[Reducing Health Inequalities: Development of a Stepwise Procedure from Data to Political Interventions]. / Verringerung der gesundheitlichen Ungleichheit: Entwicklung eines Stufenplans zur gesundheitspolitischen Entscheidungsfindung.

Low socioeconomic status (assessed by indicators such as educational level or income) is often associated with increased morbidity and mortality. This has been shown in many empirical studies, also in Germany. There are numerous calls for political interventions aimed at reducing these health inequalities, in scientific discussions as well as in the public. Asked for scientifically based recommendations on how to proceed 'from data to action̓, we have to admit that we are still faced with many questions and few answers. Developing these recommendations poses many challenges such as, for example, how to integrate the expertise from different public health disciplines. The present study focuses on the cooperation between social epidemiology, public health ethics and health economics, as we believe that these three disciplines are of particular importance here. We briefly outline what each of them could contribute to the development of practical interventions aimed at reducing health inequalities. We particularly emphasize the importance of public health ethics, as it focuses on questions that to date have largely been neglected in the German discussion: How can we evaluate the empirical data and the proposed political interventions from an ethical point of view? Which health inequalities are 'unjust̓, and how can this normative judgement be justified? Based on the expertise from the three disciplines mentioned above, the aim is to pave the way 'from data to action̓ by developing a well-structured stepwise procedure for interventions aimed at reducing health inequalities. The joint scheme could be very beneficial not only for developing practical interventions, but also for further developing each discipline in itself. The simple scheme proposed here could be a starting point that helps specify many open questions on this path 'from data to action̓.

German cooperation-network 'equity in health'-health promotion in settings.

In 2003, the German Federal Centre for Health Education (BZgA) initiated the national Cooperation-Network (CN) 'Equity in Health'. The CN is constantly increasing in size and scope, supporting setting approaches aimed at reducing health inequalities. A detailed description of the CN has not yet been available in English. The CN comprises a total of 66 institutional cooperation partners. Information concerning the structure and activities can be found on a special website. Coordination Centres (CC) have been established in the 16 federal states, for the coordination of all state-specific activities. Funding for the CN and CC is provided by the BZgA, the German statutory sickness funds and by the state-specific ministries of health. These partners also support the continuous quality improvement, which is based on the good-practice criteria developed by the Advisory Committee of the CN. In 2011, the 'Municipal Partner Process (MPP)' has been launched, specifically supporting local partners and integrated life-course approaches focussing on children. In 2015, the focus has been widened to include all age-groups. In July 2015, a new national health law concerning health promotion and prevention has been ratified by the federal Parliament, with a focus on reducing health inequalities. Currently, the details of its implementation are discussed on a nationwide basis. The CN has long advocated for such a law, and today the CN is a well-accepted partner providing concepts, methods and a strong and long-standing network. The article closes with future challenges faced by the CN.

Relevance of community structures and neighbourhood characteristics for participation of older adults: a qualitative study.

PURPOSE: Community and neighbourhood structures contribute not only to the health and well-being, but also to the participation of older adults. The degree of participation depends on both the living environment and the individual's personal characteristics, preferences and perception. However, there is still limited empirical evidence on how community and neighbourhood structures are linked to participation and health in the aged population. METHODS: A qualitative exploratory approach was chosen with a series of problem-centred, semi-structured focus group discussions. Study participants were selected from within the city of Augsburg, Southern Germany, and from two municipalities in surrounding rural districts. The interviews took place in 2013. Structuring content analysis was used to identify key concepts. RESULTS: We conducted 11 focus group discussions with a total of 78 different study participants. The study participants (33 men and 45 women) had a mean age of 74 years (range 65-92 years). Only two study participants lived in an assisted living facility. Of all study participants, 77% lived in urban and 23% in rural areas. We extracted four metacodes ('Usual activities', 'Requirements for participation', 'Barriers to participation' and 'Facilitators for participation') and 15 subcodes. Health and poorly designed infrastructure were mentioned as important barriers to participation, and friendship and neighbourhood cohesion as important facilitators. CONCLUSIONS: This qualitative study revealed that poor design and accessibility of municipal infrastructure are major barriers to participation in old age in Germany. Community and neighbourhood structures can be part of the problem but also part of the solution when accessibility and social networks are taken into account.

[Consolidated efforts to strengthen health promotion in living environments: The cooperation network "Equity in Health"]. / Gesundheitsförderung in den Lebenswelten gemeinsam stärken : Der Kooperationsverbund "Gesundheitliche Chancengleichheit".

BACKGROUND: In 2003, the German Federal Center for Health Education (BZgA) initiated a national Cooperation Network named "Equity in Health" to address scientific results, focusing on the association between social inequalities and health. The main goal is to support setting approaches aimed at reducing these health inequalities. RESULTS AND KEY ACTIVITIES: In the autumn of 2015 the Cooperation Network comprised a total of 65 (institutional) cooperation partners, e.g., from prevention and health promotion, from the medical profession, from the welfare associations, and from the municipal umbrella organziations. The website www.gesundheitliche-chancengleichheit.de was created to present the information available on all activities and structures. Further, Coordination Centers for Health Equity were established in all federal states of Germany to advise, coordinate and provide support for all those who are actively engaged in the key issues for each state. These Coordination Centers are sponsored by the statutory sickness funds and the Health Ministry of the respective states. They also support continuous quality improvement, based on the good practice criteria developed by the Cooperation Network. Since 2011, the local partner process "Health for All" (until November 2015 "Growing Up Healthily for All") has assisted the municipalities in developing their own integrated health strategies oriented toward the different stages in the life course ("prevention chains"). PERSPECTIVES: The results and structures that have emerged from the Cooperation Network form a good basis for the implementation of the new national Prevention Law passed by German Parliament in July 2015, to expand and develop further, on a country-wide basis and in the various states, living-space-oriented prevention and health promotion consolidating activities. The paper also discusses the present and future challenges of the Cooperation Network.

Individual Income, Area Deprivation, and Health: Do Income-Related Health Inequalities Vary by Small Area Deprivation?

This paper aims to explore potential associations between health inequalities related to socioeconomic deprivation at the individual and the small area level. We use German cross-sectional survey data for the years 2002 and 2006, and measure small area deprivation via the German Index of Multiple Deprivation. We test the differences between concentration indices of income-related and small area deprivation related inequalities in obesity, hypertension, and diabetes. Our results suggest that small area deprivation and individual income both yield inequalities in health favoring the better-off, where individual income-related inequalities are significantly more pronounced than those related to small area deprivation. We then apply a semiparametric extension of Wagstaff's corrected concentration index to explore how individual-level health inequalities vary with the degree of regional deprivation. We find that the concentration of obesity, hypertension, and diabetes among lower income groups also exists at the small area level. The degree of deprivation-specific income-related inequalities in the three health outcomes exhibits only little variations across different levels of multiple deprivation for both sexes.

Inequalities in health care among patients with type 2 diabetes by individual socio-economic status (SES) and regional deprivation: a systematic literature review.

INTRODUCTION: Quality of care could be influenced by individual socio-economic status (SES) and by residential area deprivation. The objective is to synthesize the current evidence regarding inequalities in health care for patients with Type 2 diabetes mellitus (Type 2 DM). METHODS: The systematic review focuses on inequalities concerning process (e.g. measurement of HbA1c, i.e. glycolised haemoglobin) and intermediate outcome indicators (e.g. HbA1c level) of Type 2 diabetes care. In total, of n = 886 publications screened, n = 21 met the inclusion criteria. RESULTS: A wide variety of definitions for 'good quality diabetes care', regional deprivation and individual SES was observed. Despite differences in research approaches, there is a trend towards worse health care for patients with low SES, concerning both process of care and intermediate outcome indicators. Patients living in deprived areas less often achieve glycaemic control targets, tend to have higher blood pressure (BP) and worse lipid profile control. CONCLUSION: The available evidence clearly points to the fact that socio-economic inequalities in diabetes care do exist. Low individual SES and residential area deprivation are often associated with worse process indicators and worse intermediate outcomes, resulting in higher risks of microvascular and macrovascular complications. These inequalities exist across different health care systems. Recommendations for further research are provided.

Long-term survival among older patients with myocardial infarction differs by educational level: results from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Socioeconomic disparities in survival after acute myocardial infarction (AMI) have been found in many countries. However, population-based results from Germany are lacking so far. Thus, the objective of this study was to examine the association between educational status and long-term mortality in a population-based sample of people with AMI. METHODS: The sample consisted of 2,575 men and 844 women, aged 28-74 years, hospitalized with a first-time AMI between 1 January 2000 and 31 December 2008, recruited from a population-based AMI registry. Patients were followed up until December 2011. Data on education, risk factors and co-morbidities were collected by individual interviews; data on clinical characteristics and AMI treatment by chart review. Cox proportional hazards models were used to assess the relationship between educational status and long-term mortality. RESULTS: During follow-up, 19.1% of the patients with poor education died compared with 13.1% with higher education. After adjustment for covariates, no effect of education on mortality was found for the total sample and for patients aged below 65 years. In older people, however, low education level was significantly associated with increased mortality (hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.05-1.98, p = 0.023). Stratified analyses showed that women older than 64 years with poor education were significantly more likely to die than women in the same age group with higher education (HR 1.57, 95% CI 1.02-2.41, p = 0.039). CONCLUSIONS: Elderly, poorly educated patients with AMI, and particularly women, have poorer long-term survival than their better educated peers. Further research is required to illuminate the reasons for this finding.

Health-related quality of life and socioeconomic status: inequalities among adults with a chronic disease.

BACKGROUND: A number of studies have shown an association between health-related quality of life (HRQL) and socioeconomic status (SES). Indicators of SES usually serve as potential confounders; associations between SES and HRQL are rarely discussed in their own right. Also, few studies assess the association between HRQL and SES among those with a chronic disease. The study focuses on the question of whether people with the same state of health judge their HRQL differently according to their SES, and whether a bias could be introduced by ignoring these differences. METHODS: The analyses were based on a representative sample of the adult population in Germany (n = 11,177). HRQL was assessed by the EQ-5D-3 L, i.e. the five domains (e.g. 'moderate or severe problems' concerning mobility) and the Visual Analog Scale (VAS). SES was primarily assessed by educational level; age, sex and family status were included as potential confounders. Six chronic diseases were selected, each having a prevalence of at least 1% (e.g. diabetes mellitus). Multivariate analyses were conducted by logistic and linear regression. RESULTS: Among adults with a chronic disease, most 'moderate or severe problems' are reported more often in the low (compared with the high) educational group. The same social differences are seen for VAS values, also in subgroups characterized by 'moderate or severe problems'. Gender-specific analyses show that for women the associations with VAS values can just be seen in the total sample. For men, however, they are also present in subgroups defined by 'moderate or severe problems' or by the presence of a chronic disease; some of these differences exceed 10 points on the VAS scale. CONCLUSIONS: Low SES groups seem to be faced with a double burden: first, increased levels of health impairments and, second, lower levels of valuated HRQL once health is impaired. These associations should be analysed and discussed in their own right, based on interdisciplinary co-operation. Social epidemiologists could include measures of HRQL in their studies more often, for example, and health economists could consider assessing whether recommendations based on HRQL scales might include a social bias.

Impact of vertigo and dizziness on self-perceived participation and autonomy in older adults: results from the KORA-Age study.

PURPOSE: The impact of vertigo and dizziness on healthy ageing, and especially on participation, is not fully understood. The objective of this study was to investigate the association of vertigo and dizziness with self-perceived participation and autonomy in older non-institutionalised individuals, adjusted for the presence of other health conditions. Specifically, we wanted to investigate the different effects of vertigo and dizziness on specific components of participation, i.e. restrictions in indoor and outdoor autonomy, family role, social life and relationships, and work and education. METHODS: Data originate from the second wave of the German KORA-Age cohort study collected in 2012. Participation and autonomy was investigated with the Impact on Participation and Autonomy Questionnaire. We used robust regression to analyse the association of vertigo and dizziness with self-perceived participation and autonomy adjusted for covariates. RESULTS: A total of 822 participants (49.6% female) had a mean age of 78.1 years (SD 6.39). Participation and autonomy were significantly lower in participants with vertigo and dizziness across all domains. Adjusted for age, sex, and chronic conditions, vertigo and dizziness were significantly associated with participation restrictions in all domains except social life and relationships. CONCLUSION: The results of our study indicate that vertigo and dizziness contribute to restrictions in participation and autonomy in individuals of older age. Recognising vertigo and dizziness as independent contributors to loss of autonomy and decreased chances for independent living may create new options for patient care and population health, such as the designing of complex interventions to maintain participation and autonomy.

Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany.

BACKGROUND: The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES). METHODS: The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity. RESULTS: We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12-1.64) as well as for obesity (OR 1.14; 95% CI 1.02-1.26). Further analyses showed that these associations were relatively similar for both men and women. CONCLUSIONS: Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.

Marital status shows a strong protective effect on long-term mortality among first acute myocardial infarction-survivors with diagnosed hyperlipidemia--findings from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Reduction of long term mortality by marital status is well established in general populations. However, effects have been shown to change over time and differ considerably by cause of death. This study examined the effects of marital status on long term mortality after the first acute myocardial infarction. METHODS: Data were retrieved from the population-based MONICA (Monitoring trends and determinants on cardiovascular diseases)/KORA (Cooperative Health Research in the Region of Augsburg)-myocardial infarction registry which assesses cases from the city of Augsburg and 2 adjacent districts located in southern Bavaria, Germany. A total of 3,766 men and women aged 28 to 74 years who were alive 28 days after their first myocardial infarction were included. Hazard ratios (HR) for the effects of marital status on mortality after one to 10 years of follow-up are presented. RESULTS: The study population included 2,854 (75.8%) married individuals. During a median follow-up of 5.3 years, with an inter-quartile range of 3.3 to 7.6 years, 533 (14.15%) deaths occurred. Among married and unmarried individuals 388 (13.6%) and 145 (15.9%) deaths occurred, respectively. Overall marital status showed an insignificant protective HR of 0.76 (95% confidence interval (CI) 0.47-1.22). Stratified analyses revealed strong protective effects only among men and women younger than 60 who were diagnosed with hyperlipidemia. HRs ranged from 0.27 (95% CI 0.13-0.59) for a two-year survival to 0.43 (95% CI 0.27-0.68) for a 10-year survival. Substitution of marital status with co-habitation status confirmed the strata-specific effect [HR: 0.52 (95% CI 0.31-0.86)]. CONCLUSIONS: Marital status has a strong protective effect among first myocardial infarction survivors with diagnosed hyperlipidemia, which diminishes with increasing age. Treatments, recommended lifestyle changes or other attributes specific to hyperlipidema may be underlying factors, mediated by the social support of spouses. Underlying causes should be examined in further studies.

Impact of educational level on health-related quality of life (HRQL): results from Germany based on the EuroQol 5D (EQ-5D).

BACKGROUND: To date, there is hardly any study focussing on the question how the concept of HRQL could deepen our understanding of health inequalities. The study aims at describing this potential by analysing data for adults from Germany. METHODS: The analyses are based on three national, representative surveys conducted from 2006 to 2008. HRQL was assessed by the EuroQol-5D (EQ-5D), the descriptive part (problems in five dimensions) and the valuation of health by visual analogue scale (VAS) rendering a value between '0' (worst) and '100' (best imaginable). The major independent variable is educational level (high vs. low). Four other variables were included (i.e. age, sex, per capita income and chronic disease). Multivariate analyses were performed by logistic and linear regression. RESULTS: Data were available for 5676 persons aged ≥ 20 years (response rate 73%). The prevalence of 'moderate or severe problems' is especially high in the dimension 'pain/discomfort' (low resp. high educational level: 46.3% resp. 25.0%). The mean VAS-value is 79.8 (low resp. high educational level: 75.3 resp. 83.6). Bivariate and multivariate analyses show that similar differences in VAS-values can be seen even after restricting the analyses to participants with a chronic disease. CONCLUSION: Empirical analyses concerning HRQL could further our understanding of health inequalities. They indicate that low status groups are faced with a double burden, first by increased levels of health impairments, and second by lower levels of HRQL once health is impaired. Thus, the extent of health inequalities could be underestimated if measures of HRQL are not taken into account.

Personal attributes that influence the adequate management of hypertension and dyslipidemia in patients with type 2 diabetes. Results from the DIAB-CORE Cooperation.

BACKGROUND: Hypertension and dyslipidemia are often insufficiently controlled in persons with type 2 diabetes (T2D) in Germany. In the current study we evaluated individual characteristics that are assumed to influence the adequate treatment and control of hypertension and dyslipidemia and aimed to identify the patient group with the most urgent need for improved health care. METHODS: The analysis was based on the DIAB-CORE project in which cross-sectional data from five regional population-based studies and one nationwide German study, conducted between 1997 and 2006, were pooled. We compared the frequencies of socio-economic and lifestyle factors along with comorbidities in hypertensive participants with or without the blood pressure target of<140/90 mmHg. Similar studies were also performed in participants with dyslipidemia with and without the target of total cholesterol/HDL cholesterol ratio<5. Furthermore, we compared participants who received antihypertensive/lipid lowering treatment with those who were untreated. Univariable and multivariable logistic regression models were used to assess the odds of potentially influential factors. RESULTS: We included 1287 participants with T2D of whom n=1048 had hypertension and n=636 had dyslipidemia. Uncontrolled blood pressure was associated with male sex, low body mass index (BMI), no history of myocardial infarction (MI) and study site. Uncontrolled blood lipid levels were associated with male sex, no history of MI and study site. The odds of receiving no pharmacotherapy for hypertension were significantly greater in men, younger participants, those with BMI<30 kg/m(2) and those without previous MI or stroke. Participants with dyslipidemia received lipid lowering medication less frequently if they were male and had not previously had an MI. The more recent studies HNR and CARLA had the greatest numbers of well controlled and treated participants. CONCLUSION: In the DIAB-CORE study, the patient group with the greatest odds of uncontrolled co-morbidities and no pharmacotherapy was more likely comprised of younger men with low BMI and no history of cardiovascular disease.

Body weight dissatisfaction by socioeconomic status among obese, preobese and normal weight women and men: results of the cross-sectional KORA Augsburg S4 population survey.

BACKGROUND: Body weight dissatisfaction is an important factor in preventing weight gain and promoting weight loss or maintenance. This study focuses on differences in the rates of body weight dissatisfaction among obese, preobese and normal weight women and men by socioeconomic status within a general adult population in Germany. METHODS: Data were analyzed from 4186 adults aged 25 to 74 who participated in a cross-sectional, representative population-based health survey (KORA S4, 1999-2001, Augsburg region/Germany). Body mass was measured anthropometrically and indexed following international standards. Among the 2123 women participating in the survey, 40.3% had a normal weight, 34.9% were preobese, and 24.8% were obese (compared to 25.9%, 51.4% and 22.6% among men, respectively). Body weight dissatisfaction, educational level, household income and occupational status were assessed by computer-aided personal interviewing. An index for socioeconomic status was calculated and categorized into quintiles. Multiple logistic regressions were performed to test for differences in the odds of body weight dissatisfaction across socioeconomic strata in normal weight, preobese and obese groups. Body mass index, age, family status, place of residence and health behaviors were adjusted for. RESULTS: Overall, being dissatisfied with one's body weight was more prevalent in women (48.3%) than in men (33.2%). In the normal weight group, no significant differences in the odds of being dissatisfied were found across socioeconomic groups among women or men. Among preobese men, compared to the lowest socioeconomic stratum, increased odds of being dissatisfied with one's body weight were associated with the highest socioeconomic index group (OR = 2.3, 95% CI: 1.4-3.8), middle and high educational level (OR = 1.6, 95% CI: 1.1-2.3, and OR = 1.9, 95% CI: 1.3-3.7), high income (OR = 1.8, 95% CI: 1.2-2.7), and middle and high occupational status (both OR = 1.8, 95% CI: 1.2-2.6). Among preobese women, the odds of being dissatisfied were only significantly elevated in those with a middle educational level (OR = 1.6, 95% CI: 1.1-2.3). Among obese men, elevated odds were found in the highest socioeconomic index group (OR = 3.7, 95% CI: 1.8-7.5) and in those with a high educational level (OR = 2.3, 95% CI: 1.3-4.1), high income (OR = 2.6, 95% CI: 1.4-4.7), and middle and high occupational status (both OR = 2.2, 95% CI: 1.3-3.6). The odds of dissatisfaction among obese women were not associated with socioeconomic status as a whole, but were associated with a high educational level, albeit with a comparatively large confidence interval (OR = 3.6, 95% CI: 1.0-12.8). CONCLUSIONS: In Germany, body weight dissatisfaction is more prevalent among obese and preobese men in high socioeconomic status groups, a pattern not found in women. The exception to this is a greater prevalence of dissatisfaction among obese and preobese women with a high educational level (albeit inconsistently). Moreover, there is a social gradient in body weight dissatisfaction, especially in obese men, which may partly explain why obesity is more prevalent in men with low socioeconomic status. It also suggests that they are a target group for obesity care in which body weight satisfaction is an important topic.

Associations between regional socioeconomic deprivation and cancer risk: Analysis of population-based Cancer Registry data from Bavaria, Germany.

OBJECTIVE: Previous research from other countries shows a positive association between cancer risk and regional deprivation. This study explores this association for lung and colorectal cancers in Germany. METHOD: Regional deprivation was assessed by the 'Bavarian Index of Multiple Deprivation'. Cancer data were provided by the Cancer Registry of Bavaria (2003-2006). The association between cancer risk and regional deprivation was evaluated by multilevel Poisson regression analysis. RESULTS: Crude incidence and mortality rates (per 1000 people) in the least deprived areas were 1.46 and 0.92 for lung cancer, 2.82 and 0.69 for colorectal cancer. For lung cancer, the age-adjusted relative risk (RR) for incidence in the most deprived districts (compared with the least deprived) in men was 1.41 (95% CI: 1.28-1.54), for mortality 1.59 (95% CI: 1.40-1.80); in women, an elevated RR was seen for mortality (1.24, 95% CI: 1.06-1.46). For colorectal cancer, the RR for incidence (men: 1.31, 95% CI: 1.17-1.46; women: 1.25, 95% CI: 1.12-1.40) and mortality (men: 1.51, 95% CI: 1.28-1.80; women: 1.49, 95% CI: 1.26-1.77) was always highest in the most deprived districts. CONCLUSION: At the district level in Bavaria, the risk for lung and colorectal cancers mostly increases with increasing regional deprivation.

Inequalities in utilisation of general practitioner and specialist services in 9 European countries.

BACKGROUND: The aim of this study is to describe the magnitude of educational inequalities in utilisation of general practitioner (GP) and specialist services in 9 European countries. In addition to West European countries, we have included 3 Eastern European countries: Hungary, Estonia and Latvia. To cover the gap in knowledge we pay a special attention to the magnitude of inequalities among patients with chronic conditions. METHODS: Data on the use of GP and specialist services were derived from national health surveys of Belgium, Estonia, France, Germany, Hungary, Ireland, Latvia, the Netherlands and Norway. For each country and education level we calculated the absolute prevalence and relative inequalities in utilisation of GP and specialist services. In order to account for the need for care, the results were adjusted by the measure of self-assessed health. RESULTS: People with lower education used GP services equally often in most countries (except Belgium and Germany) compared with those with a higher level of education. At the same time people with a higher education used specialist care services significantly more often in all countries, except in the Netherlands. The general pattern of educational inequalities in utilisation of specialist care was similar for both men and women. Inequalities in utilisation of specialist care were equally large in Eastern European and in Western European countries, except for Latvia where the inequalities were somewhat larger. Similarly, large inequalities were found in the utilisation of specialist care among patients with chronic diseases, diabetes, and hypertension. CONCLUSIONS: We found large inequalities in the utilisation of specialist care. These inequalities were not compensated by utilisation of GP services. Of particular concern is the presence of inequalities among patients with a high need for specialist care, such as those with chronic diseases.

The impact of the social environment on children's mental health in a prosperous city: an analysis with data from the city of Munich.

BACKGROUND: Children with a low socioeconomic position are more affected by mental difficulties as compared to children with a higher socioeconomic position. This paper explores whether this socioeconomic pattern persists in the prosperous German city of Munich which features high quality of life and coverage of children mental health specialists that lies well above the national average and is among the highest in Europe. METHODS: 1,265 parents of preschool children participated in a cross-sectional health survey. They were given a self-administered questionnaire (including socioeconomic variables) and the 'Strengths and Difficulties Questionnaire (SDQ)', a well-established method to identify mental difficulties among children and adolescents. Prevalence estimates for the 'SDQ-Total Difficulties Score' were calculated, with a special focus on differences by parental (resp. household) socioeconomic position. The association between parental education, household income, single parenthood, nationality, and parental working status on one hand, and their children's mental health on the other, was explored using multivariable logistic regression models. The coverage of mental health specialists per 100,000 children aged 14 or younger in the city of Munich was also calculated. RESULTS: In Munich, the distribution of mental health difficulties among children follows the same socioeconomic pattern as described previously at the national level, but the overall prevalence is about 30% lower. Comparing different indicators of socioeconomic position, low parental education and household income are the strongest independent variables associated with mental difficulties among children (OR = 2.7; CI = 1.6 - 4.4 and OR = 2.8; CI = 1.4 - 5.6, respectively). CONCLUSIONS: Socioeconomic differences in the prevalence of childhood mental difficulties are very stable. Even in a city such as Munich, which is characterized by high quality of life, high availability of mental health specialists, and low overall prevalence of these mental difficulties, they are about as pronounced as in Germany as a whole. It can be concluded that the effect of several characteristics of socioeconomic position 'overrules' the effect of a health promoting regional environment.

Socio-economic differences in life expectancy among persons with diabetes mellitus or myocardial infarction: results from the German MONICA/KORA study.

BACKGROUND: Differences in life expectancy (LE) between social groups in a specific country are a fundamental measure of health inequalities within that country. Constant monitoring of these differences provides important information on the population's general health. The purpose of the present study is to explore and quantify the socio-economic differences in LE in Germany, focussing on a topic rarely assessed in other studies, the dependency of these LE differences on the presence of myocardial infarction or diabetes mellitus. METHODS: The dataset consists of 13,427 participants (6,725 men, 6,702 women) aged 25-74 years, recruited in the region of Augsburg in Germany through three independent cross-sectional representative surveys conducted in 1984/85, 1989/90, 1994/95, with a mortality follow up in 1998 and 2002. We use a parametric model for the survival function based on the Weibull distribution, in which the hazard function is described in terms of two parameters. We estimate these parameters with a maximum likelihood method that takes into account censoring and data truncation. RESULTS: The difference in LE between the lowest and the highest socio-economic group is estimated to be 3.79 years for men and 4.10 years for women. Diabetes mellitus reduces LE of men from the upper three income quartiles by 4.88 years, and LE of men belonging to the lowest income quartile by 7.97 years. For women, the corresponding figures are 5.79 and 5.72 years. Myocardial infarction reduces LE of men and women from the upper three income quartiles by 3.65 and 3.75 years, respectively, and LE of men and women belonging to the lowest income quartile by 5.11 and 10.95 years, respectively. CONCLUSIONS: This study shows that in Germany the differences in LE by socio-economic status are comparable to those found in other European countries, and that these differences seem to increase when diabetes mellitus or myocardial infarction is present. The statistical method used allows estimates of LE with relatively small datasets.

Blood glucose testing and primary prevention of diabetes mellitus type 2--evaluation of the effect of evidence based patient information.

BACKGROUND: Evidence-based patient information (EBPI) has been recognised as important tool for informed choice in particular in the matter of preventive options. An objective, on the best scientific evidence-based consumer information about subthreshold elevated blood glucose levels (impaired fasting glucose and impaired glucose tolerance) and primary prevention of diabetes, is not available yet. Thus we developed a web-based EBPI and aim to evaluate its effects on informed decision making in people 50 years or older. METHODS/DESIGN: We conduct a web-based randomised-controlled trial to evaluate the effect of information about elevated blood glucose levels and diabetes primary prevention on five specific outcomes: (i) knowledge of elevated blood glucose level-related issues (primary outcome); (ii) attitudes to a metabolic testing; (iii) intention to undergo a metabolic testing; (iv) decision conflict; (v) satisfaction with the information. The intervention group receives a specially developed EBPI about subthreshold elevated blood glucose levels and diabetes primary prevention, the control group information about this topic, available in the internet.The study population consists of people between 50 and 69 years of age without known diabetes. Participants will be recruited via the internet page of the cooperating health insurance company, Techniker Krankenkasse (TK), and the internet page of the German Diabetes Centre. Outcomes will be measured through online questionnaires. We expect better informed participants in the intervention group. DISCUSSION: The design of this study may be a prototype for other web-based prevention information and their evaluation. TRIAL REGISTRATION: Current Controlled Trial: ISRCTN22060616.

Neuropathic pain in diabetes, prediabetes and normal glucose tolerance: the MONICA/KORA Augsburg Surveys S2 and S3.

OBJECTIVE: The prevalence of neuropathic pain in prediabetes and the associated risk factors in the general population are not known. The aim of this study was to determine the prevalence and risk factors of neuropathic pain in subjects with diabetes, impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or normal glucose tolerance (NGT). DESIGN: Survey of neuropathic painful polyneuropathy assessed by the Michigan Neuropathy Screening Instrument using its pain-relevant questions and an examination score cutpoint >2 in a diabetic and control population. An oral glucose tolerance test was performed in the control subjects. SETTING: Population of the city of Augsburg and two surrounding counties. PATIENTS: Subjects with diabetes (N = 195) and controls matched for age and sex (N = 198) from the population-based MONItoring trends and determinants in CArdiovascular/Cooperative Research in the Region of Augsburg (MONICA/KORA) Augsburg Surveys S2 and S3 aged 25-74 years. RESULTS: Among the controls, 46 (23.2%) had IGT (either isolated or combined with IFG), 71 (35.9%) had isolated IFG, and 81 had NGT. The prevalence (95% confidence interval) of neuropathic pain was 13.3 (8.9-18.9)% in the diabetic subjects, 8.7 (2.4-20.0)% in those with IGT, 4.2 (0.9-11.9)% in those with IFG, and 1.2 (0.03-6.7)% in those with NGT (overall P = 0.003). In the entire population (N = 393), age, weight, peripheral arterial disease (PAD), and diabetes were risk factors significantly associated with neuropathic pain, while in the diabetic group, these factors were age, weight, and PAD (all P < 0.05). CONCLUSIONS: The prevalence of neuropathic pain is two- to threefold increased in subjects with IGT and diabetes compared with those with isolated IFG. Apart from diabetes, the predominant risk factors are age, obesity, and PAD.