed significant differences of G1 and non-EMB for planning, being significant in the fully adjusted model, but not for willing. CONCLUSION: The findings underline the need for differentiation of migrant groups in social research and policy. When it comes to extended working lives, the first-generation migrant group, as well as foreigners may constitute risk groups and require increased attention from a work, health, and economic point of view.

Utilisation of medical rehabilitation services by persons of working age with a migrant background, in comparison to non-migrants: a scoping review.

In Germany, an ageing population is affected by societal and political changes due to demographic transition, e.g. by a prolonged working life for older employees. Demographic change also influences persons of higher working age with a migrant background. In 2018, 25% of all employees in Germany had a migrant background. Those affected by poor health at a higher working age can benefit from medical rehabilitation services, which aim to prevent early retirement and disabilities. So far, the utilisation of medical rehabilitation has been lower among persons of foreign nationality (often the only available proxy for migrant background), compared to that of Germans. The aim of this scoping review is to assess the utilisation of medical rehabilitation services by those with migrant background (PMB) and those without (non-PMB) and to identify the differences between these groups. We included 25 studies in our analysis, which were mainly secondary analyses of routine data and also a small number of primary studies. The results were inconsistent: studies published before 2018 showed a lower use of rehabilitation services for persons of foreign nationality compared to Germans. However, no differences were found between PMB and non-PMB in studies published in 2018 or later. PMB, as well as foreign nationals, showed poorer health before medical rehabilitation utilisation and had a higher chance of occupational disease and a lower education level. We identified a lower work-related performance, as well as barriers (e.g. information deficits) in the utilisation of rehabilitation services for groups of PMB. Our review is limited in that we cannot generalise our results to all PMB living in Germany. This is because of the heterogeneity, the limited number of studies and lack of representativeness in some studies. In many cases, studies only analyse the nationality, but they lack information about the second generation PMB. Future studies should survey the utilisation of medical rehabilitation services by migrant background rather than by nationality and focus on changes in the provision of rehabilitation measures following diversity-centred strategies.

Divergent Patterns and Trends in Breast Cancer Incidence, Mortality and Survival Among Older Women in Germany and the United States.

BACKGROUND: Breast cancer treatment has changed tremendously over the last decades. In addition, the use of mammography screening for early detection has increased strongly. To evaluate the impact of these developments, long-term trends in incidence, mortality, stage distribution and survival were investigated for Germany and the United States (US). METHODS: Using population-based cancer registry data, long-term incidence and mortality trends (1975-2015), shifts in stage distributions (1998-2015), and trends in five-year relative survival (1979-2015) were estimated. Additionally, trends in five-year relative survival after standardization for stage were explored (2004-2015). RESULTS: Age-standardized breast cancer incidence rates were much higher in the US than in Germany in all periods, whereas age-standardized mortality began to lower in the US from the 1990s on. The largest and increasing differences were observed for patients aged 70+ years with a 19% lower incidence but 45% higher mortality in Germany in 2015. For this age group, large differences in stage distributions were observed, with 29% (Germany) compared to 15% (US) stage III and IV patients. Age-standardized five-year relative survival increased strongly between 1979-1983 and 2013-2015 in Germany (+17% units) and the US (+19% units) but was 9% units lower in German patients aged 70+ years in 2013-2015. This difference was entirely explained by differences in stage distributions. CONCLUSIONS: Overall, our results are in line with a later uptake and less extensive utilization of mammography screening in Germany. Further studies and efforts are highly needed to further explore and overcome the increased breast cancer mortality among elderly women in Germany.