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.

Social inequality, social networks, and health: a scoping review of research on health inequalities from a social network perspective.

BACKGROUND: This review summarises the present state of research on health inequalities using a social network perspective, and it explores the available studies examining the interrelations of social inequality, social networks, and health. METHODS: Using the strategy of a scoping review, as outlined by Arksey and O'Malley (Int J Sci Res Methodol 8:19-32, 2005), our team performed two searches across eight scientific, bibliographic databases including papers published until October 2021. Studies meeting pre-defined eligibility criteria were selected. The data were charted in a table, and then collated, summarised, and reported in this paper. RESULTS: Our search provided a total of 15,237 initial hits. After deduplication (n = 6,168 studies) and the removal of hits that did not meet our baseline criteria (n = 8,767 studies), the remaining 302 full text articles were examined. This resulted in 25 articles being included in the present review, many of which focused on moderating or mediating network effects. Such effects were found in the majority of these studies, but not in all. Social networks were found to buffer the harsher effects of poverty on health, while specific network characteristics were shown to intensify or attenuate the health effects of social inequalities. CONCLUSIONS: Our review showed that the variables used for measuring health and social networks differed considerably across the selected studies. Thus, our attempt to establish a consensus of opinion across the included studies was not successful. Nevertheless, the usefulness of social network analysis in researching health inequalities and the employment of health-promoting interventions focusing on social relations was generally acknowledged in the studies. We close by suggesting ways to advance the research methodology, and argue for a greater orientation on theoretical models. We also call for the increased use of structural measures; the inclusion of measures on negative ties and interactions; and the use of more complex study designs, such as mixed-methods and longitudinal studies.

Burdening and Protective Organisational Factors among International Volunteers in Greek Refugee Camps-A Qualitative Study.

A majority of the workforce in the humanitarian aid consists of volunteers who partly suffer from health problems related to their voluntary service. To date, only a fraction of the current research focuses on this population. The aim of this qualitative explorative study was to identify burdening and protective organisational factors for health and well-being among humanitarian aid volunteers in a Greek refugee camp. To this end, interviews with 22 volunteers were held on site and afterwards analysed by using qualitative content analysis. We focused on international volunteers working in Greece that worked in the provision of food, material goods, emotional support and recreational opportunities. We identified burdening factors, as well as protective factors, in the areas of work procedures, team interactions, organisational support and living arrangements. Gender-specific disadvantages contribute to burdening factors, while joyful experiences are only addressed as protective factors. Additionally, gender-specific aspects in the experience of team interactions and support systems were identified. According to our findings, several possibilities for organisations to protect health and well-being of their volunteers exist. Organisations could adapt organisational structures to the needs of their volunteers and consider gender-specific factors.

Health Patterns among Migrant and Non-Migrant Middle- and Older-Aged Individuals in Europe-Analyses Based on Share 2004-2017.

INTRODUCTION: European populations are becoming older and more diverse. Little is known about the health differences between the migrant and non-migrant elderly in Europe. The aim of this paper was to analyse changes in the health patterns of middle- and older-aged migrant and non-migrant populations in Europe from 2004 to 2017, with a specific focus on differences in age and gender. We analysed changes in the health patterns of older migrants and non-migrants in European countries from 2004 to 2017. METHOD: Based on data from the Survey of Health, Ageing and Retirement in Europe (6 waves; 2004-2017; n = 233,117) we analysed three health indicators (physical functioning, depressive symptoms, and self-rated health). Logistic regression models for complex samples were calculated. Interaction terms (wave * migrant * gender * age) were used to analyse gender and age differences and the change over time. RESULTS: Middle- and older-aged migrants in Europe showed significantly higher rates of depressive symptoms, lower self-rated health, and a higher proportion of limitations on general activities compared to non-migrants. However, different time trends were observed. An increasing health gap was identified in the physical functioning of older males. Narrowing health gaps over time were observed in women. DISCUSSION: An increasing health gap in physical functioning in men is evidence of cumulative disadvantage. In women, evidence points towards the hypothesis of aging-as-leveler. These different results highlight the need for specific interventions focused on healthy ageing in elderly migrant men.

Educational inequalities in self-rated health and social relationships - analyses based on the European Social Survey 2002-2016.

BACKGROUND: While there is evidence for educational health inequalities in Europe, studies on time trends and on the explanatory contribution of social relations are less consistent. It has been shown that the use of welfare state typologies can be helpful to examine health inequalities in a comparative perspective. Against this background, analyses are focused on three research questions: (1) How did educational inequalities in self-rated health (SRH) develop between 2002 and 2016 in different European countries? (2) In how far can structural and functional aspects of social relations help to explain these inequalities? (3) Do these explanatory contributions vary between different types of welfare states? METHODS: Data stem from the European Social Survey. Data from 20 countries across 8 waves (2002-2016) was included in the sample (allocated to 5 types of welfare states). Structural aspects of social relations were measured by living with a partner, frequency of social contacts and social participation. Availability of emotional support was used as functional dimension. Educational level was assessed based on the International Standard Classification of Education. SRH was measured in all waves on a five-point scale by one question: "How is your health in general? Would you say it is very good, good, fair, bad or very bad?" RESULTS: Across all countries, educational inequalities were increasing between 2002 and 2016. Explanatory contribution of emotional support, living with a partner, and social contacts was small (5% or less across the eight waves). Social participation explained 11% of the educational inequalities in SRH in the European countries. There were small variations in the explanatory contribution of social participation between welfare states. CONCLUSIONS: Promoting social participation, especially of people with low education is a possible intervention to reduce inequalities in SRH in Europe.

Social relationships and GP use of middle-aged and older adults in Europe: a moderator analysis.

OBJECTIVES: This paper investigates (1) how social relationships (SRs) relate to the frequency of general practitioner (GP) visits among middle-aged and older adults in Europe, (2) if SRs moderate the association between self-rated health and GP visits, and (3) how the associations vary regarding employment status. METHODS: Data stem from the Survey of Health, Ageing and Retirement in Europe project (wave 4, 56 989 respondents, 50 years or older). GP use was assessed by frequency of contacts with GPs in the last 12 months. Predictors were self-rated health and structural (Social Integration Index (SII), social contact frequency) and functional (emotional closeness) aspects of SR. Regressions were used to measure the associations between GP use and those predictors. Sociodemographic and socioeconomic factors were used as covariates. Additional models were computed with interactions. RESULTS: Analyses did not reveal significant associations of functional and structural aspects of SR with frequency of GP visits (SII: incidence rate ratio (IRR)=0.99, 95% CI 0.97 to 1.01, social contact frequency: IRR=1.04, 95% CI 1.00 to 1.07, emotional closeness: IRR=1.02, 95% CI 1.00 to 1.04). Moderator analyses showed that 'high social contact frequency people' with better health had more statistically significant GP visits than 'low social contact frequency people' with better health. Furthermore, people with poor health and an emotionally close network showed a significantly higher number of GP visits compared with people with same health, but less close networks. Three-way interaction analyses indicated employment status specific behavioural patterns with regard to SR and GP use, but coefficients were mostly not significant. All in all, the not employed groups showed a higher number of GP visits. CONCLUSIONS: Different indicators of SR showed statistically insignificantly associations with GP visits. Consequently, the relevance of SR may be rated rather low in quantitative terms for investigating GP use behaviour of middle-aged and older adults in Europe. Nevertheless, investigating the two-way and three-way interactions indicated potential inequalities in GP use due to different characteristics of SR accounting for health and employment status.

[Reform efforts in dentistry - national and international approaches]. / Reformbemühungen in der Zahnmedizin ­ nationale und internationale Ansätze.

The Study of dentistry in Germany is in need of reform. The actual regulation on licensing dentists in Germany is from 1955, with the last changes made in 1993. Recently there have been different initiatives related to reform: a national catalogue of competency-based learning objectives in dental education (NKLZ), changes and stipulations in the respective rules relating to undergraduate curriculum in dental medicine, and an initiative of the Germany Ministry of Health to tackle and reorganize dental education in Germany.This article presents and reflects on these reform efforts in the context of actual teaching in Germany, Europe, and the United States.The reform process is an opportunity for dental education in German faculties of medicine. New dentistry programs are allowed at all faculties with model educational programs in medicine. Therefore, an example of actual reform efforts are presented based on the experiences of Hamburg. Research on dental educational programs revealed interesting approaches in dental education in other European faculties of medicine. Selected faculties were visited. These experiences led to the formulation of five main goals of reform: interdisciplinary study, problem- and symptom-based learning, early patient contact, science-based education, and communication training. The main goal is a dental education program designed along science-based, prevention-oriented, multidisciplinary, and individualized dental care that contributes to the life-long oral health of patients.

Public awareness of poverty as a determinant of health: survey results from 23 countries.

OBJECTIVES: We aim to examine (1) variations in the public awareness of poverty as a determinant of health and (2) associations of individual and macro level factors with awareness. METHODS: Analyses are based on the International Social Survey Programme. Data stem from 23 countries (N = 37,228) that were assigned to six welfare states. Sociodemographic, socio-economic, and health-related factors were considered as individual level characteristics. Gross domestic product, relative poverty rate, Gini coefficient, and magnitude of health inequalities were additionally introduced as macro level factors. RESULTS: About 47% of the respondents in all countries agreed with the statement that people suffer from severe health problems because they are poor (range 30-77%). Multilevel analyses reveal that awareness was least pronounced in Liberal, East European, and East Asian welfare regimes. Moreover, women, older adults, respondents with low education and income, as well as poor health were more likely to show awareness. CONCLUSIONS: There is a need to raise public awareness of the adverse health effects of poverty as the public opinion can be an important driver of political will on health and social issues.

Income, financial barriers to health care and public health expenditure: A multilevel analysis of 28 countries.

International studies have repeatedly shown that people with lower income are more likely to experience difficulties to access medical services. Less is known on why these relations vary across countries. This study investigates whether the association between income and financial barriers to health care is influenced by national public health expenditures (PHE, in % of total health expenditure). Data from the International Social Survey Programme (2011) was used (28 countries, 23,669 respondents). Financial barriers were assessed by the individual experience of forgone care due to financial reasons. Monthly equivalent household income was included as the main predictor. Other individual-level control variables were age, gender, education, subjective health, insurance coverage and place of living. PHE was considered as a macro-level predictor, adjusted for total health expenditure. Statistically significant associations between income and forgone care were found in 21 of 28 examined countries. Multilevel analyses across countries revealed that people with lower income have a higher likelihood to forgo needed medical care (OR: 3.94, 95%-CI: 2.96-5.24). After adjustments for individual-level covariates, this association slightly decreased (OR: 2.94, 95%-CI: 2.16-3.99). PHE did not moderate the relation between income and forgone care. The linkage between health system financing and inequalities in access to health care seems to be more complex than initially assumed, pointing towards further research to explore how PHE affects the redistribution of health resources in different health care systems.

Income and functional limitations among the aged in Europe: a trend analysis in 16 countries.

BACKGROUND: Analyses are focused on 3 research questions: (1) Are there absolute and relative income-related inequalities in functional limitations among the aged in Europe? (2) Did the absolute and relative income-related inequalities in functional limitations among the aged change between 2002 and 2014? (3) Are there differences in the changes of income-related inequalities between European countries? METHODS: Data stem from 7 waves (2002-2014) of the European Social Survey. Samples of people aged 60 years or older from 16 European countries were analysed (N=63 024). Inequalities were measured by means of absolute prevalence rate differences and relative prevalence rate ratios of low versus high income. Meta-analyses with random-effect models were used to study the trends of inequalities in functional limitations over time. RESULTS: Functional limitations among people aged 60 years or older declined between 2002 and 2014 in most of the 16 European countries. Older people with a low income had higher rates of functional limitations and elevated rate ratios compared with people with high income. These inequalities were significant in many countries and were more pronounced among men than among women. Overall, absolute and relative income-related inequalities increased between 2002 and 2014, especially in Ireland, the Netherlands and Sweden. CONCLUSIONS: High-income groups are more in favour of the observed overall decline in functional limitations than deprived groups. Results point to potential income-related inequalities in compression of morbidity in the recent past in Europe.

Are health care inequalities unfair? A study on public attitudes in 23 countries.

BACKGROUND: In this article we focus on the following aims: (1) to analyze national and welfare state variations in the public perception of income-related health care inequalities, (2) to analyze associations of sociodemographic, socioeconomic, health-related, and health care factors with the perception of health care inequalities. METHODS: Data were taken from the International Social Survey Programme (ISSP), an annually repeated cross-sectional survey based on nationally representative samples. 23 countries (N = 37,228) were included and assigned to six welfare states. Attitude towards income-related health care inequalities was assessed by asking: "Is it fair or unfair that people with higher incomes can afford better health care than people with lower incomes?" with response categories ranging from "very fair" (1) to "very unfair" (5). On the individual level, sociodemographic (gender, age), socioeconomic (income, education) health-related (self-rated health), and health care factors (health insurance coverage, financial barriers to health care) were introduced. RESULTS: About two-thirds of the respondents in all countries think that it is unfair when people with higher incomes can afford better health care than people with lower incomes. Percentages vary between 42.8 in Taiwan and 84 in Slovenia. In terms of welfare states, this proportion is higher in Conservative, South European, and East European regimes than in East Asian, Liberal, and Social-Democratic regimes. Multilevel logistic regression analyses show that women, people affected by a low socioeconomic status, poor health, insufficient insurance coverage, and foregone care are more likely to perceive income-related health care inequalities as unfair. CONCLUSIONS: In most countries a majority of the population perceives income-related health care inequalities as unfair. Large differences between countries were observed. Welfare regime classification is important for explaining the variation across countries.

The impact of care on family and health-related quality of life of parents with chronically ill and disabled children.

PURPOSE: Parents of disabled and/or chronically ill children are more vulnerable regarding their health compared to parents of healthy children. This study examines how far the burden of care is associated with health-related quality of life (QoL) in parents, across different illnesses and disabilities. Moreover, it is unclear whether and to which extent familial resources can explain the association between parents' care burden and health. METHOD: Data stem from a survey with the German Children's Network, a self-help umbrella organization of parents and families of chronically ill and disabled children. Data collection was conducted nationwide with a standardized online questionnaire, which included children's diagnoses and severity, burden of care, family and socioeconomic status, health-related QoL (SF-12) and family impact (Impact on Family Scale, IFS). 1567 parents participated. RESULTS: A higher burden of care is associated with higher risks for poor health-related QoL. Especially, social impact and financial burden, which are both associated with care, can help to explain these associations. CONCLUSIONS: Future interventions should focus not only on the affected child but also on the whole family system and its social integration, as this seems likely to relief parents from burden of care. Therefore, a sustainable cooperation of health care institutions and professionals with self-help groups and parental initiatives is recommended. Implications for Rehabilitation Parents of disabled and chronically ill children are a vulnerable group regarding their health-related quality of life. A higher burden of care is associated with less social contacts, higher financial burden and higher help-needs in the household, which significantly contribute to higher health risks. Rehabilitation should take these constraints into account and put a stronger focus on the family of disabled and chronically ill children to support their inclusion. A sustainable and formally anchored collaboration with self-help and patient groups is recommended.

The mediating effect of social relationships on the association between socioeconomic status and subjective health - results from the Heinz Nixdorf Recall cohort study.

BACKGROUND: Socioeconomic status (SES) is an important determinant of population health. Explanatory approaches on how SES determines health have so far included numerous factors, amongst them psychosocial factors such as social relationships. However, it is unclear whether social relationships can help explain socioeconomic differences in general subjective health. Do different aspects of social relationships contribute differently to the explanation? Based on a cohort study of middle and older aged residents (45 to 75 years) from the Ruhr Area in Germany our study tries to clarify the matter. METHODS: For the analyses data from the population-based prospective Heinz Nixdorf Recall (HNR) Study is used. As indicators of SES education, equivalent household income and occupational status were employed. Social relations were assessed by including structural as well as functional aspects. Structural aspects were estimated by the Social Integration Index (SII) and functional aspects were measured by availability of emotional and instrumental support. Data on general subjective health status was available for both baseline examination (2000-2003) and a 5-year follow-up (2006-2008). The sample consists of 4,146 men and women. Four logistic regression models were calculated: in the first model we controlled for age and subjective health at baseline, while in models 2 and 3, either functional or structural aspects of social relationships were introduced separately. Model 4 then included all variables. As former studies indicated different health effects of SES and social relations in men and women, analyses were conducted with the overall sample as well as for each gender alone. RESULTS: Prospective associations of SES and subjective health were reduced after introducing social relationships into the regression models. Percentage reductions between 2% and 30% were observed in the overall sample when all aspects of social relations were included. The percentage reductions were strongest in the lowest SES group. Gender specific analyses revealed mediating effects of social relationships in women and men. The magnitude of mediating effects varied depending on the indicators of SES and social relations. CONCLUSIONS: Social relationships substantially contribute to the explanation of SES differences in subjective health. Interventions for improving social relations which especially focus on socially deprived groups are likely to help reducing socioeconomic disparities in health.

Do social relations explain health inequalities? Evidence from a longitudinal survey in a changing eastern German region.

OBJECTIVES: This study explores the contribution of social relations to explain inequalities in self-rated health in a changing north-eastern German region. So far, there are only few studies that analysed the mediating effects of social relations in a longitudinal design. METHODS: We used data from the Study of Health in Pomerania (SHIP) consisting of 3,300 randomly selected men and women at baseline (2001), and at the 5-year follow-up (2006). Indicators of social inequality were education, equivalent household income and occupational status. Social relations were estimated by the Social Integration Index (SII) and the perceived instrumental and emotional support. Self-rated general health was assessed at both waves of data collection. RESULTS: Depending on the indicators used, social relations explain up to 35% of the inequalities in self-rated health. Changes in odds ratios are slightly more pronounced when education and income are used as inequality indicator and when adjusting for the SII. CONCLUSIONS: Overall findings suggest that social relations are an important explanatory factor for health inequalities in a deprived German region.

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.