Comprehensive assessment of food and nutrient intake of children and adolescents in Germany: EsKiMo II - the eating study as a KiGGS module.

BACKGROUND: As part of the second wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2), food and nutrient intake of children and adolescents aged 6-17 years living in Germany is assessed in EsKiMo II - the Eating Study as a KiGGS Module. METHODS: EsKiMo II is a cross-sectional study, conducted from June 2015 until September 2017. The study population comprises 6 to 17-year-old study participants from the cross-sectional sample of KiGGS Wave 2 in 167 KiGGS sample points, which are revisited by trained nutritionists. Dietary intake is assessed by weighted food records during three consecutive days plus one randomly selected day within the following 3 months for children aged 6-11 years. Dietary intake for adolescents aged 12-17 years is assessed by computer-assisted dietary history interviews, reflecting the past four weeks, using the software DISHES. Further information, for example, about specific diets and dietary supplement intake, is reported during a standardised computer assisted interview for all participants. Food items are coded by the German Food Code and Nutrient Database (BLS 3.02). DISCUSSION: EsKiMo II provides actual data on the dietary behaviour of children and adolescents living in Germany and their determinants. Results of EsKiMo II will be relevant for decision-making, measures, and evaluations within nutrition, consumer and health policy.

[Utilization of Medical Rehabilitation Services in Germany: A Comparative Analysis of Survey and Routine Data]. / Die Inanspruchnahme medizinischer Rehabilitationsleistungen in Deutschland im Vergleich verschiedener Survey- und Routinedatenquellen.

BACKGROUND: Population ageing leads to an increase in age-related diseases. Consequently, the need for medical rehabilitation services is also rising. Rehabilitation service in Germany is offered by several rehabilitation carriers. There is no homogeneous rehabilitation statistics, resulting in insufficient data. This paper analyses utilization of medical rehabilitation services in Germany. It uses data from a representative population-based health survey. The results were extrapolated to the general population in Germany and compared with routine data. METHODS: Survey data used were those of the German Health Interview and Examination Survey for Adults (DEGS1) with 7 988 participants. Utilization rates were extrapolated to the general population. Routine data sources are the diagnostic data of the Federal Statistical Office on patients using prevention or rehabilitation facilities. Further data sources are the published statistics of the rehabilitation carriers. In order to compute the total number of rehabilitation cases, where data were lacking in the statistics of the rehabilitation carriers, an estimate was made. RESULTS: The analysis of the different data sources shows similar results. In 2010, there were approximately 2.2 million rehabilitation cases in Germany. Around 10% of rehabilitation measures were carried out in the ambulatory setting. Analyses of structural characteristics in the routine data are possible but not recommendable because of bias in the data. CONCLUSIONS: Without detailed data on age structure and trends, challenges of demographic changes and changes in the illness spectrum cannot be adequately described. Because of a lack of sufficient diagnosis-based data, statements on the appropriateness of medical rehabilitation services offered by rehabilitation carriers cannot be made.

Age-related prevalence of cross-reactive antibodies against influenza A(H3N2) variant virus, Germany, 2003 to 2010.

To estimate susceptibility to the swine-origin influenza A(H3N2) variant virus (A(H3N2)v) in the German population, we investigated cross-reactive antibodies against this virus and factors associated with seroprotective titre using sera from representative health examination surveys of children and adolescents (n = 815, 2003­06) and adults (n = 600, 2008­10). Antibodies were assessed by haemagglutination inhibition assay (HI); in our study an HI titre ≥ 40 was defined as seroprotective. We investigated associated factors by multivariable logistic regression. Overall, 41% (95% confidence interval (CI): 37­45) of children and adolescents and 39% (95% CI: 34­44) of adults had seroprotective titres. The proportion of people with seroprotective titre was lowest among children younger than 10 years (15%; 95% CI: 7­30) and highest among adults aged 18 to 29 years (59%; 95% CI: 49­67). Prior influenza vaccination was associated with higher odds of having seroprotective titre (odds ratio (OR) for children and adolescents: 3.4; 95% CI: 1.8­6.5; OR for adults: 2.4; 95% CI: 1.7­3.4). Young children showed the highest and young adults the lowest susceptibility to the A(H3N2)v virus. Our results suggest that initial exposure to circulating seasonal influenza viruses may predict long-term cross-reactivity that may be enhanced by seasonal influenza vaccination.

[Mortality follow-up of the German Health Interview and Examination Survey for Adults (DEGS) : methods and first results]. / Mortalitäts-Follow-up der Studie zur Gesundheit Erwachsener in Deutschland (DEGS) : Methodik und erste Ergebnisse.

OBJECTIVES: Within the framework of the German Health Interview and Examination Survey for Adults (DEGS), the Robert Koch Institute (RKI) conducted a nationwide mortality follow-up study. As there is no national mortality register in Germany, mortality and causes of death were investigated individually and under observance of state-specific data protection conditions. METHODS: The German Health Interview and Examination Survey 1998 (GNHIES98) provided the database including 7,124 participants aged 18-79 years. A total of 6,979 participants of GNHIES98 (98 %) who consented to be re-contacted were invited between October 2008 and October 2011 to also participate in the first data collection wave of DEGS (DEGS1). In this context, the vital status and the causes of death for deceased participants were assessed. Age- and sex-specific probabilities of survival and death rates were calculated and grouped by main causes of death according to ICD-10 groups. RESULTS: A total of 671 individuals (285 women, 386 men) died between the two survey contacts. For all deceased persons the date of death and for 539 (80.3 %) the causes of death could be determined. With a median follow-up time of 12.0 years, 8,0742.5 person years were available for survival analysis. The crude overall death rate amounted to 8.3 per 1,000 persons-years (women: 7.2; men: 9.5). Among 539 persons with available information on causes of death, 209 (38.8 %) were attributable to cardiovascular diseases, 188 (34.9 %) to cancer, 135 (25.0 %) to other causes, and seven (1.3 %) could not be unambiguously assigned. CONCLUSIONS: A mortality follow-up was successfully integrated in the longitudinal component of DEGS as part of the national health monitoring at the RKI. Death rates and cause-specific mortality in relation to highly prevalent chronic diseases and risk factors provide essential information for assessing the potential of prevention and quality of care among adults in Germany. This requires a regular and complete conduction of mortality follow-ups.

[Trends in the utilization of outpatient medical care in childhood and adolescence: results of the KiGGS study - a comparison of baseline and first follow up (KiGGS Wave 1)]. / Trends in der Inanspruchnahme ambulant-ärztlicher Leistungen im Kindes- und Jugendalter : Ergebnisse der KiGGS-Studie - Ein Vergleich von Basiserhebung und erster Folgebefragung (KiGGS Welle 1).

This article provides information on trends in the utilization of outpatient medical care in childhood and adolescence in Germany on the basis of data from two waves of the KiGGS study (prevalences and odds ratios). In the period 2009-2012, 91.9% (95% CI 91.1-92.7%) of children and adolescents used outpatient medical services at least once a year. In the 12 months prior to the interview, 67.9% (95% CI 65.9-69.8%) of the 0- to 17-year-olds consulted a pediatrician and 34.1% (95% CI 31.6-36.3%) a general practitioner. Whereas there was no change in the use of either overall outpatient or general practice medical care compared to 2003-2006, a significant increase of 8.7% points in the utilization of pediatricians was found. This could be explained by, among other factors, an expansion of pediatric services (additional vaccinations and health screening examinations) in recent years. It may also be related to a significantly greater participation in the health screening program in early childhood (U3-U9 examinations), which was seen especially when comparing the youngest birth cohorts and in children from families with low social status (from U7 onwards). The increased use of health screening examinations can probably be attributed to the invitation, reminding and reporting procedures that have been introduced in recent years. Whereas at KiGGS baseline urban-rural differences in participation in health screening examinations could be seen, these were no longer apparent in KiGGS Wave 1. Similarly, differences between rural and urban regions in the use of general and pediatric medical services have also diminished. Nevertheless, currently children and young people in rural areas use outpatient general medical care to a greater extent than those in urban areas.

[The first KiGGS follow-up (KiGGS Wave 1): study conduct, sample design, and response]. / Die erste KiGGS-Folgebefragung (KiGGS Welle 1): Studiendurchführung, Stichprobendesign und Response.

The "German Health Interview and Examination Survey for Children and Adolescents" (KiGGS) is part of the health monitoring system of the Robert Koch Institute (RKI). Following the KiGGS baseline study (2003 - 06), which comprised interviews and physical examinations of 0- to 17-year-old participants, KiGGS Wave 1 (2009 - 2012) was carried out as a telephone-based survey. In addition to providing longitudinal data, a second essential aim of KiGGS is to regularly provide population-based cross-sectional data on the health situation of children and adolescents aged 0-17 years living in Germany. Therefore, the study population of KiGGS Wave 1 consists of re-invited participants from the baseline study (KiGGS cohort), supplemented by newly invited children aged 0-6 years. The newly invited participants were randomly chosen from local population registries in the 167 baseline sample points. This method was chosen to supplement the sample with younger age groups. This article focuses on the age groups from 0 to 17 years, which are relevant for prevalence estimations among children and adolescents. In total 12,368 children and adolescents took part; among them 4,455 newly invited and 7,913 re-invited participants (response 38.8 and 72.9%, respectively). A comparison of the net sample with the resident German population (0-17 years) regarding particular population characteristics and an analysis of the relationship between the re-participation rate and certain characteristics collected in the baseline study (7-17 years) suggest a mostly unbiased sample. To account for certain aspects of the population and nonresponse, cross-sectional and trend analyses were partially corrected by weighting factors.

[The first wave of the German Health Interview and Examination Survey for Adults (DEGS1): sample design, response, weighting and representativeness]. / Die erste Welle der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1): Stichprobendesign, Response, Gewichtung und Repräsentativität.

The "German Health Interview and Examination Survey for Adults" (DEGS) is part of the health monitoring program of the Robert Koch Institute (RKI) and is designed as a combined cross-sectional and longitudinal survey. The first wave (DEGS1; 2008-2011) comprised interviews and physical examinations. The target population were 18- to 79-year olds living in Germany. The mixed design consisted of a new sample randomly chosen from local population registries which was supplemented by participants from the "German National Health Interview and Examination Survey 1998" (GNHIES98). In total, 8,152 persons took part, among them 4,193 newly invited (response 42%) and 3,959 who had previously taken part in GNHIES98 (response 62%). 7,238 participants visited one of the 180 local study centres, 914 took part in the interview-only programme. The comparison of the net sample with the group of non-participants and with the resident population of Germany suggests a high representativeness regarding various attributes. To account for certain aspects of the population structure cross-sectional, trend and longitudinal analyses are corrected by weighting factors. Furthermore, different participation probabilities of the former participants of GNHIES98 are compensated for. An English full-text version of this article is available at SpringerLink as supplemental.

[Utilization of outpatient and inpatient health services in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1)]. / Inanspruchnahme der ambulanten und stationären medizinischen Versorgung in Deutschland: Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1).

The article provides representative benchmarks and trends for the use of medical and therapeutic services in Germany on the basis of the German Health Interview and Examination Survey for Adults (DEGS1) and the German National Health Interview and Examination Survey 1998 (GNHIES98) from the years 2008-2011 and 1997/98, respectively. DEGS1 shows that women seek most medical services more often than men. Differences by gender decreased with age. In almost all services, an increase in utilisation is recorded with age. There are large differences in utilisation depending on self-rated health, as opposed to fewer differences by social status, health insurance and region. At both time points, the proportion of the population that utilised outpatient or inpatient medical assistance at least once a year, is almost unchanged high. At the same time, a significant reduction in the annual number of contacts with medical practices and the length of hospital stay was recorded as well as an increase of the consulted specialist groups. This may be explained due to regulation effects of earlier reforms. An English full-text version of this article is available at SpringerLink as supplemental.

[DEGS: German Health Interview and Examination Survey for Adults. A nationwide cross-sectional and longitudinal study within the framework of health monitoring conducted by the Robert Koch Institute]. / DEGS: Studie zur Gesundheit Erwachsener in Deutschland. Bundesweite Quer- und Längsschnittstudie im Rahmen des Gesundheitsmonitorings des Robert Koch-Instituts.

The "German Health Interview and Examination Survey for Adults" (DEGS) is a nationwide longitudinal study carried out by the Robert Koch Institute (RKI) within the framework of a continuous health monitoring programme. The aim of this study is to provide representative data on the health status of adults in Germany on a regular basis, to calculate trends in the development of health indicators and to gain insights into the development of health during the course of life. These aims are realised by choosing a sampling design which allows establishment and follow-up of a panel and to provide a representative sample in each new wave of data collection. DEGS produces information for comprehensive health reporting, serves as a basis for health policy decision-making and provides data for epidemiological research. The first wave of data collection (DEGS1) was carried out from November 2008 until Dezember 2011 and comprises health interviews and physical examinations as well as blood and urine sampling. Detailed information on health status, health-related behaviour, healthcare and living conditions was gathered. Furthermore the study focuses on chronic diseases, mental health and implications of demographic changes for health. In order to be able to analyse longitudinal data as soon as possible, participants of the National Health Survey 1998 (BGS98) were included in DEGS1. The examination programme carried out in BGS98, was maintained and appended in DEGS1. A total of 8152 persons participated in DEGS1 and of these 3959 were former participants of BGS98. The participants of DEGS1 constitute the baseline cohort for repeated health interviews and examinations in the future. In wave 2, which is planned to begin in the middle of 2014, study participants will be followed up by interviewing. Wave 3 planned to follow in 2017, will again comprise an interview and examination survey with a supplementary sample. First results and basic analyses of all main topics of DEGS1 will follow in this journal in the middle of 2013. A public use file of DEGS1 data will be available for the scientific community by 2014.

[The KiGGS study. Nationwide representative longitudinal and cross-sectional study on the health of children and adolescents within the framework of health monitoring at the Robert Koch Institute]. / Die KiGGS-Studie. Bundesweit repräsentative Längs- und Querschnittstudie zur Gesundheit von Kindern und Jugendlichen im Rahmen des Gesundheitsmonitorings am Robert Koch-Institut.

From 2003 to 2006 the KiGGS Baseline Study was conducted, including a clustered random sample of 167 sample points and 17,641 children and adolescents from 0 to 17 years, as well as their parents in 167 sample points. The children and adolescents were medically and physically examined, and their parents answered questions about physical, psychological and social aspects of their children's health, as did, from 11 years on, the children and adolescents themselves. Within the framework of the nationwide health monitoring at the Robert Koch Institute, the KiGGS study is being continued as a prospective cohort study with an interval of approximately 5 years between follow-ups. The study sample will be cross-sectionally refilled with younger age groups at each time of measurement. The assessment of the KiGGS core study follows a core indicator concept, which is modularly complemented by external scientific cooperation partners. The field work of the first wave (KiGGS Wave 1), a telephone survey, will continue until June 2012. The second follow-up (KiGGS Wave 2) will again combine examinations and interviews, starting in 2013. On the basis of the nationally representative KiGGS data, important questions about health policy can be answered, such as trends and trajectories of health. Important results are expected, among others concerning trends in overweight and obesity, the incidence of atopic diseases, and the persistency or remission of psychopathological symptoms and disorders.

[Health monitoring at the Robert Koch Institute. Status and perspectives]. / Gesundheitsmonitoring am Robert Koch-Institut. Sachstand und Perspektiven.

Since January 2008, the Robert Koch Institute (RKI) has been administrating a Health Monitoring System, i.e., health examination surveys and health interview surveys with longitudinal components being alternatingly performed. These surveys are continuously accompanied by annual cross-sectional interview surveys of the population living in Germany. The content and structure of the Health Monitoring System is explained and the actual on-going surveys are described in this paper. An overview of future surveys and their integration within the European context demonstrates the new quality in utilizing the data obtained by longitudinal and cross-sectional analyses for health reporting, health policies and health sciences.

[The German Health Interview and Examination Survey for Children and Adolescents (KiGGS): sample design, response and nonresponse analysis]. / Der Kinder- und Jugendgesundheitssurvey (KiGGS): Stichprobendesign, Response und Nonresponse-Analyse.

From May 2003 to May 2006, the Robert Koch Institute conducted the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Aim of this nationwide interview and examination survey was to collect, for the first time, comprehensive and nationwide data on the health status of children and adolescents aged 0 to 17 years. Subject recruitment was carried out in two steps: first, 167 study locations (sample points) were chosen; second, subjects were selected from the official registers of residents of the local residents' registration offices. The percentage of quality-neutral drop-outs was comparatively low (5.3%). The participation rate was 66.6% and showed only little variation between age groups and sexes, but marked variation between resident aliens and Germans, between inhabitants of cities with a population of 100,000 or more and sample points with fewer inhabitants, as well as between the old West German states and the newly-formed German states (incl. Berlin). A total of 17,641 children and adolescents were surveyed, of whom 8,985 were boys and 8,656 were girls. The completeness of the data sets in relation to the modules was good. The main reasons for non-participation were failure to appear at an agreed appointment time (or cancellation of the appointment at short notice), the refusal of the child/adolescent himself, or lack of interest of the parents.

[The German Health Interview and Examination Survey for Children and Adolescents (KiGGS): study management and conduct of fieldwork]. / Der Kinder- und Jugendgesundheitssurvey (KiGGS): Studienmanagement und Durchführung der Feldarbeit.

UNLABELLED: From May 2003 to May 2006, the Robert Koch Institute conducted the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Nationwide data collection in 167 cities and municipalities was carried out by 4 survey teams, each consisting of a physician, centre interviewer, examiner, medical laboratory technician, environmental interviewer. Regional and seasonal factors were excluded by systematised route planning. Invitation of the participants and appointments for examinations were handled by a survey office with subsidised service telephone. Data processing in the survey office was performed using an SQL data base system programmed in the RKI. One central and several regional members of staff performing preparatory field visits were responsible for finding suitable examination rooms and for subject recruitment respectively. To further increase the response rate, continuous public relation actions were established. The survey involved questionnaires filled in by parents and parallel questionnaires for children from the age of 11 years onwards, physical examinations and tests and a computer assisted personal interview performed by the physician. The wide range of blood and urine testing carried out at central laboratories required standardised transport logistics. To achieve a high degree of standardisation of the survey, the examination teams were initially trained and then underwent continuous further training. The concept of quality management covered action of internal and independent external quality control monitoring each data collecting and data processing step as well as the training courses. CONCLUSION: Dedicated public relations activities and the deployment of staff performing preparatory field visits increased the willingness of the subjects to participate. Intensive personnel care and continuous quality checks contribute to increased job satisfaction and data quality. By bindingly defining all laboratory diagnostic processes as well as transport logistics, high-quality laboratory test results are ensured. The conduct of the study from design via conduct to data processing and analysis by one institution guarantees complete control of all steps of the survey.

[Sociodemographic characteristics in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) - operationalisation and public health significance, taking as an example the assessment of general state of health]. / Messung soziodemographischer Merkmale im Kinder- und Jugendgesundheitssurvey (KiGGS) und ihre Bedeutung am Beispiel der Einschätzung des allgemeinen Gesundheitszustands.

The German Health Interview and Examination Survey for Children and Adolescents (KiGGS) was conducted from May 2003 to May 2006 by the Robert Koch Institute in 167 communities representative of Germany. By collecting comprehensive and nationally representative data on the health status of children and adolescents aged 0 to 17 years, the study aimed to fill a longstanding evidence gap. Data from 17,641 study participants will be analysed in a timely and systematic manner by the Robert Koch Institute. Initially mainly descriptive analyses as presented in the current special issue on the KiGGS study, provide information on the distribution of main health characteristics according to sociodemographic key variables, including age, sex, region of residence (former East/West Germany), social status, and migrant background. We report here the rationale for a standard set of stratifying variables and the operationalisation of composite variables. Furthermore, we illustrate the public health relevance of the observed group differences using the example of an important health indicator: parents' evaluation of their children's general state of health.

[Prevalence of somatic diseases in German children and adolescents. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. / Prävalenz von somatischen Erkrankungen bei Kindern und Jugendlichen in Deutschland. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS).

In the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), which was conducted from 2003 to 2006, data on acute/infectious and chronic diseases were collected from a population-based sample of 17,641 subjects aged 0 to 17 years. The annual prevalence rates among acute diseases vary widely. Children and adolescents are most frequently affected by acute (infectious) respiratory conditions. 88.5 % of the surveyed children and adolescents experienced at least one episode of common cold within the last 12 months. Among the other acute respiratory infections, bronchitis and tonsillitis were the most frequently encountered conditions with 19.9 % and 18.5 %, respectively. The 12-month prevalence of otitis media and pseudocroup was 11 % and 6.6 %, respectively. 1.5 % of the children and adolescents experienced an episode of pneumonia. Apart from respiratory infections, gastrointestinal infections were very frequently stated as reasons for acute illness. Furthermore, 12.8 % of the children and adolescents experienced a herpetic infection, 7.8 % a conjunctivitis and 4.8 % a urinary tract infection. Lifetime prevalence rates of infectious diseases were as follows: pertussis 8.7 %, measles 7.4 %, mumps 4.0 %, rubella 8.5 %, varicella 70.6 %, scarlet fever 23.5 %. The various chronic somatic diseases in children and adolescents had different lifetime prevalence rates. Most frequently, children and adolescents were affected by obstructive bronchitis (13.3 %), neurodermatitis/atopic eczema (13.2 %) and hay fever (10.7 %). Scoliosis and asthma had been diagnosed by a doctor in 5.2 % and 4.7 % of subjects aged 0-17 years, respectively. The lifetime prevalence rates of the remaining diseases varied between 0.14 % for diabetes mellitus and 3.6 % for convulsions/epileptic fits. For the first time ever, these survey results provide nationwide representative information on the prevalence rates of acute/infectious and chronic diseases in children and adolescents which is based on a population-representative sample.

[Use of medical services. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. / Inanspruchnahme medizinischer Leistungen. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS).

The use of operations, visits to doctors and early diagnostic tests for children are examples of different services selected from the whole spectrum of preventative and therapeutic health service provisions in childhood and adolescence. In the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), which is representative for Germany, 17,641 children and adolescents aged 0-17 or their parents were questioned on subjects such as their use of medical services. The use made of individual early diagnostic tests for children remains above the 90 % limit until the U7 test and drops to 89.0 % at U8, falling to 86.4 % at U9. 81 % of children took part in all the early diagnostic tests provided until age 6 (U3 to U9). Another 16 % only took advantage of some parts of this service and 3 % of the children never went to one of these check-ups. As was to be expected, the annual rate of visits to paediatricians drops as children get older from 95.1 % for 0-2-year-olds to 25.4 % of the 14-17-year-olds, while the rate of visits to general practitioners rises from 11.8 % to 53.1 %. If one tracks the rate of visits to specialist doctors all the way across childhood and adolescence, different paths emerge: while children aged 3-6 most often visit the ear, nose and throat doctor, at primary school age they mainly see opticians, and 14-17-year-olds most often visit doctors of internal medicine, dermatologists and surgeons. 37.1 % of the 0-17-year-old children and adolescents had undergone an operation. In order of declining frequency, the operations named were adenoidectomy (15.2 %), tonsillectomy (5.9 %), herniotomy (3.6 %) and appendectomy (2.4 %). Circumcisions had been carried out on 10.9 % of the boys. The different way medical services are used in different subgroups may not only depend on medical factors but also on social factors, medical attitudes and the availability of services provided.

[The federal state module Schleswig-Holstein in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. / Das Landesmodul Schleswig-Holstein im Rahmen des Kinder- und Jugendgesundheitssurveys (KiGGS).

From August 2004 to June 2005, the Robert Koch Institute conducted the fieldwork for the Schleswig-Holstein module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). The KiGGS study is a nationwide representative survey of the health of children and adolescents aged 0 to 17 years. By increasing the sample size in the age group 11 to 17 years in Schleswig-Holstein, the module study generated information which is representative for this federal state. For this end, further 18 locations in this federal state were included in the module study in addition to the existing 5 study locations in Schleswig-Holstein and a study programme which was slightly reduced compared to the core survey was realised. A total of 1,931 subjects were examined in Schleswig-Holstein: 1,730 in the federal state module and 201 in the core survey. The participation rate was 69.5% in the module study. The percentage of quality-neutral drop-outs was 4.0%. The federal state module was funded by the Ministry of Social Welfare, Health, Family, Youth and Seniors of the Federal State of Schleswig-Holstein. The data collected were used for health reporting on a federal state level.

[Predictors for ambulatory medical care utilization in Germany]. / Einflussfaktoren auf die ambulante Inanspruchnahme in Deutschland.

An analysis of the possible influences on primary health care utilization is made. The theoretical framework is the health behavioural model of R. M. Andersen, dividing the influencing variables into the components predisposing characteristics, enabling resources, and need factors. The study was based on data from the German National Health Examination and Interview Survey of the adult population in 1998. The data were linked to regional structural data and aggregated account data. The total number of contacts, the number of contacts with general practitioners and internists, and the number of different specialists contacted in the last 12 months, as calculated from interview data, were used to indicate primary health care utilization. In addition to the expected strong influence of need factors such as morbidity and health-related quality of life, the predisposing characteristics such as region, urban/rural, age, and gender have a significant influence on the primary care utilization. With regard to the enabling factors, persons with a family doctor had more contacts overall, which contrasts with the family doctor's assumed gate-keeper function. From the results of the study, recommendations on possible regulatory measures are given, but also some restrictions for influencing the number of contacts are pointed out.

[The problem of response in epidemiologic studies in Germany (Part II)]. / Zum Problem der Response in epidemiologischen Studien in Deutschland (Teil II).

The first part of this paper introduced various definitions of response and discussed their significance in the context of different study types. This second part addresses incentives as a method to increase response and evaluates the impact of non response or delayed response on the validity of the study results. Recruitment aims at minimising the proportion of refusal. To achieve this, incentives can be used and potential participants can be contacted in a sequence of increasing intensity. The effectiveness of different incentives was investigated within the pretest of the German survey on children and adolescents by the Robert Koch Institute. A low response is often interpreted in terms of non-response bias. This assumption, however, is as incorrect as would be opposite conclusion, that a high response guarantees valid results. Any study of the influence of nonresponse requires information on non-responders. The comparison between early and late responders as an indirect method to evaluate systematic differences between participants and non-participants by wave analysis is demonstrated within the Northern Germany Leukaemia and Lymphoma study (NLL). The German guidelines for Good Epidemiologic Practice recommend to solicit a minimum of information on the principal hypotheses of a study from non-participants. The example of a population-based health survey (Cooperative Health Research in the Region of Augsburg, KORA) illustrates how information on non-responders within a quantitative non-responder analysis can be achieved and used for the estimation of prevalences. Recommendations how to deal with the response in epidemiological studies in Germany are suggested.

[The problem of response in epidemiological studies in Germany (part I)]. / Zum Problem der Response in epidemiologischen Studien in Deutschland (Teil I).

To achieve high response rates in German epidemiological studies is growing more difficult. Low response in epidemiological studies may decrease the acceptance of the results. Response, however, is not identical with the quality of a study. In the first part of this paper various definitions of response (contact, cooperation, response, recruitment proportions) are introduced and discussed in the context of different study designs with reference to practical examples. A population-based survey such as the Study of Health in Pomerania (SHIP) investigates the distribution of risk factors and health-related endpoints. Surveys should yield representative results which can be generalised to apply to the entire population (external validity). This study design usually requires large participitation proportions. In a prospective cohort study such as the European Investigation into Cancer and Nutrition (EPIC) the emphasis is on internal validity. A stable study population willing to participate in regular follow-ups is a primary recruitment goal. If the response in a case-control study such as the Northern Germany Leukaemia and Lymphoma Study (NLL) is low, the priority is to achieve approximately equal response proportions for cases and controls. Simultaneous public relation and media activities can improve participitation in a study. Multidimensional strategies combining public communications, cooperation with local and regional officials and frequent press and media coverage are emphasised. The second part of this paper will discuss methods to quantify the effects of the response proportions on the validity of the study results.