Geographische Aspekte von Gesundheit und Versorgung

The present thesis presents the broad subject of geographical public health and health services research. It discusses the theoretical background on why there are geographical variations in health, health behavior or health services utilization starting with aspects of social theory and explanations from a social epidemiological perspective. The influences of socio-economic inequality, environmental inequality and area deprivation are presented and discussed. It includes five single publications to this subject

Politische Partizipation und politische Bildung in der Schweiz. Eine empirische Untersuchung des Partizipationsverhaltens junger Erwachsener in der Schweiz

Im Vorfeld wie auch im Rückblick auf eidgenössische, kantonale oder lokale Wahlen und Abstimmungen wurde in den letzten Jahren wiederholt die angebliche Politikmüdigkeit oder gar Politikverdrossenheit thematisiert. Vor allem die jüngste Generation wird dabei oft als besonders desinteressiert an der Politik im Allgemeinen und einem politischen Engagement im Speziellen charakterisiert. Die Medien wie die Politik verorten die Gründe dafür vor allem im fehlenden politischen Interesse sowie in der angeblich mangelhaften politischen Bildung während der obligatorischen Schulzeit. Zwar zeigen diverse Wahl- und Abstimmungsstudien, dass sich junge Erwachsene in der Schweiz tatsächlich vergleichsweise unterdurchschnittlich politisch beteiligen, allerdings fehlen Untersuchungen, die einerseits das vollständige Partizipationsspektrum – also auch Partizipationsformen jenseits des institutionellen Rahmens wie Teilnahme an Demonstrationen, Online-Partizipation oder politscher Konsum – berücksichtigen und andererseits nach den Gründen fragen, warum junge Menschen sich auf die eine oder andere Weise politisch einbringen oder nicht. Insbesondere der Einfluss politischer Bildung im schulischen Unterricht wurde bisher kaum in eine solche Studie einbezogen. In meiner Dissertation widme ich daher diesen Fragen mit dem Ziel, ein umfassendes Bild davon zu präsentieren, wie und aufgrund welcher Voraussetzungen sich junge Bürgerinnen und Bürger politisch engagieren sowie welche Rolle der politische Unterricht dabei spielt, um damit einige Lücken der bisherigen Forschung zu schliessen. Unter der Annahme, dass das individuelle Verhalten – hier die politische Beteiligung – von verschiedenen individuellen wie kontextuellen Ressourcen beeinflusst wird, lehnt sich das Untersuchungsmodell an Verba et al.‘s Ressourcenmodell (1995, 2001) an. Zu den individuellen Ressourcen zählen nebst soziodemografischen und sozioökonomischen Determinanten vor allem das soziale und politische Kapital, die verfügbaren Civic Skills, Einflussfaktoren wie das politische Interesse, das Wirksamkeitsempfinden oder die Identifikation mit politischen Parteien, aber auch das politische Engagement des sozialen Umfelds sowie ausgewählte Wertvorstellungen. Auf der kontextuellen Ebene werden einerseits der politische Unterricht gemäss den Lehrplänen, andererseits das politische System im Wohnkanton berücksichtigt. Die Analysen stützen sich dabei auf eine Umfrage, welche 2013 in über 250 Klassen an Gymnasien und Berufsschulen durchgeführt wurde, sowie auf eine durch die Verfasserin durchgeführte Analyse der Lehrpläne dieser Klassen. Letztere gibt erstmals genaueren Aufschluss darüber, ob und in welchem Rahmen politische Bildung auf Sekundarstufe II unterrichtet wird. Die Ergebnisse bestätigen zum einen, dass individuelle Voraussetzungen sowie das politische Engagement im sozialen Umfeld eine zentrale Rolle spielen, ob und wie eine junge Erwachsene oder ein junger Erwachsener politisch aktiv ist. Zum anderen weisen die Lehrplananalysen auf ein sehr heterogenes Bild hin. Wo in einigen Lehrplänen viele verschiedene politische Themen und Fertigkeiten in detaillierter Art und Weise angeführt werden, enthalten andere Dokumente kaum Hinweise auf Inhalte und Kompetenzen, welche im Rahmen des politischen Unterrichts weitergegeben werden sollten.In recent years, the subject of supposed political fatigue and disenchantment of Swiss voters is repeatedly raised in the run-up to and following national, cantonal and local elections and votes. The youngest generation, in particular, is thought to be especially disinterested in politics and political engagement. The media and politicians identify the main reasons for this phenomenon as a lack of interest in politics and the reputedly deficient political education during compulsory education. Various studies about election and voting behavior have shown the comparatively low political participation of young adults in Switzerland. However, there are few studies that, on the one hand, focus on a broader range of forms of political engagement beyond institutionalized activities – such as demonstrations, online participation and political consumerism – and on the other hand, focus on the reasons why some young adults show interest in politics and elections, and others do not. Most notably, the effect of political education as taught in school was rarely included in such research. In my dissertation, I will focus on these questions with the goal of presenting a broad picture of how and why young citizens in Switzerland engage in politics and which role political education plays therein, therefore filling some of the gaps in the existing research. The principal research model is based upon Verba et al.’s resource model (1995, 2001), which assumes that individual behavior – in this case, political participation – is affected by various individual and contextual resources. Individual resources include: socio-demographic and socioeconomic determinants such as social and political capital; civic skills; influencing factors such as political interest, efficacy and identification with political parties; the political interest of one’s social environment; and select values. At the contextual level, political education according to the school curricula, and the political system of the canton of residence are taken into account. The analysis builds upon a survey that was conducted in over 250 classes in high schools and vocational training schools in 2013, as well as the author’s analysis of the respective curricula of these schools. The latter analysis provides insight for the first-time into whether and how political education is taught at this educational level. The results confirm that, on the one hand, individual preconditions as well as political engagement of one’s social environment play an important role regarding if and whether young citizens are politically active. On the other hand, the analysis of the curricula points to a very heterogeneous picture. Some curricula include many different political topics and skills, whereas other curricula provide only limited references to content and competences that should be passed on to students during classes.Durant les dernières années, lors des votations et élections fédérales, cantonales et locales, autant lors des campagnes qu’avec les résultats, on a beaucoup évoqué une supposée lassitude ou même frustration face à la politique. Ce sont avant tout les jeunes générations que l’on caractérise comme spécialement désintéressées de la politique en général et de l’engagement en particulier. Les médias ainsi que le monde politique l’expliquent par un manque d’intérêt pour ce thème ainsi qu’une formation civique considérée lacunaire durant l’école obligatoire. Diverses études montrent qu’effectivement les jeunes adultes en Suisse participent en moyenne moins à la vie politique que les autres groupes de la population. Cependant, peu d’analyses prennent en compte le spectre de la participation politique dans son ensemble, c’est-à-dire toutes les formes de contribution, également celles au-delà des cadres institutionnels, comme les manifestations, la participation en ligne et la consommation politiquement motivée. De même, peu d’études posent la question des motivations derrière les différentes formes d’engagement ou leur absence. L’influence des cours d’éducation civique dans l’enseignement scolaire a été particulièrement peu intégrée dans de telles recherches. Je consacre donc ma thèse à ces questions, m’efforçant de dresser un tableau complet de l’engagement politique des jeunes citoyennes et citoyens, de ses conditions et du rôle de l’éducation civique, dans le but de combler les lacunes de la recherche actuelle. En partant de l’hypothèse que les comportements individuels – ici l’engagement politique - soient influencés par différentes ressources individuelles et contextuelles, le modèle des ressources de Verba et al. (1995, 2001) s’impose. Outre les déterminants démographiques et socio-économiques – particulièrement le capital social et politique, ainsi que les civic skills (aptitudes civiques) – on compte parmi les ressources individuelles des facteurs d’influence comme l’intérêt pour la politique, le sentiment d’efficacité ou l’identification aux partis, mais aussi l’engagement politique de son entourage social ou encore certaines valeurs. Concernant les variables contextuelles, on prend en compte les plans d’études qui régissent l’éducation civique et le système politique du canton de domicile. Les analyses présentées ici se basent sur une enquête réalisée en 2013 dans plus de 250 classes de gymnases et d’écoles professionnelles, ainsi que sur une analyse des plans d’études de ces classes réalisée par l’auteure, qui permet pour la première fois de gagner de plus amples connaissances sur l’enseignement politique au secondaire II et ses déterminants. Les résultats permettent premièrement de confirmer que les conditions préalables individuelles ainsi que l’engagement politique de l’entourage jouent un rôle primordial dans l’engagement politique des jeunes adultes. Deuxièmement, il ressort que les plans d’études sont très hétérogènes. Alors que certains abordent des thèmes et compétences politiques de manière très détaillée, d’autres ne contiennent que peu de ce qui devrait être transmis dans le cadre d’une formation civique

Psychiatric Comorbidity and Stress in Medical Students Using Neuroenhancers

Background: Pharmacological neuroenhancement (PN) is a common healthcare problem at least among students. PN seems to be associated with stressful situations. There is a lack of data about personal characteristics, comorbidities, and coping strategies regarding stress and factors of resilience in students and medical staff. Methods: A web-based survey about the non-medical use of PN drugs with a focus on neuroenhancement was developed and distributed among medical students throughout Germany; the questionnaire was open in April and May of 2020. The survey contained questions about the use of well-known PN drugs, frequency, special purposes, reasons for the use, psychiatric disorders, use of psychotropic drugs apart from PN purposes, and factors of resilience using the brief resilience scale. Results: Data of 1,159 students of medicine were analyzed. The most frequently used substances for PN were coffee (78.8% lifetime prevalence rate), energy drinks (45.7%), caffeine tablets (24.3%), methylphenidate (5.2%), illicit amphetamines (2.0%), and cocaine (1.7%). 98.4% suspected that PN drug use could lead to addiction. PN drug use specifically for PN was significantly associated with the use of (a) any psychotropic drug (other than neuroenhancers), (b) any psychiatric disorder, and (c) higher values of feeling pressure to perform in professional/students' life and in private life as well as (d) the subjective feeling of pressure to perform to be burdening and (e) harmful to one's own health. PN drug use in general was significantly associated with being less resilient. The use of illicit PN drugs, over the counter drugs and prescription drugs was associated with being less resilient. Conclusion: This study indicates that PN with legal and illegal drugs is a widespread phenomenon among German medical students. Users seem to be more often burdened by psychiatric disorders, especially addictive disorders, the perception of stress, pressure to perform and low levels of resilience. These aspects should be considered in further investigation of PN drug use

Multimorbidity and long-term care dependency - a five-year follow-up.

BACKGROUND: Not only single, but also multiple, chronic conditions are becoming the normal situation rather than the exception in the older generation. While many studies show a correlation between multimorbidity and various health outcomes, the long-term effect on care dependency remains unclear. The objective of this study is to follow up a cohort of older adults for 5 years to estimate the impact of multimorbidity on long-term care dependency. METHODS: This study is based on claims data from a German health insurance company. We included 115,203 people (mean age: 71.5 years, 41.4% females). To identify chronic diseases and multimorbidity, we used a defined list of 46 chronic conditions based on ICD-10 codes. Multimorbidity was defined as three or more chronic conditions from this list. The main outcome was "time until long-term care dependency". The follow-up started on January 1st, 2005 and lasted for 5 years until December 31st, 2009. To evaluate differences between those with multimorbidity and those without, we calculated Kaplan-Meier curves and then modeled four distinct Cox proportional hazard regressions including multimorbidity, age and sex, the single chronic conditions, and disease clusters. RESULTS: Mean follow-up was 4.5 years. People with multimorbidity had a higher risk of becoming care dependent (HR: 1.85, CI 1.78-1.92). The conditions with the highest risks for long-term care dependency are Parkinson's disease (HR: 6.40 vs. 2.68) and dementia (HR: 5.70 vs. 2.27). Patients with the multimorbidity pattern "Neuropsychiatric disorders" have a 79% higher risk of care dependency. CONCLUSIONS: The results should form the basis for future health policy decisions on the treatment of patients with multiple chronic diseases and also show the need to introduce new ways of providing long-term care to this population. A health policy focus on chronic care management as well as the development of guidelines for multimorbidity is crucial to secure health services delivery for the older population

Referral trajectories in patients with vertigo, dizziness and balance disorders and their impact on health-related quality of life and functioning: results from the longitudinal multicenter study MobilE-TRA

BACKGROUND: Due to reported barriers in the management of patients with vertigo, dizziness and balance problems (VDB), referral trajectories starting from primary care might be determined by other factors than medical necessity. The objective of this paper was to examine the impact of disease-related and other determinants on referral trajectories of older patients with VDB and to investigate, how these trajectories affect the patients’ functioning and health-related quality of life (HRQoL). METHODS: Data originate from the longitudinal multicenter study MobilE-TRA, conducted in two German federal states. Referrals to neurologists or ear-nose-throat (ENT) specialists were considered. Referral patterns were visualized using a state sequence analysis. Predictors of referral trajectories were examined using a multinomial logistic regression model. Linear mixed models were calculated to assess the impact of referral patterns on the patients’ HRQoL and functioning. RESULTS: We identified three patterns of referral trajectories: primary care physician (PCP) only, PCP and neurologist, and PCP and ENT. Chances of referral to a neurologist were higher for patients with a neurological comorbidity (OR = 3.22, 95%-CI [1.003; 10.327]) and lower for patients from Saxony (OR = 0.08, 95%-CI [0.013; 0.419]). Patients with a PCP and neurologist referral pattern had a lower HRQoL and lower functioning at baseline assessment. Patients with unspecific diagnoses also had lower functioning. CONCLUSION: Referral trajectories were determined by present comorbidities and the regional healthcare characteristics. Referral trajectories affected patients’ HRQoL. Unspecific VDB diagnoses seem to increase the risk of ineffective management and consequently impaired functioning. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00415-022-11060-8

Overutilization of ambulatory medical care in the elderly German population? – An empirical study based on national insurance claims data and a review of foreign studies

Background: By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healtcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008. Methods: The study is based on the claims data of all insurants aged >= 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were = 50 contacts with practices or contacts with = 10 different practices or = 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases. Results: Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent. Conclusion: We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people

Geografische Ansätze in der Gesundheitsberichterstattung

The interest in using geographic methods for health monitoring has grown strongly over the last two decades. Through these methods, analysis and visualization of health data can be more focused and target-group specific. The application in health monitoring is possible mostly due to broader technical possibilities and more available datasets. In this article, we show which geographic aspects are adapted in health monitoring at different levels (federal, state, municipality). For example, at the federal level, surveillance methods are used; at the state level health atlases are created; and on the municipality level geographic analyses are performed for possible public health interventions.Methods range from simple maps on different levels of aggregation to more complex methods like space-temporal visualization or spatial-smoothing methods. While the technical possibilities are in place, a broader implementation of geographic methods is mostly hindered by missing data access to small-area information and data protection policies. Better access to data could especially improve the possibility for geographic methods in health monitoring and could inform the population and decision makers to inform and improve population health or healthcare.Das Interesse an geografischen Darstellungen in der Gesundheitsberichterstattung (GBE) ist in den letzten beiden Jahrzehnten stark gewachsen. Gesundheitsdaten können mit diesen Methoden anschaulich und zielgruppenorientiert visualisiert werden. Neue technische Möglichkeiten und die breitere Verfügbarkeit von Daten tragen zur verstärkten Anwendung in der GBE bei. In diesem Artikel soll gezeigt werden, welche geografischen Ansätze in der GBE auf Bundes‑, Länder- und Kommunalebene jeweils aktuell verfolgt werden. Insbesondere soll dabei auf die verwendeten Methoden fokussiert werden. Es wird gezeigt, dass auf Bundesebene geografische Methoden z. B. in der Surveillance angewendet werden; auf Länderebene gibt es z. B. Gesundheitsatlanten und auf der Kommunalebene verschiedene geografische Analysen. Die methodische Spannweite reicht von einfacheren Kartendarstellungen auf unterschiedlichen Aggregationsebenen bis hin zu komplexeren Verfahren wie raum-zeitlichen Darstellungen und räumlichen Glättungsverfahren. Fehlender Datenzugang oder datenschutzrechtliche Aspekte behindern noch häufig die Verbindung mit weiteren Datenquellen oder kleinräumigere Darstellungen. Vor allem ein besserer Zugang zu Daten auf kleinräumiger Ebene könnte die GBE aber erheblich erleichtern. Die Bevölkerung und Entscheidungsträger könnten dadurch noch umfassender informiert und folglich die Gesundheit und die gesundheitliche Versorgung der Bevölkerung verbessert werden