Christian Janßen

Der Einfluss von sozialer Ungleichheit auf die medizinische und gesundheitsbezogene Versorgung in Deutschland

Der vorliegende Beitrag untersucht anhand einer systematischen Literaturrecherche den Einfluss der sozialen Ungleichheit auf die medizinische und gesundheitsbezogene Versorgung in Deutschland. Das Thema „Soziale Ungleichheit, medizinische und gesundheitsbezogene Versorgung in Deutschland“ ist auserst komplex, da im allgemeinen verschiedenste Komponenten der sozialen Ungleichheit in der Versorgung darunter verstanden werden. So konnen unter sozialer Ungleichheit horizontale Ungleichheiten wie Alter und Geschlecht wie auch vertikale Ungleichheiten wie Beruf, Bildung und Einkommen, also der soziale Status bzw. die soziale Schicht, untersucht werden. Der vorliegende Beitrag konzentriert sich auf diese - auch soziookonomischen Merkmale genannten - Aspekte der sozialen Ungleichheit, d.h. auf die Unterschiede in Bildung, Beruf und Einkommen (Jockel 1998, Mielck 2000). Zur Analyse der horizontalen Ungleichheit sei an dieser Stelle exemplarisch auf jungste umfassende Arbeiten zu diesem Thema bzw. Beitrage im vorliegenden Band verwiesen (Babitsch 2005, Knesebeck 2005, Richter 2005, siehe auch die Beitrage der Autoren in diesem Band).

The influence of social determinants on the use of prevention and health promotion services: Results of a systematic literature review

Background: The following analysis aims to determine whether differences in the use of prevention and health promotion services in Germany can be attributed to health inequality between different social status groups measured by education, occupation and income and where certain improvements can be made in health promotion and prevention efforts and research to reduce those differences. Methods: A systematic literature search was conducted using MedPilot to identify relevant articles published between 1998 and 2010 in the Medline, Medizinische Gesundheit, CC Med, Deutsches Ärzteblatt and Sozialmedizin (SOMED) databases, the Hogrefe, Karger, Krause and Pachermegg and Thieme publisher databases, the Cochrane Database of Systematic Reviews (CDSR), the Cochrane Database of Abstracts of Reviews of Effectiveness (DARE), and the Cochrane Central Register of Controlled Trials. Results: A total of 23 empirical studies on the topic of “prevention, health prevention and social inequality” met the criteria for inclusion in the review. 20 of the 23 reviewed studies provided relatively clear evidence of a significant association between higher social status and greater use of prevention and health promotion services. According to the reviewed studies, gender tends to have a greater effect on the use of prevention and health promotion services than characteristics of vertical social inequality. No studies were found dealing with tertiary prevention or using qualitative methods to explore their research questions. Conclusions: Overall, the review shows that there is sufficient evidence for the relationship between social status and the use of prevention and health promotion services and that this association is both significant and relevant. There are, however, a few “blind spots” in research on this topic, such as a lack of studies on tertiary prevention, especially with regards to prevention and health promotion services use among men, as well as general studies on health promotion among men and women. There is also a lack of published intervention studies demonstrating how to better reach the socially disadvantaged.

Health care utilization in Germany: The NWIn research network.

Recent national and international socio-epidemiological research has consistently demonstrated a significant social gradient in health-related quality of life, morbidity andmortality, favoring the higher and disadvantaging the lower social status groups. This holds true both for Germany and Europe in general as well as for other industrialized countries such as USA or Canada. For instance, in Germany differences in life expectancy between top and lowest income groups range up to 10 years. Against this background, a crucial scientific and political question is whether the health care system inor decreases this gap. First research findings in Germany indicate that the gap might be influenced more by differences in utilization than in supply. In 2002, the working group “Health Care Research” was founded within the German Association of Medical Sociology (Deutsche Gesellschaft fur Medizinische Soziologie, DGMS), consisting of about 30 scientists. In the following years, several workshops at national and international conferences were held by members of this group. In 2007, a first book resulted from this collaboration, which was published by Juventa and presentedmedical sociological health care research in its full scope [1]. Subsequently, the special importance of utilization of health care triggered a proposal to the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) for funding a scientific network on “Health care utilization in Germany”. After its approval (grant no.: JA-1849, 1-1), the network started off under the designation of NWIn Research Network (NWIn: “Netzwerk Inanspruchnahme”, i.e. “Utilization Network”) in January 2010 for a three years funding period. In 2013, a book publication provisionally entitled “Health care utilization in Germany: theory, methodology, and outcomes” is scheduled to be published by Springer Science + Business Media. As one of its key features, all chapters of this edited book will relate to one and the same theoretical approach, namely one (if not the) internationally leading framework for utilization research: the Behavioral Model of Health Care Utilization (BM) by US medical sociologist and health services researcher Ronald M. Andersen [2], [3]. Prior to this book publication, we are happy to present for the NWIn Research Network this special issue of GMS Psycho-Social-Medicine (P-S-M). In the first of six contributions, Birgit Babitsch, Daniela Gohl and Thomas von Lengerke via a systematic review assess the explicit use of Andersen’s BM in studies conducted in Europe or Anglo-American countries and published between January 1998 and March 2011 [4]. Although associations of higher utilization were found with older age, being a woman, higher income and poorer health, there were several inconsistencies across studies, among others that the operationalizations of the model revealed that only a small common set of variables was used, and that there were huge variations in the way these variables were categorized, especially in regard to predisposing and en-

Einflussfaktoren auf das Vertrauen schwerverletzter Patienten in den Krankenhausarzt

ZusammenfassungHintergrundDas Vertrauen des Patienten in den behandelnden Arzt ist ein wichtiger Faktor in der Arzt-Patient-Beziehung. Das Ziel der vorliegenden Arbeit besteht darin, Faktoren zu identifizieren, die einen Einfluss auf das Vertrauen schwerverletzter Patienten in den Krankenhausarzt haben.Material und Methoden121 schwerverletzten Patienten, die sich in NRW in zwei Kliniken im Zeitraum von 1996–2001 aufgrund von Arbeits- oder Verkehrsunfällen behandeln lassen mussten, wurde im Jahr 2002 ein Fragebogen zugeschickt. Die Rücklaufquote betrug 74,4% (n=90).ErgebnisseNach bivariater Vorselektion konnte ein logistisches Regressionsmodell entwickelt werden, welches 4 hochsignifikante Einflussfaktoren auf das Vertrauen schwerverletzter Patienten in den behandelnden Arzt identifizierte: (I) Das durch den Patienten beurteilte Informationsverhalten des Arztes und (II) die wahrgenommene Einbeziehung des Patienten in die Therapie sowie (III) der durch den Patienten beurteilte Erfolg der Behandlung und (IV) das Alter des Patienten.SchlussfolgerungDie Ergebnisse der vorliegenden Arbeit zeigen u. a. die Wichtigkeit psychosozialer Interaktionsaspekte für das Vertrauen von Patienten in den behandelnden Arzt. Dabei könnte aus unserer Sicht eine fundierte Vermittlung kommunikativer Fertigkeiten auch im unfallchirurgischen Bereich dazu beitragen, das Vertrauen der Patienten in ihren Arzt zu steigern.AbstractBackgroundSeveral studies have shown negative effects of insufficient physician-patient interaction leading to a lack of compliance, worse subjective and objective evaluation of treatment outcome, increased consumption of pain medication, and decreased patient satisfaction. The aim of the present study was to identify patient-, physician-, and/or hospital-specific determinants which have a significant influence on the trust of severely injured patients in their physicians.MethodsA written questionnaire was sent to 121 severely injured patients hurt predominantly in traffic accidents and treated between July 1996 and July 2001 in two departments of surgery in the German state of Northrhine-Westfalia. Applying the Total Design Method, a response rate of 74.4% (n=90) could be achieved.ResultsUsing univariate analysis as a preselection tool, we developed a logistic regression model which identified four significant predictors of patients’ trust in their physicians: (1) patient evaluation of information, (2) patient evaluation of their physician’s decision policy, (3) patient evaluation of treatment success, and (4) patient age.ConclusionsBesides age of patient and subjective evaluation of treatment success, it is psychosocial aspects of interaction which influence trust in a physician. The results of this analysis confirm the importance of physician-patient communication for medical education, also for surgeons.