A longitudinal analysis of health inequalities from adolescence to young adulthood and their underlying causes.

Research suggests that children of low-educated parents face greater health burdens during the passage from adolescence to young adulthood, as they are more likely to become low-educated themselves, establish behavioural and psychosocial disadvantages, or being exposed to unhealthy working conditions. However, studies examining the development and drivers of health inequalities during this particular life stage are limited in number and have produced varied results. This study investigates trajectories of self-rated health and overweight from 14 to 25 years of age, stratified by parental education, and explores the role of potential mediators (educational achievement, health behaviours, psychosocial factors, working conditions). We rely on prospective cohort data from the National Educational Panel Study (NEPS), a representative sample of 14,981 German ninth graders interviewed yearly from 2011 to 2021 (n = 90,096 person-years). First, we estimated random-effects growth curves for self-rated health and overweight over participants' age and calculated the average marginal effect of high versus low parental education. Second, a series of simulation-based mediation analyses were performed to test how much of health inequalities were explained by children's educational attainment (years of school education, years in university), health behaviours (smoking, alcohol, physical inactivity), psychosocial factors (number of grade repetitions, years in unemployment, chronic stress, self-esteem) and working conditions (physical and psychosocial job demands). We accounted for potential confounding by controlling for age, sex, migration background, residential area, household composition, and interview mode. Results show that higher parental education was related to higher self-rated health and lower probabilities of being overweight. Interaction between parental education and age indicated that, after some equalisation in late adolescence, health inequalities increased in young adulthood. Furthermore, educational attainment, health behaviours, psychosocial factors, and early-career working conditions played a significant role in mediating health inequalities. Of the variables examined, the level of school education and years spent in university were particular strong mediating factors. School education accounted for around one-third of the inequalities in self-rated health and one-fifth of the differences in overweight among individuals. Results support the idea that the transition to adulthood is a sensitive period in life and that early socio-economic adversity increases the likelihood to accumulate health disadvantages in multiple dimensions. In Germany, a country with comparatively low educational mobility, intergenerational continuities in class location seem to play a key role in the explanation of health inequalities in youth.

Health inequalities among young workers: the mediating role of working conditions and company characteristics.

OBJECTIVE: Few studies have investigated health inequalities among young workers. The objectives of this study are to assess the extent of health inequalities in a sample of job starters and to explore the contribution of job demands and organisational factors. METHODS: We analyze data from the BIBB/BAuA Youth Employment Survey 2012. The cross-sectional survey includes a representative sample of 3214 German employees, apprentices, and trainees aged 15-24 years. Individuals were grouped by their years of schooling into low (< 12 years) and high levels of education (≥ 12 years). Regression analysis estimated the link between education and four health outcomes: self-rated health, number of health events, musculoskeletal symptoms, and mental health problems over the last 12 months. Counterfactual mediation analysis tested for indirect effects of education via working conditions (i.e., physical and psychosocial job demands) and company characteristics (i.e., company size, health prevention measures, financial situation, downsizing). All analyses were adjusted for age, sex, nationality, region, working hours, job tenure, employment relationship, and economic sector. RESULTS: Highly educated workers reported better self-rated health (b = 0.24, 95% CI 0.18-0.31) and lower numbers of health events (Rate Ratio (RR) = 0.74, 95% CI 0.67-0.82), musculoskeletal symptoms (RR = 0.73, 95% CI 0.66-0.80) and mental health problems (RR = 0.84, 95% CI 0.76-0.93). Total job demands explained between 21.6% and 87.2% of the educational differences (depending on health outcome). Unfavourable company characteristics were associated with worse health, but showed no or only small mediation effects. CONCLUSIONS: Health inequalities are already present at the early working career due to socio-economically stratified working hazards. To enhance prevention measures that aim at reducing inequalities in workplace health, we propose shifting attention towards earlier stages of life.

Associations of Migration, Socioeconomic Position and Social Relations With Depressive Symptoms - Analyses of the German National Cohort Baseline Data.

Objectives: We analyze whether the prevalence of depressive symptoms differs among various migrant and non-migrant populations in Germany and to what extent these differences can be attributed to socioeconomic position (SEP) and social relations. Methods: The German National Cohort health study (NAKO) is a prospective multicenter cohort study (N = 204,878). Migration background (assessed based on citizenship and country of birth of both participant and parents) was used as independent variable, age, sex, Social Network Index, the availability of emotional support, SEP (relative income position and educational status) and employment status were introduced as covariates and depressive symptoms (PHQ-9) as dependent variable in logistic regression models. Results: Increased odds ratios of depressive symptoms were found in all migrant subgroups compared to non-migrants and varied regarding regions of origins. Elevated odds ratios decreased when SEP and social relations were included. Attenuations varied across migrant subgroups. Conclusion: The gap in depressive symptoms can partly be attributed to SEP and social relations, with variations between migrant subgroups. The integration paradox is likely to contribute to the explanation of the results. Future studies need to consider heterogeneity among migrant subgroups whenever possible.

[Occupational differences of COVID-19 morbidity and mortality in Germany. An analysis of health insurance data from 3.17 million insured persons]. / Berufsbedingte Unterschiede bei COVID-19-Morbidität und -Mortalität in Deutschland. Eine Analyse von Krankenkassendaten von 3,17 Mio. Versicherten.

INTRODUCTION: During the COVID-19 pandemic, occupation was assumed to play a central role in the occurrence of infection and disease. For Germany, however, there are only a few studies that analyse occupational differences in risk of COVID-19, COVID-19-associated hospitalisation, and mortality. METHODS: The study uses longitudinal health insurance data from the research database of the Institute for Applied Health Research (InGef) with information on 3.17 million insured persons aged 18-67 years (1,488,452 women; 1,684,705 men). Outcomes (morbidity, hospitalisation, and mortality) were determined on the basis of submitted COVID-19 diagnoses between 1 January 2020 and 31 December 2021. Occupations were classified according to four groupings of the official German classification of occupations. In addition to cumulative incidences, relative risks (RR) were calculated - separately for men and women. RESULTS: There is an increased risk of disease in personal service occupations, especially in health care, compared to other occupations (RR for women 1.46; for men 1.30). The same applies to social and cultural service occupations (but only for women) and for manufacturing occupations (only for men). In addition, the risks for hospitalisation and mortality are increased for cleaning occupations and transport and logistics occupations (especially for men). For all three outcomes, the risks are higher in non-managerial occupations and differ by skill level (highest for unskilled jobs and lowest for expert positions). CONCLUSION: The study provides important findings on work- and gender-related differences in COVID-19 morbidity and mortality in Germany, which indicate starting points for structural infection protection measures.

Young people's health and well-being during the school-to-work transition: a prospective cohort study comparing post-secondary pathways.

BACKGROUND: At the end of secondary education, young people can either start vocational training, enter university, directly transition to employment or become unemployed. Research assumes that post-secondary pathways have immediate and/or long-term impacts on health and well-being, but empirical investigations on this are scarce and restricted to few countries. Therefore, this study traced the development of health and well-being throughout the highly institutionalised school-to-work transition (STWT) in Germany. METHODS: We used longitudinal data of the National Educational Panel Study (NEPS), a representative sample of 11,098 school-leavers (50.5% girls) repeatedly interviewed between 2011 and 2020. We estimated the effect of post-secondary transitions on self-rated health and subjective well-being by applying fixed-effects (FE) regression, eliminating bias resulting from time-constant confounding and self-selection into different pathways. A multiple-sample strategy was used to account for the increasing diversity of STWTs patterns. Models were controlled for age, as well as household and residential changes to minimise temporal heterogeneity. RESULTS: Findings indicate that leaving school was good for health and well-being. Compared with participants who did not find a training position after school, direct transitions to vocational training or university were linked to higher absolute levels of health and well-being, but also to a lower relative decline over time. Furthermore, upward transitions (e.g. to programs leading to better education or from unemployment to employment) were associated with improvements in health and well-being, while downward transitions were followed by deteriorations. CONCLUSION: Findings suggest that school-leave is a sensitive period and that post-secondary pathways provide young people with different abilities to maintain health and well-being. Youth health interventions might benefit when setting a stronger focus on unsuccessful school-leavers.

Authors' response: Occupation and SARS-CoV-2 infection risk among workers during the first pandemic wave in Germany: potential for bias.

We thank van Tongeren et al for responding to our study on occupational disparities in SARS-CoV-2 infection risks during the first pandemic wave in Germany (1). The authors address the potential for bias resulting from differential testing between occupational groups and propose an alternative analytical strategy for dealing with selective testing. In the following, we want to discuss two aspects of this issue, namely (i) the extent and reasons of differential testing in our cohort and (ii) the advantages and disadvantages of different analytical approaches to study risk factors for SARS-CoV-2 infection. Our study relied on nationwide prospective cohort data including more than 100 000 workers in order to compare the incidence of infections between different occupations and occupational status positions. We found elevated infection risks in personal services and business administration, in essential occupations (including health care) and among people in higher occupational status positions (ie, managers and highly skilled workers) during the first pandemic wave in Germany (2). Van Tongeren's et al main concern is that the correlations found could be affected by a systematic bias because people in healthcare professions get tested more often than employees in other professions. A second argument is that better-off people could be more likely to use testing as they are less affected by direct costs (prices for testing) and the economic hardship associated with a positive test result (eg, loss of earnings in the event of sick leave). We share the authors' view that differential testing must be considered when analysing and interpreting the data. Thus, in our study, we examined the proportion of tests conducted in each occupational group as part of the sensitivity analyses (see supplementary figure S1, accessible at www.sjweh.fi/article/4037). As expected, testing proportions were exceptionally high in medical occupations (due to employer requirements). However, we did not observe systematic differences among non-medical occupations or when categorising by skill-level or managerial responsibility. This might be explained by several reasons. First, SARS-CoV-2 testing was free of charge during the first pandemic wave in Germany, but reporting a risk contact or having symptoms was a necessary condition for testing ( https://www.bundesgesundheitsministerium.de/coronavirus/chronik-coronavirus.html (accessed 5 September 2022). The newspaper article cited by van Tongeren et al is misleading as it refers to a calendar date after our study period. Second, different motivation for testing due to economic hardship in case of a positive test result is an unlikely explanation, because Germany has a universal healthcare system, including paid sick leave and sickness benefits for all workers (3). Self-employed people carry greater financial risks in case of sickness. We therefore included self-employment in the multivariable analyses to address this potential source of bias. While the observed inverse social gradient may be surprising, it actually matches with findings of ecological studies from Germany (4, 5), the United States (6, 7) as well as Spain, Portugal, Sweden, The Netherlands, Israel, and Hong Kong (8), all of which observed higher infection rates in wealthier neighbourhoods during the initial outbreak phase of the pandemic. One possible explanation is the higher mobility of managers and better educated workers, who are more likely to participate in meetings and engage in business travel and holiday trips like skiing. Given the increasing number of studies providing evidence for this hypothesis, we conclude that the inverse social gradient in our study likely reflects different exposure probabilities and is not a result of systematic bias. This also holds true for the elevated infection risks in essential workers, which is actually corroborated by a large body of research (9-11). Regarding differential likelihood of testing, van Tongeren et al state that "[i]t is relatively simple to address this problem by using a test-negative design" (1). As van Tongeren et al describe, this is a case-control approach only including individuals who were tested (without considering those who were not tested). However, the proposed analytical strategy can lead to another (more serious) selection bias if testing proportions and/or testing criteria differ between groups (12). This can be easily illustrated when comparing the results based on a time-incidence design with those obtained by a test-negative design as shown in table 1 (see PDF). Both approaches show similar results in terms of vertical occupational differences. Infection was more common if individuals had a high skill level or had a managerial position, but associations were stronger in the time-incidence design and did not reach statistical significance in the test-negative design (as indicated by the confidence intervals overlapping "1"). Unfortunately, the test-negative approach relies on a strongly reduced sample size and thus results in greater statistical uncertainty and loss of statistical power (13). In contrast, the test-negative design yields a different picture when estimating the association between essential occupation and infection risk: In this analysis, essential workers did not differ from non-essential workers in their chance of being infected with SARS-CoV-2 (the test-negative design even exhibits a lower chance for essential workers). This is rather counter-intuitive and is not in accordance with what we know about the occupational hazards of healthcare workers during the pandemic (14). The main problem is that proportions of positive tests are highly unreliable when testing proportions and/or testing criteria differ between groups. As essential workers were tested more often without being symptomatic (due to employer requirements), a lower proportion of positive tests in this group does not necessarily correspond to a lower risk of infection. Consequently, we are not convinced that the test-negative design should be the 'gold standard' for studying risk factors for SARS-CoV-2 infections (15). Especially problematic is the loss of statistical power (increasing the probability of a type II error) and the low validity of the test-positivity when test criteria and/or test proportions differ between groups. References 1. van Tongeren M, Rhodes S, Pearce N. Occupation and SARS-CoV-2 infection risk among workers during the first pandemic wave in Germany: potential for bias. Scand J Work Environ Health 2022;48(7):586-587. https://doi.org/10.5271/sjweh.4052. 2. Reuter M, Rigó M, Formazin M, Liebers F, Latza U, Castell S, et al. Occupation and SARS-CoV-2 infection risk among 108 960 workers during the first pandemic wave in Germany. Scand J Work Environ Health 2022;48:446-56. https://doi.org/10.5271/sjweh.4037. 3. Busse R, Blümel M, Knieps F, Bärnighausen T. Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition. Lancet 2017;390:882-97. https://doi.org/10.1016/S0140-6736(17)31280-1. 4. Wachtler B, Michalski N, Nowossadeck E, Diercke M, Wahrendorf M, Santos-Hövener C, et al. Socioeconomic inequalities in the risk of SARS-CoV-2 infection - First results from an analysis of surveillance data from Germany. J Heal Monit 2020;5:18-29. https://doi.org/10.25646/7057. 5. Plümper T, Neumayer E. The pandemic predominantly hits poor neighbourhoods? SARS-CoV-2 infections and COVID-19 fatalities in German districts. Eur J Public Health 2020;30:1176-80. https://doi.org/10.1093/eurpub/ckaa168. 6. Abedi V, Olulana O, Avula V, Chaudhary D, Khan A, Shahjouei S, et al. Racial, Economic, and Health Inequality and COVID-19 Infection in the United States. J Racial Ethn Heal Disparities 2021;8:732-42. https://doi.org/10.1007/s40615-020-00833-4. 7. Mukherji N. The Social and Economic Factors Underlying the Incidence of COVID-19 Cases and Deaths in US Counties During the Initial Outbreak Phase. Rev Reg Stud 2022;52. https://doi.org/10.52324/001c.35255. 8. Beese F, Waldhauer J, Wollgast L, Pförtner T, Wahrendorf M, Haller S, et al. Temporal Dynamics of Socioeconomic Inequalities in COVID-19 Outcomes Over the Course of the Pandemic-A Scoping Review. Int J Public Health 2022;67:1-14. https://doi.org/10.3389/ijph.2022.1605128. 9. Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo C-G, Ma W, et al. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Heal 2020;5:e475-83. https://doi.org/10.1016/S2468-2667(20)30164-X. 10. Chou R, Dana T, Buckley DI, Selph S, Fu R, Totten AM. Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers. Ann Intern Med 2020;173:120-36. https://doi.org/10.7326/M20-1632. 11. Stringhini S, Zaballa M-E, Pullen N, de Mestral C, Perez-Saez J, Dumont R, et al. Large variation in anti-SARS-CoV-2 antibody prevalence among essential workers in Geneva, Switzerland. Nat Commun 2021;12:3455. https://doi.org/10.1038/s41467-021-23796-4. 12. Accorsi EK, Qiu X, Rumpler E, Kennedy-Shaffer L, Kahn R, Joshi K, et al. How to detect and reduce potential sources of biases in studies of SARS-CoV-2 and COVID-19. Eur J Epidemiol 2021;36:179-96. https://doi.org/10.1007/s10654-021-00727-7. 13. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd Editio. New York: Routledge; 2013. https://doi.org/10.4324/9780203771587. 14. The Lancet. The plight of essential workers during the COVID-19 pandemic. Lancet 2020;395:1587. https://doi.org/10.1016/S0140-6736(20)31200-9. 15. Vandenbroucke JP, Brickley EB, Pearce N, Vandenbroucke-Grauls CMJE. The Evolving Usefulness of the Test-negative Design in Studying Risk Factors for COVID-19. Epidemiology 2022;33:e7-8. https://doi.org/10.1097/EDE.0000000000001438.

School-to-work and school-to-university transition and health inequalities among young adults: a scoping review.

OBJECTIVES: The main objective was to systematically map evidence regarding the emergence of health inequalities in individuals aged 16-24 years during school-to-work and school-to-university transition (STWT). Second, we aimed to summarise the evidence on potential effects of contextual and compositional characteristics of specific institutional contexts entered during STWT on health and health behaviours. DESIGN: Scoping review. STUDY SELECTION: Relevant literature was systematically searched following the methodological framework proposed by Arksey and O'Malley. Ovid MEDLINE and Web of Science, and websites of the International Labour Organization and National Institute for Occupational Safety and Health were searched, using a predetermined search strategy. Articles in English or German published between 1 January 2000 and 3 February 2020 were considered. DATA EXTRACTION: To collect the main information from the selected studies, a data extraction spreadsheet was created. Data were summarised and grouped into five health outcomes and five institutional contexts (school, vocational training, university, work, unemployment). RESULTS: A total of 678 articles were screened for inclusion. To be able to draw a picture of the development of various health outcomes over time, we focused on longitudinal studies. Forty-six prospective studies mapping health-related outcomes during STWT were identified. Higher family socioeconomic position (SEP) was associated with higher levels of health behaviour and lower levels of health-damaging behaviour, but there was also some evidence pointing in the opposite direction. Disadvantaged family SEP negatively impacted on mental health and predicted an adverse weight development. There was limited evidence for the outcomes physical/somatic symptoms and self-rated health. Meso-level characteristics of the institutional contexts identified were not systematically assessed, only individual-level factors resulting from an exposure to these contexts, rendering an analysis of effects of contextual and compositional characteristics on health and health behaviours impossible. CONCLUSIONS: This scoping review demonstrated a wide range of health inequalities during STWT for various health outcomes. However, knowledge on the role of the core institutional contexts regarding the development of health inequalities is limited.

Associations of individual factors and early childhood education and care (ECEC) centres characteristics with preschoolers' BMI in Germany.

BACKGROUND: The number of obese children is rising worldwide. Many studies have investigated single determinants of children's body mass index (BMI), yet studies measuring determinants at different potential levels of influence are sparse. The aim of this study is to investigate the independent role of parental socioeconomic position (SEP), additional family factors at the micro level, as well as early childhood education and care (ECEC) centre characteristics at the meso level regarding BMI. METHODS: Analyses used the baseline data of the PReschool INtervention Study (PRINS) including up to 1,151 children from 53 ECEC centres. Multi-level models first estimated the associations of parental SEP indicators (parental school education, vocational training, and household income) with the children's standard deviation scores for BMI (SDS BMI, standardised for age and gender). Second, structural (number of siblings), psychosocial (strained family relationships), and nutrition behavioural (soft-drink consumption, frequency of fast-food restaurant visits) family factors at the micro level were included. Third, characteristics of the ECEC centre at the meso level in terms of average group size, the ratio of overweight children in the group, ECEC centre type (all-day care), and the location of the ECEC centre (rural vs urban) were included. All analyses were stratified by gender and adjusted for age, migration background, and parental employment status. RESULTS: Estimates for boys and girls appeared to differ. In the full model, for boys the parental SEP indicators were not related to SDS BMI. Factors related to SDS BMI in boys were: two or more siblings; B = -.55; p = 0.045 [ref.: no sibling]), the characteristics of the ECEC centre in terms of average group size (20 - 25 children; B = -.54; p = 0.022 [ref.: < 20 children]), and the ratio of overweight children (more overweight children B = -1.39; p < 0.001 [ref.: few overweight children]). For girls the number of siblings (two and more siblings; B = .67; p = 0.027 [ref.: no sibling]) and average group size (> 25 children; B = -.52; p = 0.037 [ref.: < 20 children]) were related to SDS BMI. CONCLUSIONS: The BMI of preschool children appears to be associated with determinants at the micro and meso level, however with some gender differences. The identified factors at the micro and meso level appear largely modifiable and can inform about possible interventions to reduce obesity in preschool children.

Regional disparities in SARS-CoV-2 infections by labour market indicators: a spatial panel analysis using nationwide German data on notified infections.

BACKGROUND: Regional labour markets and their properties are named as potential reasons for regional variations in levels of SARS-CoV-2 infections rates, but empirical evidence is missing. METHODS: Using nationwide data on notified laboratory-confirmed SARS-CoV-2 infections, we calculated weekly age-standardised incidence rates (ASIRs) for working-age populations at the regional level of Germany's 400 districts. Data covered nearly 2 years (March 2020 till December 2021), including four main waves of the pandemic. For each of the pandemic waves, we investigated regional differences in weekly ASIRs according to three regional labour market indicators: (1) employment rate, (2) employment by sector, and (3) capacity to work from home. We use spatial panel regression analysis, which incorporates geospatial information and accounts for regional clustering of infections. RESULTS: For all four pandemic waves under study, we found that regions with higher proportions of people in employment had higher ASIRs and a steeper increase of infections during the waves. Further, the composition of the workforce mattered: rates were higher in regions with larger secondary sectors or if opportunities of working from home were comparatively low. Associations remained consistent after adjusting for potential confounders, including a proxy measure of regional vaccination progress. CONCLUSIONS: If further validated by studies using individual-level data, our study calls for increased intervention efforts to improve protective measures at the workplace, particularly among workers of the secondary sector with no opportunities to work from home. It also points to the necessity of strengthening work and employment as essential components of pandemic preparedness plans.

Occupation and SARS-CoV-2 infection risk among 108 960 workers during the first pandemic wave in Germany.

OBJECTIVE: The aim of this study was to identify the occupational risk for a SARS-CoV-2 infection in a nationwide sample of German workers during the first wave of the COVID-19 pandemic (1 February-31 August 2020). METHODS: We used the data of 108 960 workers who participated in a COVID follow-up survey of the German National Cohort (NAKO). Occupational characteristics were derived from the German Classification of Occupations 2010 (Klassifikation der Berufe 2010). PCR-confirmed SARS-CoV-2 infections were assessed from self-reports. Incidence rates (IR) and incidence rate ratios (IRR) were estimated using robust Poisson regression, adjusted for person-time at risk, age, sex, migration background, study center, working hours, and employment relationship. RESULTS: The IR was 3.7 infections per 1000 workers [95% confidence interval (CI) 3.3-4.1]. IR differed by occupational sector, with the highest rates observed in personal (IR 4.8, 95% CI 4.0-5.6) and business administration (IR 3.4, 95% CI 2.8-3.9) services and the lowest rates in occupations related to the production of goods (IR 2.0, 95% CI 1.5-2.6). Infections were more frequent among essential workers compared with workers in non-essential occupations (IRR 1.95, 95% CI 1.59-2.40) and among highly skilled compared with skilled professions (IRR 1.36, 95% CI 1.07-1.72). CONCLUSIONS: The results emphasize higher infection risks in essential occupations and personal-related services, especially in the healthcare sector. Additionally, we found evidence that infections were more common in higher occupational status positions at the beginning of the pandemic.

Socioeconomic position and self-rated health among female and male adolescents: The role of familial determinants in explaining health inequalities. Results of the German KiGGS study.

OBJECTIVE: Although health inequalities in adolescence are well documented, the underlying mechanisms remain unclear. Few studies have examined the role of the family in explaining the association between the family's socioeconomic position and adolescents' self-rated health. The current study aimed to explore whether the association between socioeconomic position and self-rated health was mediated by familial determinants. METHODS: Using data from wave 2 of the"German Health Interview and Examination Survey for Children and Adolescents" (KiGGS) (1,838 female and 1,718 male 11- to 17-year-olds), linear regression analyses were conducted to decompose the total effects of income, education, occupational status, socioeconomic position index and adolescents' subjective social status on self-rated health into direct effects and indirect effects through familial determinants (family cohesion, parental well-being, parental stress, parenting styles, parental obesity, smoking and sporting activity). RESULTS: A significant total effect of all socioeconomic position indicators on self-rated health was found, except for income in male adolescents. In female adolescents, more than 70% of the total effects of each socioeconomic position indicator were explained by familial mediators, whereas no significant direct effects remained. The most important mediator was parental well-being, followed by family cohesion, parental smoking and sporting activity. In male adolescents, the associations between income, parental education, the socioeconomic position index and subjective social status were also mediated by familial determinants (family cohesion, parental smoking, obesity and living in a single-mother family). However, a significant direct effect of subjective social status remained. CONCLUSION: The analysis revealed how a family's position of socioeconomic disadvantage can lead to poorer health in adolescents through different family practices. The family appears to play an important role in explaining health inequalities, particularly in female adolescents. Reducing health inequalities in adolescence requires policy interventions (macro-level), community-based strategies (meso-level) and programs to improve parenting and family functioning (micro-level).

Increase in Mental Disorders During the COVID-19 Pandemic-The Role of Occupational and Financial Strains.

BACKGROUND: Numerous studies have reported an increase in mental disorders during the COVID-19 pandemic, but the exact reasons for this development are not well understood. In this study we investigate whether pandemic-related occupational and financial changes (e.g., reduced working hours, working from home, financial losses) were associated with increased symptoms of depression and anxiety compared with the situation before the pandemic. METHODS: We analyzed data from the German National Cohort (NAKO) Study. Between May and November 2020, 161 849 study participants answered questions on their mental state and social circumstances. Their responses were compared with data from the baseline survey before the pandemic (2014-2019). Linear fixed-effects models were used to determine whether individual changes in the severity of symptoms of depression (PHQ-9) or anxiety (GAD-7) were associated with occupational/ financial changes (controlling for various covariates). RESULTS: The prevalence of moderate or severe symptoms of depression and anxiety increased by 2.4% and 1.5%, respectively, during the COVID-19 pandemic compared with the preceding years. The mean severity of the symptoms rose slightly. A pronounced increase in symptoms was observed among those who became unemployed during the pandemic (+ 1.16 points on the depression scale, 95% confidence interval [0.91; 1.41], range 0-27). Increases were also seen for reduced working hours with no short-time allowance, increased working hours, working from home, insecurity regarding employment, and financial strain. The deterioration in mental health was largely statistically explained by the occupational and financial changes investigated in the model. CONCLUSION: Depressive symptoms and anxiety disorders increased slightly in the study population during the first year of the COVID-19 pandemic. Occupational and financial difficulties were an essential contributory factor. These strains should be taken into account both in the care of individual patients and in the planning of targeted prevention measures.

SPECTRE-A novel dMRI visualization technique for the display of cerebral connectivity.

The visualization of diffusion MRI related properties in a comprehensive way is still a challenging problem. We propose a simple visualization technique to give neuroradiologists and neurosurgeons a more direct and personalized view of relevant connectivity patterns estimated from clinically feasible diffusion MRI. The approach, named SPECTRE (Subject sPEcific brain Connectivity display in the Target REgion), is based on tract-weighted imaging, where diffusion MRI streamlines are used to aggregate information from a different MRI contrast. Instead of using native MRI contrasts, we propose to use continuous template information as the underlying contrast for aggregation. In this respect, the SPECTRE approach is complementary to normative approaches where connectivity information is warped from the group level to subject space by anatomical registration. For the purpose of demonstration, we focus the presentation of the SPECTRE approach on the visualization of connectivity patterns in the midbrain regions at the level of subthalamic nucleus due to its importance for deep brain stimulation. The proposed SPECTRE maps are investigated with respect to plausibility, robustness, and test-retest reproducibility. Clear dependencies of reliability measures with respect to the underlying tracking algorithms are observed.

Mapping the evidence regarding school-to-work/university transition and health inequalities among young adults: a scoping review protocol.

INTRODUCTION: School-to-work/university transition is a sensitive period that can have a substantial impact on health and health behaviour over the life course. There is some indication that health and health behaviour is socially patterned in the age span of individuals in this transition (16-24 years) and that there are differences by socioeconomic position (SEP). However, evidence regarding this phenomenon has not been systematically mapped. In addition, little is known about the role of institutional characteristics (eg, of universities, workplaces) in the development of health and possible inequalities in health during this transition. Hence, the first objective of this scoping review is to systematically map the existing evidence regarding health and health behaviours (and possible health inequalities, for example, differences by SEP) in the age group of 16-24 years and during school-to-work transition noted in Germany and abroad. The second objective is to summarise the evidence on the potential effects of contextual and compositional characteristics of specific institutions entered during this life stage on health and health behaviours. Third, indicators and measures of these characteristics will be summarised. METHODS AND ANALYSIS: We will systematically map the evidence on health inequalities during school-to-work-transitions among young adults (aged 16-24 years), following the methodological framework proposed by Arksey and O'Malley. The literature search is performed in Ovid MEDLINE, Web of Science, International Labour Organization and National Institute for Occupational Safety and Health, using a predetermined search strategy. Articles published between January 2000 and February 2020 in English or German are considered for the review. The selection process follows a two-step approach: (1) screening of titles and abstracts, and (2) screening of full texts, both steps by two independent reviewers. Any discrepancies in the selection process are resolved by a third researcher. Data extraction will be performed using a customised data extraction sheet. The results will be presented in tabular and narrative form. ETHICS AND DISSEMINATION: Ethical approval is not required for this scoping review. The results will be published in a peer-reviewed scientific journal and presented at international conferences and project workshops.

Working while sick in context of regional unemployment: a Europe-wide cross-sectional study.

BACKGROUND: Research suggests that areas with high unemployment have lower rates of sickness absence, but the underlying mechanisms remain unclear. One assumption is that when unemployment is high people are more likely to work while being sick (discipline hypothesis). Against this background, we investigate the association between regional unemployment and sickness presenteeism. Second, we study interactions with factors of occupational disadvantage. METHODS: We combined survey data of 20 974 employees collected 2015 in 232 regions from 35 European countries with data on regional unemployment rates obtained from Eurostat. Presenteeism was assessed by the fraction of days worked while ill among all days with illness (presenteeism propensity). To investigate if unemployment was related to presenteeism, we estimated multi-level models (individuals nested in regions) that were adjusted for socio-demographic and occupational covariates to account for compositional differences of the regions. RESULTS: The mean presenteeism propensity was 34.8 (SD 40.4), indicating that workers chose presenteeism in 1 out of 3 days with sickness. We found that a change in unemployment by +10 percentage points was associated with a change in presenteeism by +5 percentage points (95% CI 1.2 to 8.6). This relationship was more pronounced among workers with low salary, low skill-level, and industrial and healthcare workers. CONCLUSION: Our results support the assumption that high unemployment elevates presenteeism, and that people in disadvantaged occupations are particularly affected. Policies managing presenteeism should consider the labour market context, particularly during the aftermath of the COVID-19 pandemic.

Precarious employment and self-reported experiences of unwanted sexual attention and sexual harassment at work. An analysis of the European Working Conditions Survey.

Unwanted sexual attention (UWSA) and sexual harassment (SH) are prevalent experiences for women in working life and often accompanied by poor health. Despite increasing numbers especially of young people working in insecure and irregular employment settings, there is little empirical evidence if such precarious arrangements are associated with UWSA or SH. To investigate this, we used a representative sample of the European working population consisting of 63,966 employees in 33 countries who participated in the European Working Conditions Survey in 2010 or 2015. Precarious employment (PE) was assessed on the basis of seven indicators and a formative index derived from them: temporary employment, contractual duration < 1 year, schedule unpredictability, involuntary part-time, low information on occupational health and safety risks (OSH), low pay (wage < 60%), and multiple job-holding. We measured self-reported experiences of workplace UWSA during the last month and SH during the last 12 months each using a single-item questionnaire. Multi-level Poisson regressions were used to estimate prevalence ratios for UWSA and SH according to PE adjusted for survey year, age, education, type of household, migration background, job tenure, weekly working hours, occupational position, working sector, company size, workplace gender ratio, and visiting customers or clients. 0.8% of men reported UWSA in the last month and 2.6% of the women. SH in the last year was reported by 0.4% of the men and 1.3% of the women. For both men and women, PE was significantly associated with elevated prevalence of UWSA and SH, in particular when reporting schedule unpredictability, multiple job-holding and low information on OSH. Our results suggest that precariously employed individuals may be more prone to experience unwanted sexual behaviour at the workplace compared with workers in non-precarious settings.

[Socio-demographic and employment-related factors in the German National Cohort (GNC; NAKO Gesundheitsstudie)]. / Soziodemografische und erwerbsbezogene Merkmale in der NAKO Gesundheitsstudie.

BACKGROUND: In epidemiologic studies, standardised measurement of socio-demographic and employment-related factors is becoming increasingly important, as variables such as gender, age, education or employment status are factors influencing health and disease risks. AIMS: The article gives an overview of the scientific background and assessment of socio-demographic factors in the German National Cohort Study. In addition, the distribution of individual characteristics in the cohort as well as relationships with health-related measures are presented by way of example. MATERIAL AND METHODS: The analysis is based on the data of the first half of the baseline survey (n = 101,724). On this basis, we present the distribution of key socio-demographic characteristics and analyse relationships with exemplary selected health indicators (body mass index, self-reported health) to assess the validity of socio-demographic data measurements. RESULTS: On average, study participants were 52.0 years old (SD = 12.4). Of the participants, 53.6% were women, 54.3% had high education, 60.1% were married and 72% were employed while 3.4% were unemployed. Well-established correlations between socio-demographic factors and health could be reproduced with the German National Cohort data. For example, low education, old age and unemployment were associated with an increased prevalence of obesity and poor self-reported health. DISCUSSION: The German National Cohort provides a comprehensive measurement of socio-demographic characteristics. Combined with a wide range of health data and the longitudinal measurements available in the future, this opens up new opportunities for health science and social epidemiological research in Germany.

Do Temporary Workers More Often Decide to Work While Sick? Evidence for the Link between Employment Contract and Presenteeism in Europe.

European employees are increasingly likely to work in cases of illness (sickness presenteeism, SP). Past studies found inconsistent evidence for the assumption that temporary workers decide to avoid taking sick leave due to job insecurity. A new measure to identify decision-based determinants of SP is presenteeism propensity (PP), which is the number of days worked while ill in relation to the sum of days worked while ill and days taken sickness absence. We investigated the link between employment contract and PP using cross-sectional data from 20,240 employees participating in the 2015 European Working Conditions Survey. Workers were grouped by type and duration of employment contract. The link between contract and PP was estimated using a multilevel Poisson model adjusted for socio-demographical, occupational and health-related covariates. We found that European employees worked 39% of the days they were ill. In contrast to previous studies, temporary workers were significantly more likely to decide for presenteeism than permanent workers were, especially when the contract was limited to less than 1 year. Controlling for perceived job insecurity did just marginally attenuate this association. Presenteeism was also more common among young and middle-aged workers; however, we did not find a significant interaction between contract and age affecting presenteeism. In conclusion, the employment contract is an important determinant of presenteeism. Our results give reason to believe that temporary workers show increased attendance behavior independent of job insecurity, because they are less likely to have access to social protection in case of illness.

Young Workers' Access to and Awareness of Occupational Safety and Health Services: Age-Differences and Possible Drivers in a Large Survey of Employees in Italy.

Young workers are in particular need of occupational safety and health (OSH) services, but it is unclear whether they have the necessary access to such services. We compared young with older workers in terms of the access to and awareness of OSH services, and examined if differences in employment conditions accounted for age-differences. We used survey data from Italy (INSuLA 1, 2014), with a sample of 8000 employed men and women aged 19 to 65 years, including 732 young workers aged under 30 years. Six questions measured access to services, and five questions assessed awareness of different OSH issues. Several employment conditions were included. Analyses revealed that young workers had less access and a lower awareness of OSH issues compared with older workers. For instance, odds ratios (OR) suggest that young workers had a 1.44 times higher likelihood [95%-confidence interval 1.21⁻1.70] of having no access to an occupational physician, and were more likely (2.22 [1.39⁻3.38]) to be unaware of legal OSH frameworks. Adjustment for selected employment conditions (company size, temporary contract) substantially reduced OR's, indicating that these conditions contribute to differences between older and younger workers. We conclude that OSH management should pay particular attention to young workers in general and, to young workers in precarious employment, and working in small companies in particular.