Olaf von dem Knesebeck’s research while affiliated with University Medical Center Hamburg - Eppendorf and other places

In research on organisational health literacy (OHL), there is a lack of standardised assessment tools for measuring and comparing the OHL of different organisations. This article therefore examines (1) which criteria for assessing OHL can be derived from research and practice, (2) how these are implemented in organisations and (3) the psychometric properties of a questionnaire developed from them. OHL criteria were identified by means of literature research and workshops. The criteria were agreed upon in a Delphi study and an assessment tool was developed. An online questionnaire was developed and psychometrically tested. Measures such as Cronbach’s alpha, item selectivity and difficulty, and floor/ceiling effects were used for the analysis. Over 500 criteria were identified and an assessment tool of 77 criteria (5 main categories and 17 sub-categories) was developed. The subject of “Barrier-free access and navigation” was best implemented in healthcare organisations. The psychometric properties showed a good to excellent internal consistency of the questionnaire structure. Only one main category showed significant floor effects; there were no ceiling effects. At the item level, ceiling effects were found for 13 items, and 39 items showed a satisfactory discriminatory power. OHL is a multidimensional construct that is well represented by the assessment tool. Further validation with larger samples is necessary for the use of the tool as a questionnaire for measuring OHL and for comparison between institutions. A reduction in the number of criteria can improve the consistency of the content of the main and sub-categories.

Introduction Fatigue is a frequent somatic symptom impacting health and well-being and lately receiving increased attention as a long-term consequence of COVID-19. Emerging evidence suggests that persons afflicted with fatigue symptoms are often stigmatized and discriminated because their symptoms are still poorly understood and not recognizable to others. Existing stigma research mainly focused on specific medical conditions and domains and overlooked intersectional discrimination – the negative amplification effect of intersecting social identities. The purpose of the current study is to examine perceived discrimination in fatigue across different medical conditions and domains, also considering intersectional discrimination. Materials and methods Semi-structured telephone interviews were carried out with 19 patients with clinically significant fatigue, considering a variety of different social identities like gender, history of migration, and occupational status. The interviews were analyzed using a structured qualitative content approach with consensual coding. Results The findings on perceived discrimination could be subsumed in eight practices: (nonverbal) communication, negative emotional reaction, medical treatment, leadership responsibility, structural barriers, diagnostic terminology, and scientific controversy. Participants reported overlapping experiences of perceived discrimination across several intertwined domains: medical setting, work, social, public, and at an overarching structural level. Thereby, especially discrimination in the medical setting and on structural level occurred with great impact on health care and social protection. By applying an intersectional approach, intersectional discrimination specific for certain stigmatized social identities, like female gender and low occupational status became apparent. Discussion These findings need to be further researched and addressed in intervention strategies increasing resilience and public knowledge to reduce intersectional discrimination and health inequalities.

Objective Individuals with low socioeconomic status (SES) exhibit higher rates of mental disorders; however, data in oncological populations are insufficient. This study investigated the course of DSM‐5 mental disorders in cancer patients, stratified by SES, over a period of 1.5 years following initial cancer diagnosis. Methods This multi‐center prospective longitudinal study assessed cancer patients within two months of cancer diagnosis (t1), and at 6‐, 12‐, and 18‐month follow‐up (t2–t4) using the SCID‐5 interview for mental disorders based on DSM‐5 criteria. Chi‐square‐tests were tested for frequency changes over time. A generalized linear mixed model (GLMM) was applied with fixed effects for SES and time on mental disorders. Results Out of 1030 patients with a SCID‐5 at baseline (53.2% men, 60 years), 821, 719 and 654 participated at respective follow‐ups. The most common diagnoses were skin and prostate cancer. Point prevalence of mental disorders was 20.9% at baseline, decreasing to 18.2%, 14.6%, and 15.0% (t2–t4; χ ² (3) = 15.3, p = 0.002). Patients with low SES consistently showed highest prevalence rates, whereas patients with high SES showed decreasing rates of mental disorders over time, with a main effect of time (χ ² (3) = 19.9, p < 0.001) and SES (χ ² (2) = 8.8, p = 0.01) in the GLMM. Two thirds never met diagnostic criteria for a mental disorder. Sensitivity analysis among study completers (n = 592) revealed a similar pattern to the main analysis. Conclusions Cancer patients with low SES exhibit impaired coping with cancer‐related stressors, increasing their risk for mental disorders. Social disparities affect physical and mental health, possibly via health behavior or health literacy, and need to be addressed by tailored survivorship care planning.

Background Socioeconomic status (SES) has consistently been associated with depressive symptoms, however, it remains unclear which subset of SES variables is most relevant to the development of depressive symptoms. This study determined a standardized SES-Index to test the relationship of its sub-dimensions with depressive symptoms. Methods HCHS data (N = 10,000; analysis sample n = 8,400), comprising participants 45+ years of age, was used. A standardized approach to quantify SES was employed. Depressive symptoms were quantified using the Patient Health Questionnaire-9 (PHQ-9). Using multiple linear regression models, PHQ-9-scores were modeled as a function of age and sex, and (1a) total SES-Index score versus (1b) its three sub-dimension scores (education, occupational status, income). Models were compared on explained variance and goodness of fit. We determined risk ratios (RR, concerning a PHQ-9 sum score ≥ 10) based on (low, middle, high; 2a) SES-Index scores and (2b) the sub-dimension scores, with groups further differentiated by sex and age (45–64 versus 65+). We distinguished between the total SES-Index score and its three sub-dimension scores to identify relevant SES sub-dimensions in explaining PHQ-9-variability or risk of depression. Results Among all regression models (total explained variance 4–6%), income explained most variance, but performance of the SES-Index was comparable. Low versus high income groups showed the strongest differences in depressive trends in middle-aged females and males (RRs 3.57 and 4.91). In older age, this result was restricted to females (RR ≈ 2). Middle-aged males (versus females) showed stronger discrepancies in depressive trends pertaining to low versus high SES groups. In older age, the effect of SES was absent. Education was related to depressive trends only in middle-aged females and males. In an exploratory analysis, marital status and housing slightly increased model fit and explained variance while including somatic symptoms lead to substantial increases (R²adj = 0.485). Conclusion In line with previous research, the study provides evidence for SES playing a significant role in depressive symptoms in mid to old age, with income being robustly linked to depressive trends. Overall, the relationship between SES and depressive trends appears to be stronger in males than females and stronger in mid compared to old age.

Background Overall, research on social determinants of access and quality of outpatient care in Germany is scarce. Therefore, social disparities (according to sex, age, income, migration background, and health insurance) in perceived access and quality of consultation in outpatient care (primary care physicians and specialists) in Germany were explored in this study. Methods Analyses made use of a cross-sectional online survey. An adult population sample was randomly drawn from a panel which was recruited offline (N = 2,201). Perceived access was assessed by waiting time for an appointment (in days) and travel time to the practice (in minutes), while quality of consultation was measured by consultation time (in minutes) and quality of communication (scale of four items, Cronbach’s Alpha 0.89). Results In terms of primary care, perceived access and quality of consultation was worse among women compared to men. Estimated consultation time was shorter among people with statutory health insurance compared to privately insured respondents. Regarding specialist care, people aged 60 years and older reported shorter waiting times and better quality of communication. Lower income groups reported lower quality of communication, while perceived access and quality of consultation was worse among respondents with a statutory health insurance. Variances explained by the social characteristics ranged between 1% and 4% for perceived access and between 3% and 7% for quality of consultation. Conclusion We found social disparities in perceived access and quality of consultation in outpatient care in Germany. Such disparities in access may indicate structural discrimination, while disparities in quality of consultation may point to interpersonal discrimination in health care.

Background The purpose of this study was to provide the 4-week prevalence estimates of mental disorders in newly diagnosed cancer patients in relation to socioeconomic status (SES). Patients and methods We enrolled newly diagnosed patients with a confirmed solid tumor within 2 months of diagnosis. We calculated patients’ SES on the basis of their educational level, professional qualification, income and occupational status. We used the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition—Clinical Version (SCID-5-CV) to assess the 4-week prevalence of mental disorders in addition to a comorbidity questionnaire to assess the level of physical impairment. Results We identified a total of 1702 patients with mixed cancers after reviewing their medical records and contacting them in person or by post due to coronavirus pandemic patient safety restrictions. 1030 patients (53.2% men, mean age 60.2 years) had completed SCID-5-CV. When weighted according to the SES distribution to account for over- and under-sampling of SES groups, 20.9% [95% confidence interval (CI) 18.1% to 23.6%] of patients were diagnosed with any mental disorder. The most prevalent were depressive disorders (9.9%, 95% CI 7.9% to 11.9%), trauma and stress-related disorders (6.3%, 95% CI 4.7% to 7.9%) and anxiety disorders (4.2%, 95% CI 2.9% to 5.6%). We found no difference in any mental disorder between patients with high, medium or low SES. Multivariate logistic regression analyses revealed higher proportion of patients with any mental disorder in patients younger than 60 years [odds ratio (OR) 0.42; P < 0.001], in patients without a partner (OR 1.84; P < 0.001), in women with tumor in female genital organs (OR 2.45; P < 0.002) and in those with a higher level of impairment (OR 1.05, 95% CI 1.03-1.07; P < 0.001). Conclusions SES had no significant influence on mental comorbidity in early cancer survivorship.

Background Intersectional approaches are needed to disaggregate the complex interaction of social identities contributing to (mental) health disparities. Health anxiety represents an overlooked public mental health issue. Therefore, intersectional inequalities in health anxiety were examined using multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Methods Analyses are based on cross-sectional data of the adult population living in Germany (N = 2,413). Health anxiety was assessed with the Whiteley Index-7. Applying intersectional MAIHDA, health anxiety in the intersectional strata of gender, history of migration, and income was predicted. Discriminatory accuracy was assessed via the intra-class correlation and the proportional change in variance. Results Analyses revealed additive social inequalities in health anxiety with greatest impact of low income but no clear intersectional gradient. Most affected by health anxiety were females who immigrated themselves with low income, males whose parent(s) immigrated with low income, and males who immigrated themselves with medium income. Conclusion Intersectional approaches contribute to a more comprehensive understanding of (mental) health disparities. In addition to general efforts to counteract health inequalities, combining universal screening and targeted psychotherapeutic treatment seems promising to specifically reduce inequalities in health anxiety.

Background It is well established that emergency department (ED) crowding leads to worse health outcomes. Although various patient surveys provide information about reasons to visit EDs, less is known in terms of beliefs about EDs among the general population. This study examines public beliefs regarding accessibility and quality of EDs and their associations with social characteristics (gender, age, education, immigration background) as well as knowledge about emergency care services and health literacy. Methods We conducted a cross-sectional study based on a random sample of 2,404 adults living in Hamburg, Germany, in winter 2021/2022. We developed eight statements regarding accessibility and quality of EDs leading to two scales (Cronbach’s α accessibility = 0.76 and quality of care = 0.75). Descriptive statistics of the eight items are shown and linear regression were conducted to determine associations of the two scales with social characteristics as well as knowledge about emergency care services and health literacy (HLS-EU-Q6). Results Nearly 44% of the respondents agreed that “you can always go to an ED, if you do not get a short-term appointment with a general practitioner or specialist.” And 38% agreed with the statement, “If you do not have the time during normal practice hours due to your work, you can always go to an ED.” In terms of quality, 38% believed that doctors in EDs are more competent than doctors in general practice, and 25% believed that doctors in EDs are more competent than doctors in specialized practices. In the fully adjusted model, public beliefs about emergency care accessibility and quality of EDs were significantly associated with all social characteristics and knowledge of emergency care options with the strongest associations between knowledge and accessibility (β = −0.17; P < 0.001) and between education and quality (β = −0.23; P < 0.001). Conclusion We found endorsement of public beliefs about accessibility and quality of EDs that can lead to inappropriate utilization. Our results also suggest that knowledge of different emergency services plays an important role. Therefore, after system-related reorganizations of emergency care, information campaigns about such services tailored to socially deprived populations may help alleviate the issue of crowding.