Stage of cancer diagnoses among migrants from the former Soviet Union in comparison to the German population – are diagnoses among migrants delayed?

Background: In this study, we compared stage at diagnosis, standardized incidence ratio (SIR) and standardized mortality ratio (SMR) of most frequent cancer diagnoses between re-settlers (Aussiedler) from the former Soviet Union and the general population in the Saarland in Germany to assess possible delays in diagnosis of cancer among this migrant group. Methods: Lung cancer, colorectal cancer, breast cancer, prostate cancer, malignant melanoma of the skin and stomach cancer diagnoses among a cohort of 18,619 re-settlers living in the Saarland between 1990 and 2009 were identified by the federal state’s cancer registry. Vital status was available for the respective time-period and used to calculate SIR and SMR in comparison to the autochthonous population. Tumor stages were condensed into local and advanced stages. Odds ratios (OR) for an advanced tumor stage were modeled in dependence of re-settler-status and relevant covariates by logistic regression. Missing values were addressed in a sensitivity analysis. The influence of duration of stay in Germany on advanced stage diagnosis was analyzed among re-settlers. Results: SIR and SMR of lung and breast cancer were lower among female re-settlers, while SIR and SMR of colorectal and prostate cancer were lower among male re-settlers. SIR and SMR of stomach cancer were elevated among both sexes. Female re-settlers showed an elevated OR for being diagnosed with advanced stage breast cancer. Both male and female re-settlers showed an elevated OR when observing all six sites combined (OR among males 1.47, p = 0.04; OR among females 1.37, p = 0.05). The result of elevated ORs was supported in the sensitivity analysis. Finally, male re-settlers showed a weak association between duration of stay in Germany and reduced risk for advanced stage diagnosis. Conclusion: Re-settlers were more likely to be diagnosed at an advanced tumor stage. These findings are in line with previous research having shown unfavorable health care utilization of re-settlers. Overall, low mortality rates despite an increased risk of advanced stage at diagnosis argue for a sufficient follow-up care, comparable to the autochthonous population

The Health Status and Healthcare Utilization of Ethnic Germans in Russia

Ethnic German resettlers from the former Soviet Union are one of the largest migrant groups in Germany. In comparison with the majority of the German population, resettlers exhibit worse subjective health and utilize fewer preventive measures. However, there is little evidence on health among ethnic Germans who remained in Russia. Hence, the objective of this study was to determine the differences in subjective health, diabetes, smoking, and utilization of health check-ups between ethnic Germans and the majority population in Russia. We used data from the Russian Longitudinal Monitoring Survey II from 1994 to 2018 (general population of Russia n = 41,675, ethnic Germans n = 158). Multilevel logistic regression was used to calculate odds ratios (ORs) adjusted for age, sex, period, and place of residence. Analyses were furthermore stratified by the periods 1994–2005 and 2006–2018. Ethnic Germans in Russia rated their health less often as good compared with the Russian majority population (OR = 0.67, CI = 0.48–0.92). Furthermore, ethnic Germans were more likely to smoke after 2006 (OR = 1.91, CI = 1.09–3.37). Lower subjective health among ethnic Germans in Russia is in line with findings among minority populations in Europe. Increased odds of smoking after 2006 may indicate the deteriorating risk behavior of ethnic Germans in Russia

Using decision tree analysis to identify population groups at risk of subjective unmet need for assistance with activities of daily living

Abstract Background Identifying predictors of subjective unmet need for assistance with activities of daily living (ADL) is necessary to allocate resources in social care effectively to the most vulnerable populations. In this study, we aimed at identifying population groups at risk of subjective unmet need for assistance with ADL and instrumental ADL (IADL) taking complex interaction patterns between multiple predictors into account. Methods We included participants aged 55 or older from the cross-sectional German Health Update Study (GEDA 2019/2020-EHIS). Subjective unmet need for assistance was defined as needing any help or more help with ADL (analysis 1) and IADL (analysis 2). Analysis 1 was restricted to participants indicating at least one limitation in ADL (N = 1,957). Similarly, analysis 2 was restricted to participants indicating at least one limitation in IADL (N = 3,801). Conditional inference trees with a Bonferroni-corrected type 1 error rate were used to build classification models of subjective unmet need for assistance with ADL and IADL, respectively. A total of 36 variables representing sociodemographics and impairments of body function were used as covariates for both analyses. In addition, the area under the receiver operating characteristics curve (AUC) was calculated for each decision tree. Results Depressive symptoms according to the PHQ-8 was the most important predictor of subjective unmet need for assistance with ADL. Further classifiers that were selected from the 36 independent variables were gender identity, employment status, severity of pain, marital status, and educational level according to ISCED-11. The AUC of this decision tree was 0.66. Similarly, depressive symptoms was the most important predictor of subjective unmet need for assistance with IADL. In this analysis, further classifiers were severity of pain, social support according to the Oslo-3 scale, self-reported prevalent asthma, and gender identity (AUC = 0.63). Conclusions Reporting depressive symptoms was the most important predictor of subjective unmet need for assistance among participants with limitations in ADL or IADL. Our findings do not allow conclusions on causal relationships. Predictive performance of the decision trees should be further investigated before conclusions for practice can be drawn

Non-response in a national health survey in Germany: An intersectionality-informed multilevel analysis of individual heterogeneity and discriminatory accuracy.

BACKGROUND:Dimensions of social location such as socioeconomic position or sex/gender are often associated with low response rates in epidemiological studies. We applied an intersectionality-informed approach to analyze non-response among population strata defined by combinations of multiple dimensions of social location and subjective health in a health survey in Germany. METHODS:We used data from the cross-sectional sample of the German Health Interview and Examination Survey for Adults (DEGS1) conducted between 2008 and 2011. Information about non-responders was available from a mailed non-responder questionnaire. Intersectional strata were constructed by combining all categories of age, sex/gender, marital status, and level of education in scenario 1. Subjective health was additionally used to construct intersectional strata in scenario 2. We applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to calculate measures of discriminatory accuracy, proportions of non-responders among intersectional strata, as well as stratum-specific total interaction effects (intersectional effects). Markov chain Monte Carlo methods were used to estimate multilevel logistic regression models. RESULTS:Data was available for 6,534 individuals of whom 36% were non-responders. In scenario 2, we found weak discriminatory accuracy (variance partition coefficient = 3.6%) of intersectional strata, while predicted proportions of non-response ranged from 20.6% (95% credible interval (CI) 17.0%-24.9%) to 57.5% (95% CI 48.8%-66.5%) among intersectional strata. No evidence for intersectional effects was found. These results did not differ substantially between scenarios 1 and 2. CONCLUSIONS:MAIHDA revealed that proportions of non-response varied widely between intersectional strata. However, poor discriminatory accuracy of intersectional strata and no evidence for intersectional effects indicate that there is no justification to exclusively target specific intersectional strata in order to increase response, but that a combination of targeted and population-based measures might be appropriate to achieve more equal representation

Classification tree analysis for an intersectionality-informed identification of population groups with non-daily vegetable intake

Background!#!Daily vegetable intake is considered an important behavioural health resource associated with improved immune function and lower incidence of non-communicable disease. Analyses of population-based data show that being female and having a high educational status is most strongly associated with increased vegetable intake. In contrast, men and individuals with a low educational status seem to be most affected by non-daily vegetable intake (non-DVI). From an intersectionality perspective, health inequalities are seen as a consequence of an unequal balance of power such as persisting gender inequality. Unravelling intersections of socially driven aspects underlying inequalities might be achieved by not relying exclusively on the male/female binary, but by considering different facets of gender roles as well. This study aims to analyse possible interactions of sex/gender or sex/gender related aspects with a variety of different socio-cultural, socio-demographic and socio-economic variables with regard to non-DVI as the health-related outcome.!##!Method!#!Comparative classification tree analyses with classification and regression tree (CART) and conditional inference tree (CIT) as quantitative, non-parametric, exploratory methods for the detection of subgroups with high prevalence of non-DVI were performed. Complete-case analyses (n = 19,512) were based on cross-sectional data from a National Health Telephone Interview Survey conducted in Germany.!##!Results!#!The CART-algorithm constructed overall smaller trees when compared to CIT, but the subgroups detected by CART were also detected by CIT. The most strongly differentiating factor for non-DVI, when not considering any further sex/gender related aspects, was the male/female binary with a non-DVI prevalence of 61.7% in men and 42.7% in women. However, the inclusion of further sex/gender related aspects revealed a more heterogenous distribution of non-DVI across the sample, bringing gendered differences in main earner status and being a blue-collar worker to the foreground. In blue-collar workers who do not live with a partner on whom they can rely on financially, the non-DVI prevalence was 69.6% in men and 57.4% in women respectively.!##!Conclusions!#!Public health monitoring and reporting with an intersectionality-informed and gender-equitable perspective might benefit from an integration of further sex/gender related aspects into quantitative analyses in order to detect population subgroups most affected by non-DVI

Differential trends of admissions in accident and emergency departments during the COVID-19 pandemic in Germany

Background!#!Recent studies have shown a decrease of admissions to accident and emergency (A&E) departments after the local outbreaks of COVID-19. However, differential trends of admission counts, for example according to diagnosis, are less well understood. This information is crucial to inform targeted intervention. Therefore, we aimed to compare admission counts in German A&E departments before and after 12th march in 2020 with 2019 according to demographic factors and diagnosis groups.!##!Methods!#!Routine data of all admissions between 02.12.2019-30.06.2020 and 01.12.2018-30.06.2019 was available from six hospitals in five cities from north-western, eastern, south-eastern, and south-western Germany. We defined 10 diagnosis groups using ICD-10 codes: mental disorders due to use of alcohol (MDA), acute myocardial infarction (AMI), stroke or transient ischemic attack (TIA), heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), cholelithiasis or cholecystitis, back pain, fractures of the forearm, and fractures of the femur. We calculated rate ratios comparing different periods in 12.03.2020-30.06.2020 with 12.03.2019-30.06.2019.!##!Results!#!Forty-one thousand three hundred fifty-three cases were admitted between 12.03.2020-30.06.2020 and 51,030 cases between 12.03.2019-30.06.2019. Admission counts prior to 12.03. were equal in 2020 and 2019. In the period after 12.03., the decrease of admissions in 2020 compared to 2019 was largest between 26.03. and 08.04. (- 30%, 95% CI - 33% to - 27%). When analysing the entire period 12.03.-30.06., the decrease of admissions was heterogeneous among hospitals, and larger among people aged 0-17 years compared to older age groups. In the first 8 weeks after 12.03., admission counts of all diagnoses except femur fractures and pneumonia declined. Admissions with pneumonia increased in this early period. Between 07.05. and 30.6.2020, we noted that admissions with AMI (+ 13%, 95% CI - 3% to + 32%) and cholelithiasis or cholecystitis (+ 20%, 95% CI + 1% to + 44%) were higher than in 2019.!##!Conclusions!#!Our results suggest differential trends of admission counts according to age, location, and diagnosis. An initial decrease of admissions with MDA, AMI, stroke or TIA, heart failure, COPD, cholelithiasis or cholecystitis, and back pain imply delays of emergency care in Germany. Finally, our study suggests a delayed increase of admissions with AMI and cholelithiasis or cholecystitis

Investigating people’s attitudes towards participating in longitudinal health research: an intersectionality-informed perspective

Abstract Background Increasing evidence suggests that participation proportions in longitudinal health research vary according to sex/gender, age, social class, or migration status. Intersectionality scholarship purports that such social categories cannot be understood in isolation and makes visible the co-dependent nature of the social determinants of health and illness. This paper uses an intersectionality-informed approach in order to expand the understanding of why people participate in health research, and the impact of intersecting social structures and experiences on these attitudes. Methods A sample of 80 respondents who had previously either accepted or declined an invitation to participate in the German National Cohort (NAKO) participated in our interview study. Interviews were semi-structured and contained both narrative elements and more structured probes. Data analysis proceeded in two steps: first, the entire data set was analysed thematically (separately for participants and non-participants); second, key themes were compared across self-reported sex/gender, age group and migration status to identify differences and commonalities. Results Respondents’ attitudes towards study participation can be categorised into four themes: wanting to make a contribution, seeking personalised health information, excitement and feeling chosen, and seeking social recognition. Besides citing logistical challenges, non-participants narrated adverse experiences with or attitudes towards science and the healthcare system that deterred them from participating. A range of social experiences and cultural value systems shaped such attitudes; in particular, this includes the cultural authority of science as an arbiter of social questions, transgressing social categories and experiences of marginalisation. Care responsibilities, predominantly borne by female respondents, also impacted upon the decision to take part in NAKO. Discussion Our findings suggest that for participants, health research constitutes a site of distinction in the sense of making a difference and being distinct or distinguishable, whereas non-participants inhabited an orientation towards science that reflected their subjective marginalisation through science. No clear relationship can thereby be presumed between social location and a particular attitude towards study participation; rather, such attitudes transgress and challenge categorical boundaries. This challenges the understanding of particular populations as more or less disadvantaged, or as more or less inclined to participate in health research

Öffentliche Gesundheit in Deutschland: Eine Perspektive des Nachwuchses

Akçay M, Drees S, Geffert K, et al. Öffentliche Gesundheit in Deutschland: Eine Perspektive des Nachwuchses. Das Gesundheitswesen. 2019;81(03):176-181.**Zusammenfassung** Der aktuelle Reformprozess der öffentlichen Gesundheit in Deutschland hat die Möglichkeit einer Stärkung dieses Faches und des entsprechenden Praxis- und Politikfeldes in Deutschland eröffnet. Im vorliegenden Beitrag werden anstehende Herausforderungen und notwendigen Maßnahmen aus einer Nachwuchsperspektive dargestellt. Notwendig sind insbesondere eine umfassende Stärkung und Reform der Aus- und Weiterbildungsstrukturen der öffentlichen Gesundheit. Zudem gilt es, Strukturen und Prozesse zu schaffen, mittels derer die Fachgemeinschaft ihre Expertise stärker und wirkungsvoller als bislang in Politik und Gesellschaft einbringen kann. Dies schließt den Aufbau einer handlungsfähigen Fachvertretung mit ein. Die hierzu in den vergangenen Jahren u. a. im Rahmen des Zukunftsforums Public Health begonnene Diskussion sollte zeitnah strukturbildend konkretisiert und in praktische Umsetzungen überführt werden