Climate change and health equity: A public health perspective on climate justice.

Background: The discourse on climate justice has developed from the theoretical approaches and discussions on environmental justice. A central tenet of the concept of environmental and climate justice is that environmental and climate issues cannot be seen in isolation from issues of social justice. Methods: A conceptual model was developed on the relationship between climate change impacts, social dimensions, adaptive capacities, biological sensitivity, and health equity in order to systematically analyse climate justice. Based on an exploratory literature review and the evaluation of the individual contributions of the status report on climate change and health, the evidence in Germany on social inequalities in exposure to climate change impacts and vulnerability to their direct and indirect health effects was summarised. Results: This paper provides an overview of the international debate and examples of evidence on climate justice in Germany. Climate justice in the sense of avoidable, unjust social inequalities in exposure, vulnerability, and the effects of climate mitigation and adaptation measures on health inequalities is still insufficiently addressed in Germany. Conclusions: A consistent integration of equity issues into climate policy is necessary. With reference to the international literature, options for action and research needs are identified.

Operationalization of a multidimensional sex/gender concept for quantitative environmental health research and implementation in the KORA study: Results of the collaborative research project INGER.

Background: In environmental health research, sex and gender are not yet adequately considered. There is a need to improve data collection in population-based environmental health studies by comprehensively surveying sex/gender-related aspects according to gender theoretical concepts. Thus, within the joint project INGER we developed a multidimensional sex/gender concept which we aimed to operationalize and to test the operationalization for feasibility. Methods: In an iterative process, we created questionnaire modules which quantitatively captured the requirements of the INGER sex/gender concept. We deployed it in the KORA cohort (Cooperative Health Research in the Region of Augsburg, Germany) in 2019 and evaluated response and missing rates. Results: The individual sex/gender self-concept was surveyed via a two-step approach that asked for sex assigned at birth and the current sex/gender identity. Additionally, we used existing tools to query internalized sex/gender roles and externalized sex/gender expressions. Adapted to the KORA population, we asked for discrimination experiences and care and household activities contributing to explain structural sex/gender relations. Further intersectionality-related social categories (e.g., socio-economic position), lifestyle and psychosocial factors were covered through data available in KORA. We could not identify appropriate tools to assess the true biological sex, sexual orientation and ethnic/cultural identity, which have yet to be developed or improved. The response-rate was 71%, the evaluation of 3,743 questionnaires showed a low missing rate. Prevalence of marginalized groups regarding sex/gender identity and definable by experiences of discrimination was very low. Conclusion: We have shown how the multidimensional INGER sex/gender concept can be operationalized according to an European and North American understanding of sex/gender for use in quantitative research. The questionnaire modules proved feasible in an epidemiologic cohort study. Being a balancing act between theoretical concepts and its quantitative implementation our operationalization paves the way for an adequate consideration of sex/gender in environmental health research.

Do Multiple Sex/Gender Dimensions Play a Role in the Association of Green Space and Self-Rated Health? Model-Based Recursive Partitioning Results from the KORA INGER Study.

Exposure to green space has a positive impact on health. Whether sex/gender modifies the green space-health association has so far only been studied through the use of a binary sex/gender category; however, sex/gender should be considered more comprehensively as a multidimensional concept based on theoretical approaches. We therefore explored whether sex/gender, operationalized through multiple sex/gender- and intersectionality-related covariates, modifies the green space-self-rated health association. We collected data from participants involved in the German KORA study (Cooperative Health Research in the Region of Augsburg) in 2019. Self-rated health was assessed as a one-question item. The availability of green spaces was measured subjectively as well as objectively. The multiple sex/gender- and intersectionality-related covariates were measured via self-assessment. To analyze the data, we used model-based recursive partitioning, a decision tree method that can handle complex data, considering both multiple covariates and their possible interactions. We showed that none of the covariates operationalizing an individual sex/gender self-concept led to subgroups with heterogeneous effects in the model-based tree analyses; however, we found effect heterogeneity based on covariates representing structural aspects from an intersectionality perspective, although they did not show the intersectional structuring of sex/gender dimensions. In one identified subgroup, those with a lower education level or a feeling of discrimination based on social position showed a positive green space-self-rated health association, while participants with a higher education level or no feeling of discrimination based on social position had a high level of self-rated health regardless of the availability of green spaces. Model-based recursive partitioning has the potential to detect subgroups exhibiting different exposure-outcome associations, with the possibility of integrating multiple sex/gender- and intersectionality-related covariates as potential effect modifiers. A comprehensive assessment of the relevance of sex/gender showed effect heterogeneity based on covariates representing structural aspects from an intersectionality perspective.

Consideration of sex/gender in publications of quantitative health-related research: Development and application of an assessment matrix.

During the last years the need to integrate sex and gender in health-related research for better and fairer science became increasingly apparent. Various guidelines and checklists were developed to encourage and support researchers in considering the entangled dimensions of sex/gender in their research. However, a tool for the assessment of sex/gender consideration and its visualization is still missing. We aim to fill this gap by introducing an assessment matrix that can be used as a flexible instrument for comprehensively evaluating the sex/gender consideration in quantitative health-related research. The matrix was developed through an iterative and open process based on the interdisciplinary expertise represented in our research team and currently published guidelines. The final matrix consists of 14 different items covering the whole research process and the publication of results. Additionally, we introduced a method to graphically display this evaluation. By developing the matrix, we aim to provide users with a tool to systematically compare sex/gender consideration qualitatively between different publications and even different fields of study. This way, the assessment matrix represents a tool to identify research gaps and a basis for future research. In the long term, the implementation of this tool to evaluate the consideration of sex/gender should contribute to more sex/gender equitable health-related research.

Decision Tree Analyses to Explore the Relevance of Multiple Sex/Gender Dimensions for the Exposure to Green Spaces: Results from the KORA INGER Study.

Recently, attention has been drawn to the need to integrate sex/gender more comprehensively into environmental health research. Considering theoretical approaches, we define sex/gender as a multidimensional concept based on intersectionality. However, operationalizing sex/gender through multiple covariates requires the usage of statistical methods that are suitable for handling such complex data. We therefore applied two different decision tree approaches: classification and regression trees (CART) and conditional inference trees (CIT). We explored the relevance of multiple sex/gender covariates for the exposure to green spaces, measured both subjectively and objectively. Data from 3742 participants from the Cooperative Health Research in the Region of Augsburg (KORA) study were analyzed within the INGER (Integrating gender into environmental health research) project. We observed that the participants' financial situation and discrimination experience was relevant for their access to high quality public green spaces, while the urban/rural context was most relevant for the general greenness in the residential environment. None of the covariates operationalizing the individual sex/gender self-concept were relevant for differences in exposure to green spaces. Results were largely consistent for both CART and CIT. Most importantly we showed that decision tree analyses are useful for exploring the relevance of multiple sex/gender dimensions and their interactions for environmental exposures. Further investigations in larger urban areas with less access to public green spaces and with a study population more heterogeneous with respect to age and social disparities may add more information about the relevance of multiple sex/gender dimensions for the exposure to green spaces.

Sunk costs under stress: Acute stress reduces the impact of past expenses on risky decisions.

Rational choice should be guided solely by the prospects of available options. However, our decisions are often influenced by irrecoverable past costs, even when the current course of action turns out to be unfavorable, reflecting a cognitive bias known as the "sunk-cost effect". In everyday life, many decisions are made under stress or elicit stress themselves. Whether and how stress impacts the sunk-cost effect, however, is not known. Based on evidence suggesting that the sunk-cost effect critically depends on the dorsolateral prefrontal cortex, which in turn is highly sensitive to stress, we hypothesized that stress may reduce the influence of past expenses on current decisions. Participants underwent a psychosocial stress manipulation or control procedure, before we assessed their sunk-cost tendency in a monetary investment task. Overall, participants showed a pronounced sunk-cost effect, particularly for options with low expected value. Acute stress reduced this tendency to invest in risky options with low probability of success following high prior investments. Moreover, the strength of this reduction of the sunk-cost effect was predicted by individual cortisol reactivity. These findings show that acute stress may reduce the impact of past expenses on current choice and that this effect may be mediated by glucocorticoid action.

Integrating Sex/Gender into Environmental Health Research: Development of a Conceptual Framework.

There is a growing awareness about the need to comprehensively integrate sex and gender into health research in order to enhance the validity and significance of research results. An in-depth consideration of differential exposures and vulnerability is lacking, especially within environmental risk assessment. Thus, the interdisciplinary team of the collaborative research project INGER (integrating gender into environmental health research) aimed to develop a multidimensional sex/gender concept as a theoretically grounded starting point for the operationalization of sex and gender in quantitative (environmental) health research. The iterative development process was based on gender theoretical and health science approaches and was inspired by previously published concepts or models of sex- and gender-related dimensions. The INGER sex/gender concept fulfills the four theoretically established prerequisites for comprehensively investigating sex and gender aspects in population health research: multidimensionality, variety, embodiment, and intersectionality. The theoretical foundation of INGER's multidimensional sex/gender concept will be laid out, as well as recent sex/gender conceptualization developments in health sciences. In conclusion, by building upon the latest state of research of several disciplines, the conceptual framework will significantly contribute to integrating gender theoretical concepts into (environmental) health research, improving the validity of research and, thus, supporting the promotion of health equity in the long term.

Sex/Gender Differences in the Association between Residential Green Space and Self-Rated Health-A Sex/Gender-Focused Systematic Review.

Though sex/gender is an important social determinant of health, sex/gender inequalities have not been considered comprehensively in environmental health research thus far. The aim of this systematic review was to clarify whether sex/gender theoretical concepts were addressed in studies on the impact of residential green space on self-rated health and whether effect modification by sex/gender was observed. Three electronic databases were searched to identify epidemiological studies on perceived or objective residential green/blue space and self-rated health. Necessary for study inclusion was mentioning at least one keyword for sex/gender in title or abstract, adult study participants and data on self-rated health and on availability and/or use of green/blue spaces. Decisive for study inclusion was consideration of sex/gender differences in the impact of perceived or objective residential green/blue spaces on self-rated health in the analysis and presentation of results. Seven studies were included. They presented an overall positive impact of green space on self-rated health. No consistent sex/gender differences in the impact of green space on self-rated health were found in these studies. However, all studies used a binary operationalization male/female without further theoretical foundation. Research quality could be enhanced by integrating sex/gender-theoretical concepts into study design and interpretation of results.

Time-dependent motor memory representations in prefrontal cortex.

How memories evolve over time is fundamental for understanding memory. Hippocampus-dependent episodic memories are generally assumed to undergo a time-dependent neural reorganization involving an increased reliance on neocortical areas. Yet, whether other forms of memory undergo a similar reorganization over time remains unclear. Here, we examined whether the neural underpinnings of motor sequence memories change over time. Participants were trained on a motor sequence learning task. Either 1d or 28d later, they performed a retention test for this task in the fMRI scanner. Sequence-specific motor memory was observed both 1d and 28d after initial training. Bayesian second-level fMRI analyses suggested a higher probability for task activity in the middle frontal gyrus and frontal pole 28d compared to 1d after initial motor learning. Searchlight representational similarity analysis indicated that areas in middle and superior frontal cortex were more involved in differentiating between multivariate activity patterns for old motor sequence memories and newly learned motor sequences in the 28d-group compared to the 1d-group. This increased involvement of lateral frontal areas during the task after 28 days was not paralleled by a decrease in those areas that were involved in performing the motor sequence retention task after 1d. These novel findings provide insights into how memories beyond the hippocampus evolve over time.

Dorsolateral Prefrontal Cortex Enables Updating of Established Memories.

Updating established memories in light of new information is fundamental for memory to guide future behavior. However, little is known about the brain mechanisms by which existing memories can be updated. Here, we combined functional magnetic resonance imaging and multivariate representational similarity analysis to elucidate the neural mechanisms underlying the updating of consolidated memories. To this end, participants first learned face-city name pairs. Twenty-four hours later, while lying in the MRI scanner, participants were required to update some of these associations, but not others, and to encode entirely new pairs. Updating success was tested again 24 h later. Our results showed increased activity of the dorsolateral prefrontal cortex (dlPFC) specifically during the updating of existing associations that was significantly stronger than when simple retrieval or new encoding was required. The updating-related activity of the dlPFC and its functional connectivity with the hippocampus were directly linked to updating success. Furthermore, neural similarity for updated items was markedly higher in the dlPFC and this increase in dlPFC neural similarity distinguished individuals with high updating performance from those with low updating performance. Together, these findings suggest a key role of the dlPFC, presumably in interaction with the hippocampus, in the updating of established memories.

Author Correction: Time-dependent memory transformation along the hippocampal anterior-posterior axis.

In the originally published version of this Article, the rightmost graph in Fig. 2c was inadvertently replaced with a duplicate of the central panel. This has now been corrected in both the PDF and HTML versions of the Article.

Time-dependent memory transformation along the hippocampal anterior-posterior axis.

With time, memories undergo a neural reorganization that is linked to a transformation of detailed, episodic into more semantic, gist-like memory. Traditionally, this reorganization is thought to involve a redistribution of memory from the hippocampus to neocortical areas. Here we report a time-dependent reorganization within the hippocampus, along its anterior-posterior axis, that is related to the transformation of detailed memories into gist-like representations. We show that mnemonic representations in the anterior hippocampus are highly distinct and that anterior hippocampal activity is associated with detailed memory but decreases over time. Posterior hippocampal representations, however, are more gist-like at a later retention interval, and do not decline over time. These findings indicate that, in addition to the well-known systems consolidation from hippocampus to neocortex, there are changes within the hippocampus that are crucial for the temporal dynamics of memory.

Stress-induced cortisol hampers memory generalization.

Integrative encoding and generalization across past experiences depends largely on the hippocampus, an area known to be particularly sensitive to stress. Yet, whether stress influences the ability to generalize memories is unknown. We exposed volunteers to a stressor or a control manipulation before they completed an acquired equivalence task probing memory generalization. While stress left learning performance intact, it reduced participants' ability to generalize and this deficit was directly linked to the cortisol response to the stressor. These findings show that stress, presumably through the action of glucocorticoids, creates rather rigid memories that are difficult to transfer to novel situations.