Is the built environment associated with morbidity and mortality? A systematic review of evidence from Germany.

The empirical evidence on this relationship mainly comes from Anglo-American countries whereas evidence from Germany is only emerging. Our objective is to provide a narrative overview and critical appraisal of the existing empirical evidence on the relationship between the built environment and morbidity/mortality in Germany. We conducted a systematic literature search where we included all empirical studies that linked the built environment aspects with morbidity or mortality outcomes. Findings were summarized and critically evaluated according to the Newcastle Ottawa Scale. Eighteen studies met the inclusion criteria and underwent in-depth analysis. Findings indicate that traffic exposure and green space tend to be associated with acute respiratory symptoms but not with chronic respiratory conditions. Evidence was inconsistent for the role of infrastructural aspects and urbanicity. Our review confirms the well-established association between traffic and respiratory health. Yet, the consistency between self-reported and objective measures of respiratory health should be investigated in more detail.

In-depth statistical analysis of the use of a website providing patients' narratives on lifestyle change when living with chronic back pain or coronary heart disease.

OBJECTIVE: To investigate the use of lebensstil-aendern.de ("lifestyle change"), a website providing peer narratives of experiences with successful lifestyle change, and to analyze whether peer model characteristics, clip content, and media type have an influence on the number of visitors, dwell time, and exit rates. METHODS: An in-depth statistical analysis of website use with multilevel regression analyses. RESULTS: In two years, lebensstil-aendern.de attracted 12,844 visitors. The in-depth statistical analysis of usage rates demonstrated that audio clips were less popular than video or text-only clips, longer clips attracted more visitors, and clips by younger and female interviewees were preferred. User preferences for clip content categories differed between heart and back pain patients. Clips about stress management drew the smallest numbers of visitors in both indication modules. CONCLUSIONS: Patients are interested in the experiences of others. Because the quality of information for user-generated content is generally low, healthcare providers should include quality-assured patient narratives in their interventions. User preferences for content, medium, and peer characteristics need to be taken into account. PRACTICE IMPLICATIONS: If healthcare providers decide to include patient experiences in their websites, they should plan their intervention according to the different needs and preferences of users.

Built environment and health: a systematic review of studies in Germany.

Objectives: Empirical research on the relationship between the built environment and health is increasing at a tremendous pace. However, findings from Anglo-American countries may not apply to the European context. Therefore, we systematically reviewed the existing evidence on the role of the built environment for leading risk factors and health behavior in Germany. Methods: Through an extensive search via PubMed and Web of Science, using predefined selection criteria, two independent reviewers identified 25 empirical studies. We described the main study variables (year of publication, study design, data source, sample characteristics), classified the studies according to their respective operationalization of environmental features and health outcomes, and qualitatively summarized the main results. Results: The majority of the studies focused on anthropometric measures and physical activity. Access to respective destinations was associated with sports-related physical activity but not with body composition. Also, people living in urban structures tended to show more health-adverse behaviors such as smoking and drinking. Some evidence indicated that higher levels of noise and air pollution were related to higher blood pressure levels. No association was observed between green spaces or street design and health. Conclusions: Future research should investigate relationships using a sound theoretical basis and research designs that better account for the complex relationship between the built environment and health.

Community gardening, community farming and other local community-based gardening interventions to prevent overweight and obesity in high-income and middle-income countries: protocol for a systematic review.

INTRODUCTION: The worldwide prevalence of overweight/obesity has continued to rise over the last decades. To reverse this trend, public health authorities are exploring cost-effective interventions, especially in high-income and middle-income countries. Community gardening offers a unique opportunity for individuals to enhance physical activity levels and improve their diet. However, synthesised evidence on the short-term or long-term effectiveness and on the costs of community gardening interventions to prevent overweight/obesity remains limited. Therefore, this review will investigate: (1) the effectiveness of voluntary participation in community gardening compared with no or a control intervention on overweight/obesity and associated health outcomes, (2) effects on different subgroups of populations and (3) the costs of community gardening interventions. METHODS AND ANALYSIS: We will conduct a systematic review, limited to evaluations of community gardening interventions with controlled quantitative and interrupted time series designs. To identify relevant articles, we will systematically search 12 academic and 5 grey literature databases, as well as 2 trial registers and 6 websites. Articles will then be assessed for eligibility based on a predefined set of criteria. At least two independent reviewers will assess each article for relevance, before evaluating the methodological quality and potential bias of the studies. Data relevant to the objectives of this review will be extracted and cross-validated. Any disagreements will be mediated by a third reviewer. If feasible, meta-analyses of primary outcomes (overweight/obesity, physical activity, food intake, energy intake) will be conducted. We will use the Grading of Recommendations Assessment, Development and Evaluation method to assess the overall quality of evidence. ETHICS AND DISSEMINATION: For this review, no ethical approval is required as we will only extract and analyse secondary data. We aim to submit the final review manuscript to an open access journal for publication and disseminate results via conferences and social media. TRIAL REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (PROSPERO)(CRD42017043696).

Cross-cultural measurement invariance of the General Health Questionnaire-12 in a German and a Colombian population sample.

While the General Health Questionnaire, 12-item version (GHQ-12) has been widely used in cross-cultural comparisons, rigorous tests of the measurement equivalence of different language versions are still lacking. Thus, our study aims at investigating configural, metric and scalar invariance across the German and the Spanish version of the GHQ-12 in two population samples. The GHQ-12 was applied in two large-scale population-based samples in Germany (N = 1,977) and Colombia (N = 1,500). To investigate measurement equivalence, confirmatory factor analyses were conducted in both samples. In the German sample mean GHQ-12 total scores were higher than in the Colombian sample. A one-factor model including response bias on the negatively worded items showed superior fit in the German and the Colombian sample; thus both versions of the GHQ-12 showed configural invariance. Factor loadings and intercepts were not equal across both samples; thus GHQ-12 showed no metric and scalar invariance. As both versions of the GHQ-12 did not show measurement equivalence, it is not recommendable to compare both measures and to conclude that mental distress is higher in the German sample, although we do not know if the differences are attributable to measurement problems or represent a real difference in mental distress. The study underlines the importance of measurement equivalence in cross-cultural comparisons.

The association between physical environment and health: indicating the direction of effects using German panel data.

BACKGROUND: A growing body of research has identified an association between health and physical residential environmental characteristics. However, the direction of effects remains unclear, and further research is needed to determine whether the residential environment influences health. OBJECTIVES: To specify the direction of the association between environmental disadvantage and self-reported health. METHODS: Longitudinal data were obtained from the German Socioeconomic Panel and were examined at two points in time. Participants were grouped by relocation status assessed across a five-year period. Structural equation modeling was used to examine the effect of baseline environmental disadvantage on baseline health and on health five years later. RESULTS: In both groups, environmental disadvantage was cross-sectionally correlated with poor health. Only among people who did not relocate was baseline environmental disadvantage significantly related to health five years later in bivariate analyses. Results from the structural equation model found that environmental disadvantage was no longer significantly related to poor health five years later within the group of non-movers (ß = -.02, p = .052). In addition, there was no effect in this direction within the group of movers (ß = .02, p = .277). CONCLUSIONS: Our results suggest the existence of a weak contextual effect as group differences in longitudinal associations indicated the direction of ecological effects.

Adjustment disorder as proposed for ICD-11: Dimensionality and symptom differentiation.

Although Adjustment Disorder as a diagnostic category is widely used in clinical practice it is critically discussed that it has not been conceptualized as a category with unique symptoms. Hence, the conceptualization of Adjustment Disorder is subject to substantive change in ICD-11 including core symptoms and additional features in a uni-faceted concept. Adjustment Disorder was assessed with a self-rating instrument in a representative sample of the German general population (N=2512). Confirmatory factor analyses (CFA) were applied to test the dimensionality of symptoms according to the new diagnostic concept. Latent class analysis (LCA) was applied to test whether there are distinguishable subgroups with respect to symptomatology. 2.0% of the sample were diagnosed with Adjustment Disorder according to the new diagnostic algorithm. The proposed six factor model shows best fit with good reliability of the factors in the CFA compared to competing models. However the factors are highly correlated and not distinguishable. The LCA identified three latent classes, reflecting low, mild and moderate to severe symptoms. The findings support the uni-faceted concept of Adjustment Disorder as it is conceptualized in the new diagnostic concept in ICD-11 in a general population sample. This clearer diagnostic concept will inform research as well as clinical practice.

The independent relations of both residential self-selection and the environment to physical activity.

Residential self-selection is supposed to bias the relation between residential environments and physical activity, but empirical analyses are still rare. This study examines the association while simultaneously considering the effect of residential self-selection criteria. One thousand two hundred and forty-five German students were asked to report their physical activity, their perceived environment, and their reasons for choosing their neighbourhood. Structural equation modelling was employed. Reasons for choosing a neighbourhood were related to actual environmental characteristics. Utilitarian reasons were related to less physical activity, hedonic reasons were related to higher physical activity. The street network was related to higher physical activity independent of residential self-selection. Our results support the weight of both individual preferences and the street network on physical activity. The residential environment has an impact on people's amount of physical activity regardless of their reasons for choosing a neighbourhood and should therefore be considered a resource in health prevention and promotion.

A web-based peer-modeling intervention aimed at lifestyle changes in patients with coronary heart disease and chronic back pain: sequential controlled trial.

BACKGROUND: Traditional secondary prevention programs often fail to produce sustainable behavioral changes in everyday life. Peer-modeling interventions and integration of peer experiences in health education are a promising way to improve long-term effects in behavior modification. However, effects of peer support modeling on behavioral change have not been evaluated yet. Therefore, we implemented and evaluated a website featuring patient narratives about successful lifestyle changes. OBJECTIVE: Our aim is to examine the effects of using Web-based patient narratives about successful lifestyle change on improvements in physical activity and eating behavior for patients with coronary heart disease and chronic back pain 3 months after participation in a rehabilitation program. METHODS: The lebensstil-aendern ("lifestyle-change") website is a nonrestricted, no-cost, German language website that provides more than 1000 video, audio, and text clips from interviews with people with coronary heart disease and chronic back pain. To test efficacy, we conducted a sequential controlled trial and recruited patients with coronary heart disease and chronic back pain from 7 inpatient rehabilitation centers in Germany. The intervention group attended a presentation on the website; the control group did not. Physical activity and eating behavior were assessed by questionnaire during the rehabilitation program and 12 weeks later. Analyses were conducted based on an intention-to-treat and an as-treated protocol. RESULTS: A total of 699 patients were enrolled and 571 cases were included in the analyses (control: n=313, intervention: n=258; female: 51.1%, 292/571; age: mean 53.2, SD 8.6 years; chronic back pain: 62.5%, 357/571). Website usage in the intervention group was 46.1% (119/258). In total, 141 trial participants used the website. Independent t tests based on the intention-to-treat protocol only demonstrated nonsignificant trends in behavioral change related to physical activity and eating behavior. Multivariate regression analyses confirmed belonging to the intervention group was an independent predictor of self-reported improvements in physical activity regularity (ß=.09, P=.03) and using less fat for cooking (ß=.09, P=.04). In independent t tests based on the as-treated protocol, website use was associated with higher self-reported improvements in integrating physical activity into daily routine (d=0.22, P=.02), in physical activity regularity (d=0.23, P=.02), and in using less fat for cooking (d=0.21, P=.03). Multivariate regression analyses revealed that using the website at least 3 times was the only factor associated with improved lifestyle behaviors. CONCLUSIONS: Usage of the lebensstil-aendern website corresponds to more positive lifestyle changes. However, as-treated analyses do not allow for differentiating between causal effects and selection bias. Despite these limitations, the trial indicates that more than occasional website usage is necessary to reach dose-response efficacy. Therefore, future studies should concentrate on strategies to improve adherence to Web-based interventions and to encourage more frequent usage of these programs.

The German Version of the Hopkins Symptoms Checklist-25 (HSCL-25) --factorial structure, psychometric properties, and population-based norms.

PURPOSE: The Hopkins Symptom Checklist-25 (HSCL-25) has often been used in cross-cultural settings and in studies focussing on asylum seekers, refugees etc. It is available in a number of languages. The present study investigates the psychometric properties of the German version of the HSCL-25 and delivers population-based norms. METHODS: Psychometric properties are investigated in a population-based representative sample of the German general population (N=2516). Seven different factorial models are compared using confirmatory factor analysis. RESULTS: Two out of the seven models show the best model fit. Because of the high inter-correlations of the factors of the tripartite model, the bifactor model is the preferable factor solution. The internal consistencies (Cronbach's alpha) were 0.84, 0.92, and 0.94 for the anxiety, the depression and the total score, respectively. The correlations of both subscales of this model with the subscales of the Brief-Symptom-Inventory-18 or the Patient Health Questionnaire-4 point out, that there is only marginal differential information of the subscales. CONCLUSION: Considering the third ("general") factor of the bifactor model with all items loading on it and the absence of differential correlations of the subscales with the external criteria (PHQ-4, BSI-18) the HSCL-25 seems to assess something like "mental distress" with a focus on symptoms of depression and anxiety. The population-based norms support the application of the HSCL-25 for individual diagnostics as well as for the comparison of specific samples with the general population.

[A short version of the Narcissistic Personality Inventory (NPI-15): dimensionality and psychometric properties in a representative sample of the German population]. / Psychometrische Überprüfung einer Kurzform des Narcissistic Personality Inventory (NPI-15): Dimensionalität und psychometrische Eigenschaften des NPI-15 in einer repräsentativen Bevölkerungsstichprobe.

The Narcissistic Personality Inventory (NPI) is a commonly used measure of narcissism. This study administered a 15 item short version of the NPI (NPI-15). Central aims of the present study were to examine its dimensionality, and to provide data on its psychometric properties. NPI-15 and Hospital Anxiety and Depression Scale (HADS-D) were assessed in a representative sample of the German population (N=2,512). According to Scree-plot and model fit, a solution with 2 or 3 factors seemed feasible. Because of factor loadings and item-level associations to depression/anxiety we decided to favour a 2-factor-solution. 2 subscales reflecting different facets of narcissism were compiled (leadership ability/personality [LA/LP], grandiosity [G]). The psychometric properties of these scales were good (LA/LP) respectively unsatisfactory (G). The validity of the NPI-15 needs to be further studied.

A short form of the General Self-Efficacy Scale (GSE-6): Development, psychometric properties and validity in an intercultural non-clinical sample and a sample of patients at risk for heart failure.

OBJECTIVE: General self-efficacy has been found to be an influential variable related to the adaptation to stress and chronic illness, with the General Self-Efficacy (GSE) Scale by Jerusalem and Schwarzer being a reliable and valid instrument to assess this disposition. The aim of this study was to construct and test a short form of this scale to allow for a more economical assessment of the construct. METHODS: The item characteristics of the original scale were assessed using an intercultural non-clinical sample (n=19,719). Six items with the highest coefficient of variation and good discrimination along the range of the trait were selected to build a short form of the instrument (GSE-6). Subsequently, the psychometric properties and the concurrent and predictive validity of the GSE-6 were tested in a longitudinal design with three measurements using a sample of patients with risk factors for heart failure (n=1,460). RESULTS: Cronbach's alpha for the GSE-6 was between .79 and .88. We found negative associations with symptoms of depression (-.35 and -.45), anxiety (-.35), and vital exhaustion (-.38) and positive associations with social support (.30), and mental health (.36). In addition, the GSE-6 score was positively associated with active problem-focused coping (.26) and distraction/self-encouragement (.25) and negatively associated with depressive coping (-.34). The baseline GSE-6 score predicted mental health and physical health after 28 months, even after controlling for the respective baseline score. The relative stability over twelve and 28 months was r=.50 and r=.60, respectively, while the mean self-efficacy score did not change over time. CONCLUSIONS: The six item short form of the GSE scale is a reliable and valid instrument that is useful for the economical assessment of general self-efficacy in large multivariate studies and for screening purposes.

What is the General Health Questionnaire-12 assessing? Dimensionality and psychometric properties of the General Health Questionnaire-12 in a large scale German population sample.

Since the dimensionality and the related psychometric properties of the 12-item General Health Questionnaire (GHQ-12) are still under debate, the present study compares different factor solutions from the literature to determine which shows the best fit and to investigate reliability and construct validity. The analyses are based on a German population based representative sample (N=2,041), using face-to-face-interviews. The confirmatory factor analysis indicates the best fit to the one-factor model including response bias on the negative worded items according to Hankins. Thus, the importance of methodical aspects for the dimensionality was emphasized. Moreover, the correlations of the different subscales of the two- and three-factor models with several external criteria (BDI, PHQ-2, SF-36, PHQ-Anxiety, SPIN) do not substantially differ. The preferred unidimensional model shows good psychometric properties. According to its associations with the external criteria under study, the GHQ-12 as a unidimensional measure seems to be a useful screening tool for the assessment of mental distress or a minor psychiatric morbidity with a main focus on depressive symptomatology.

Type D personality and persistence of depressive symptoms in a German cohort of cardiac patients.

BACKGROUND: Depression is associated with a negative prognosis in coronary heart disease and heart failure patients. Type D personality has been shown to predict the persistence of depressive symptoms over 12 months. Data on longer follow-up periods and on the effectiveness of Type D as a screening tool compared to established measures of depressive symptoms are missing. METHODS: Type D personality and depressive mood were assessed with the DS14 and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) in 679 consecutive cardiac patients (22.2% female, mean age 62.4±10.2 years) over a period of 6 years. Latent class and growth mixture models with Type D, comorbidity, age, and sex as covariates were used to model individual depression trajectory classes and to predict trajectories and class membership. Estimates of specificity and sensitivity were calculated for Type D and the HADS-D baseline cut-off point. RESULTS: In a model with four latent classes (mild symptoms, moderate and increasing symptoms, significant but decreasing symptoms, and significant and increasing symptoms), Type D predicted the membership in the class with significant and increasing symptoms (OR=10.94, 4.93, and 3.15). Sensitivity and specificity were 59% and 78% for Type D and 47% and 80% for the HADS-D. LIMITATIONS: Some possible confounders might be missing. With just two measurement points only linear trajectories could be modeled. CONCLUSIONS: Type D personality is a stronger predictor for persistent depressive symptoms than the baseline HADS-D score, but the predictive power seems low for clinical practice.

Six year stability of Type-D personality in a German cohort of cardiac patients.

OBJECTIVE: The aim of the study was to systematically analyze the stability of Type-D personality over a time span of several years in a clinical sample. METHODS: In a prospective cohort study, cardiac patients from different medical settings in Germany were assessed using the DS14 questionnaire at baseline (n=1240) and at a mean follow-up time of six years (n=679). Different types of stability were examined and compared with the stability of the Hospital Anxiety and Depression Scale (HADS). RESULTS: Rank-order stability was moderate (r=.61 for Negative Affectivity [NA] and r=.60 for Social Inhibition [SI]) and didn't differ from the rank-order stability of the HADS. Whereas the mean level of SI didn't change over time, the mean level of NA increased (d=0.08). On an individual level, approximately one quarter of the participants showed a significant increase or decrease. The factorial structure of the DS14 was stable over time. Finally, the agreement of Type-D classification between the two measurement points was moderate (κ=.42) with 22% of the participants changing their Type-D classification over time. CONCLUSION: The stability of NA and SI didn't differ from the stability of measures of emotional distress that are generally considered to be less stable. In particular, the only moderate stability of the dichotomous Type-D classification raises some questions.

Association between type D personality and prognosis in patients with cardiovascular diseases: a systematic review and meta-analysis.

BACKGROUND: Since 1995, the association of type D personality and mortality in patients with cardiovascular diseases has been increasingly investigated. PURPOSE: The aim of this meta-analysis was to integrate conflicting results and to examine possible moderators of this association. METHODS: Prospective studies assessing type D personality and hard endpoints were selected and pooled in meta-analyses. Cardiovascular diagnosis, type and quality of adjustment, and publication date were examined in moderator analyses. RESULTS: Twelve studies on patients with cardiovascular diseases (N = 5,341) were included. Pooled crude and adjusted effects demonstrated a significant association of type D personality and hard endpoints (odds ratio (OR) of 2.28 (95% CI [1.43-3.62]), adjusted hazard ratio (HR) of 2.24 (95% CI [1.37-3.66])). The OR decreased over time (OR 5.02 to OR 1.54). There was no association in congestive heart failure patients. CONCLUSIONS: More recent methodologically sound studies suggest that early type D studies had overestimated the prognostic relevance.

[The German Version of the Childhood Trauma Questionnaire (CTQ): psychometric characteristics in a representative sample of the general population]. / Die deutsche Version des Childhood Trauma Questionnaire (CTQ) - psychometrische Eigenschaften in einer bevölkerungsrepräsentativen Stichprobe.

The Childhood Trauma Questionnaire (CTQ) has become internationally accepted as an assessment of traumatic childhood experiences. The short version assesses aspects of childhood abuse and neglect. In order to check the psychometric properties of the German short form, the CTQ was used within a representative sample of the German population (N=2 500). The five factor structure of the original version showed only a sufficient model fit, because of high intercorrelations and weak internal consistency of the scale "physical neglect". The internal consistency of the other subscales was high with α≥0.80. Construct validity was supported by positive correlations with measures of anxiety/depression and negative correlations with life satisfaction. The German short form of the CTQ is a reliable and valid self rating instrument to assess childhood maltreatment retrospectively. The subscale "physical neglect" should be applied with caution.

Type D personality and all-cause mortality in cardiac patients--data from a German cohort study.

OBJECTIVE: Type D personality has been established as a predictor of adverse clinical events in patients with cardiovascular diseases. To date, all studies except one have been conducted by a single research group. Thus, the aim of our study was to provide an independent replication of the results regarding the prognostic validity of Type D personality in a German sample of cardiac patients. METHODS: Cardiac patients (n = 1040) were recruited from cardiac rehabilitation centers (n = 484), an outpatient clinic (n = 249), and a university hospital (n = 307). Main analyses were based on the combined data from these three subsamples. Cardiac health status, medical risk factors, sociodemographic characteristics, psychological symptoms, and Type D personality were assessed at baseline. The primary end point was all-cause mortality. The Cox proportional hazards regression model was used to estimate the relative risk of death. RESULTS: Vital status was known for 977 patients (22.5% women; mean [standard deviation] = 63.3 [10.7] years). Within the follow-up time (mean [standard deviation] = 71.5 [3.6] months), 172 patients died. Type D personality was found in 25.2% of survivors and in 22.2% of nonsurvivors (χ²= 0.78, p = .38). Depressive symptoms (p = .13) and anxiety (p = .27) were also not predictive of mortality. In the multivariate analyses, neither Type D (p = .95) nor negative affectivity (p = .71) and social inhibition (p = .59), as well as their interaction (p = .88), were associated with all-cause mortality. CONCLUSIONS: In the present study, Type D personality and its constituents are not associated with increased mortality in patients with heart disease. The discrepancies with previous results deserve further investigation.