Social inequalities in aggravating factors of somatic symptom persistence (SOMA.SOC): study protocol for a mixed-method observational study focusing on irritable bowel syndrome and fatigue.

INTRODUCTION: Some studies indicate that persistent somatic symptoms (PSS) are more prevalent among individuals with a low socioeconomic status (SES) and a migration background. However, factors explaining social inequalities in PSS are largely unknown. It is expected that aggravating factors of PSS like illness perception, illness beliefs (health literacy, stigma), illness behaviour and health anxiety may play an important role for this explanation. The SOMA.SOC study will examine social inequalities (according to SES and migration) in factors contributing to symptom persistence in irritable bowel syndrome (IBS) and fatigue. METHODS AND ANALYSIS: The project will collect both quantitative and qualitative data. Quantitative data will be gathered via a representative telephone survey in Germany (N=2400). A vignette design will be used depicting patients varying in sex, condition (IBS/fatigue), occupational status (low/high) and migration (yes/no). In the survey, we will assess public knowledge and beliefs (eg, health literacy), attitudes (stigma) and personal experiences with the condition (eg, somatic symptom burden). Complementary, longitudinal qualitative interviews will be conducted with patients (n=32 at three time points, resulting in N=96 interviews) who will also vary according to sex, condition, occupational status and migration. Patients will be recruited from primary care practices in Hamburg. The interviews will cover origin and development of the condition, coping and help-seeking as well as social interactions and perception of the disease by others (eg, perceived stigma). SOMA.SOC is part of the interdisciplinary SOMACROSS (Persistent SOMAtic Symptoms ACROSS Diseases) research unit. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of the Hamburg Medical Association on 25 January 2021 (reference number: 2020-10194- BO-ff). Informed consent will be obtained from all participants. The main findings will be submitted for publication in peer-reviewed journals within 12 months of study completion.

Social inequalities in health anxiety: A systematic review and meta-analysis.

OBJECTIVE: The association between a low socioeconomic status and poor health, also known as social inequalities in health, has been shown in numerous studies. This also applies to most mental illnesses, such as somatization or anxiety disorders. It is unclear, however, whether social inequalities are evident in health anxiety as well. Therefore, this review and meta-analysis systematically examines social inequalities in health anxiety. METHODS: A systematic literature search was conducted covering all studies published until August 2021. The databases PubMED, Web of Science, PsycINFO, and PSYNDEX were screened to identify quantitative studies using validated tools to measure health anxiety and examining the association with socioeconomic status. Meta-analytic methods were applied by using random-effect models. The study quality was assessed with the Effective Public Health Practice Project Quality Assessment Tool. RESULTS: Overall, 37 studies were eligible for meta-analysis. Effect sizes of 27 studies using screening scales and 10 studies using diagnostic interviews to measure health anxiety were calculated separately. Meta-analyses revealed a significant association between socioeconomic status and health anxiety (r - 0.14, 95%-CI -0.18 to -0.09 (screening scales) and OR 0.63, 95%-CI 0.43 to 0.92 (diagnostic interviews)), indicating a lower risk for health anxiety in people with higher socioeconomic status. CONCLUSION: Findings suggest that the health-related disadvantage of socially deprived people is also evident regarding health anxiety. This should be considered in programs to reduce social inequalities in health. PROSPERO registration number CRD42021237550.

What Does the Public Know About Varying Depression Severity?-Results of a Population Survey.

Objectives: In this study, we examine the public's knowledge about different levels of depression severity in Germany. Methods: Data stem from a national telephone survey in Germany. A total of 1,009 persons participated, response rate was 46.8%. A vignette was presented with signs of mild, moderate or severe depression. Participants were asked what they think the person has, which persons and services are helpful and how effective different treatment options are. Differences between the three vignettes were tested with 95% confidence intervals and χ 2-tests. Results: 55.3% of the respondents identified depression as the health problem in question. Participants who heard the vignette with moderate symptomatology recognized depression more often. Across groups, a general practitioner was named most frequently concerning helpful persons/services. Effectiveness of psychotherapy received high levels of approval, online therapy and books were less often rated as effective. There were only few significant differences between the three vignettes. Conclusions: This is the first study examining public depression literacy for different severity levels. Small differences between severity levels indicate a lack of knowledge, which may have adverse consequences for adherence to treatment, especially for mild depression.

Obesity stigma in Germany and the United States - Results of population surveys.

INTRODUCTION: Over the past decades, obesity stigma has become a substantial public health issue as studies have highlighted its negative consequences for mental and physical health. However, comparative studies are scarce. In this cross-national study, we focus on the following research questions: (1) Are there differences in the magnitude of public obesity stigma between Germany and the United States (US), and (2) are there differences in the associations of sociodemographic as well as experience (i.e. former obesity experience) and contact-related (i.e. contact to a person with obesity) factors with public obesity stigma between these two countries? MATERIAL AND METHODS: National telephone surveys in Germany and the United States were conducted (total sample = 2,802) by using vignettes for the description of a person with obesity. Fat Phobia Scale, negative reactions, and desire for social distance were assessed as components of public obesity stigma. All three stigma components were examined with multilevel linear regression analyses. RESULTS: Overall, results show that public obesity stigma is significantly more pronounced in the US than in Germany. Relationships between obesity stigma and sociodemographic as well as experience and contact-related factors remain rather inconclusive, though, in general, stronger associations are shown in the US. CONCLUSIONS: Contrary to the normalization hypothesis, findings indicate that a comparatively high prevalence of obesity like in the US is associated with a higher level of obesity stigma.

Social deprivation, gender and obesity: multiple stigma? Results of a population survey from Germany.

OBJECTIVES: Individuals with obesity are subject to stigmatisation, resulting in discrimination. Studies focusing on obesity stigma often do not account for social conditions that also may be associated with stigmatisation. Following an intersectional approach, social categories such as gender and socioeconomic status (SES) can interact and form a basis for multiple stigma. The present study analyses differences in public obesity stigma depending on gender and SES, as well as possible interdependencies between these social categories. DESIGN: Representative cross-sectional telephone survey. PARTICIPANTS: 692 randomly selected adults (≥ 18 years) in Germany. METHODS: Different vignettes were presented, depicting a lawyer (male/female) or a janitor/cleaner (male/female) with obesity. Following the vignette, different components of stigma were assessed: (1) fat phobia, (2) emotional reactions to a person with obesity and (3) desire for social distance. Associations between gender, SES and stigma components were tested in multiple linear regression analyses. RESULTS: A low SES in the obesity vignette (janitor/cleaner) was significantly associated with higher fat phobia scores as well as desire for social distance, compared with the vignette with a person with obesity and a high SES (lawyer). Being a male with obesity was significantly associated with more pronounced negative emotional reactions and greater desire for social distance. There were no significant interaction effects between gender and SES. CONCLUSIONS: Results support the hypothesis of multiple stigma. Being male or of low SES was significantly associated with more pronounced negative attitudes in the German public. Following the concept of intersectionality, our findings indicate that obesity stigma can exacerbate pre-existing inequalities. This needs to be considered in development and implementation of prevention and anti-stigma measures.

[Self-Stigma of Depression Scale SSDS - Evaluation of the German Version]. / Self-Stigma of Depression Scale SSDS ­ Evaluation der deutschen Skalenversion.

OBJECTIVES: A better understanding of self-stigma facilitates the development and evaluation of anti-stigma measures. In this study, the Self-Stigma of Depression Scale (SSDS) is applied for the first time in Germany. The focus lies on feasibility and psychometric characteristics of the scale. METHODS: Data stem from a representative population survey in Germany (N = 2,013). The 16 items of the original SSDS are used to assess anticipated self-stigma in case of depression. Main component analysis is applied to analyze the factor structure. RESULTS: The original version of the SDSS could not be replicated in the German sample. Instead of four, three factors emerged in the German version. They are similar to three subscales of the original SSDS: "social inadequacy", "help-seeking inhibition" and "self-blame". The internal reliability of the total scale as well as of the first two subscales is acceptable. CONCLUSION: SSDS is a multidimensional construct and can serve as an important instrument in research regarding self-stigma of depression in Germany. A further development of the German scale is recommended in order to gain greater insight into the nature of (anticipated) depression self-stigma.

Differences in depression stigma towards ethnic and socio-economic groups in Germany - Exploring the hypothesis of double stigma.

BACKGROUND: Ethnic minorities and people with a low socio-economic status (SES) are often mentioned groups potentially affected by double stigma when faced with the burden of mental illness. Against this background we examine differences in public attitudes towards a) migrant vs. non-migrant persons with depression and b) low vs. high SES persons with depression. METHOD: Analyses are based on data of a representative cross-sectional telephone survey among the adult population in Germany (N=2013). To compare the four groups, different depression vignettes were presented to the respondents. Three components of stigma were assessed in the survey: (1) characteristics ascribed to persons with a depression, (2) emotional reactions to people afflicted by depression, and (3) desire for social distance. RESULTS: Respondents less often felt annoyed when the person in the depression vignette was a migrant coming from Turkey. However, differences are not statistically significant in the vast majority of the analyzed items. In terms of the comparison between high and low SES persons, analyses reveal small and inconsistent differences in public depression stigma. LIMITATIONS: The study focusses on two deprived groups (ethnic minorities and people with a low SES) and is restricted to Germany. CONCLUSIONS: Individuals with a low SES (compared to those with a high SES) and migrants (compared to non-migrants) with depression do not seem to be confronted with double public stigma in terms of stereotypes, emotional reactions, and desire for social distance.

Sex differences in attitudes towards females with eating disorders.

BACKGROUND: This study aims to examine the public's attitudes and predictors of social distance towards women afflicted by eating disorders (anorexia nervosa [AN] and bulimia nervosa [BN]) under specific consideration of the respondents' sex. Eating disorders are still often seen as a women's health issue, and those afflicted remain stigmatized in Western societies. The concept of social distance is a frequently used indicator in awareness campaigns. Sex-specific results could add important information to destigmatization programs. METHODS: Data originate from a German telephone survey which was conducted in 2011. Vignettes with signs and symptoms either suggestive of AN or BN were presented to the respondents randomly, who subsequently answered questions regarding beliefs about causes, contact to persons afflicted as well as desire for social distance. Stratified multiple linear regression analyses according to disorder under study were performed to examine associations between different predictors and desire for social distance. RESULTS: There were significant sex differences in desire for social distance, causal attributions, and emotional reactions towards women with eating disorders. E.g., with respect to AN, women exhibited a significantly greater desire for social distance than men (p<.001), and more frequently believed that AN could be caused by sexual abuse during childhood. Regarding predictors of social distance, there was a significant positive association between age and desire for social distance equally among men and women. However, distinct sex differences came into effect concerning other predictors depending on the eating disorder under study. In BN, attribution of brain disease emerged as significant predictor of social distance among men. This is not true for women, where the attribution of weak will significantly predicted the desire for social distance. CONCLUSION: Sex-dependent differences in attitudes and predictors of social distance towards females afflicted should be met with tailored measures in anti-stigma campaigns, addressing women and men on different levels.

Benefit and adherence of the disease management program "diabetes 2": a comparison of Turkish immigrants and German natives with diabetes.

There is an ongoing debate about equity and equality in health care, and whether immigrants benefit equally from services as the non-immigrant population. The study focuses on benefits from and adherence to the diabetes mellitus type 2 (DM 2) disease management program (DMP) among Turkish immigrants in Germany. So far, it has not been researched whether this group benefits from enrollment in the DMP as well as diabetics from the non-immigrant population. Data on the non-immigrant sample (N = 702) stem from a survey among members of a German health insurance, the Turkish immigrant sample (N = 102) was recruited in the area of Hamburg. Identical questions in both surveys enable comparing major components. Regarding process quality, Turkish diabetics do not differ from the non-immigrant sample; moreover, they have significantly more often received documentation and diabetes training. In terms of outcome quality however, results display a greater benefit on behalf of the non-immigrant sample (e.g., blood parameters and body mass index), and they also met more of the DMP criteria. This underlines the need of diabetics with Turkish background for further education and information in order to become the empowered patient as is intended by the DMP as well as to prevent comorbidities.

Beliefs about depression--do affliction and treatment experience matter? Results of a population survey from Germany.

BACKGROUND: There is not much known about the associations of beliefs about depression (depression literacy) with a history of depression and treatment experience. METHODS: Analyses were based on a telephone survey in two large German cities (Hamburg and Munich). Written vignettes with typical signs and symptoms suggestive of a depression were presented to 1293 respondents. Respondents were then asked about beliefs about causes, symptoms, prevalence, and treatment using a standardized questionnaire. For the analysis respondents were divided into three groups: (1) people who never had a depression, (2) people who had a depression but were not treated and (3) people with treatment experience. RESULTS: Respondents with experience in treatment for depression were more likely to correctly recognize the disorder, to positively evaluate treatability and to favor external factors (adverse conditions in childhood and psychosocial stress) as potential causes of depression compared to those who never were afflicted. There were no significant differences between these two groups regarding beliefs about the effectiveness of treatment options. There were only few significant differences in depression literacy between respondents who have a history of depression but have not sought help and those who never were afflicted. LIMITATIONS: The three groups were constituted on the basis of respondents׳ self-reports, not medical diagnoses. CONCLUSIONS: Our findings only partly support the general assumption that being afflicted and having sought help is associated with beliefs closer to those of professionals.

Education and the public's desire for social distance from people with depression and schizophrenia: the contribution of emotional reactions and causal attributions.

BACKGROUND: Association between education and desire for social distance from people with mental illness is unclear. AIMS: (1) Is there an association between education and social distance from people with a depression or schizophrenia? (2) Can this association be explained by beliefs about causes of and emotional reactions to the mental disorders? (3) Are there differences between the two mental disorders? METHODS: Analyses are based on a telephone survey in two large German cities (Hamburg and Munich, N = 2,014, response rate 51%). Vignettes with typical signs and symptoms suggestive of depression and schizophrenia were presented. Respondents were asked about beliefs about causes of the mental disorders, their emotional reactions and their desire for social distance. RESULTS: Lower education is significantly associated with a stronger tendency for social distance in the case of depression but not in case of schizophrenia, when age and gender are controlled. In case of depression, the association decreases when beliefs about possible causes are additionally controlled. In terms of schizophrenia, associations between education and social distance become stronger when emotional reactions are introduced. CONCLUSIONS: Our results underline that campaigns aimed at reducing stigma and social distance should consider specific emotional reactions and information needs of people with low education regarding different mental disorders.

Estimated prevalence of mental disorders and the desire for social distance--results from population surveys in two large German cities.

The study is focused on two research questions: What are the public's estimates of the prevalence of depression, schizophrenia, bulimia nervosa and anorexia nervosa? What is the relationship between the estimated prevalence of the mental disorders and the public's desire for social distance? Analyses are based on a telephone survey in two large German cities (Hamburg and Munich, N=2014, response rate 51%). Vignettes with typical signs and symptoms suggestive of a depression, schizophrenia, bulimia nervosa and anorexia nervosa were presented. Respondents were asked about the lifetime prevalence of the mental disorders and their desire for social distance. Across all four disorders under study the respondents markedly overestimate the rates of lifetime prevalence. Increasing prevalence estimation is associated with a significant decrease in the desire for social distance in case of schizophrenia. As for depression, anorexia nervosa and bulimia nervosa there are no significant associations. Many campaigns aimed at reducing stigma emphasize the high prevalence of mental disorders. The assumption of these campaigns is that reduction of the perceived distinction leads to a decrease of the desire for social distance towards those afflicted. Our results indicate that this may not generally be an effective way to reduce stigma.