Federal States Of Germany Research Articles

Effects of the COVID-19 pandemic on acute coronary syndromes in Germany during the first wave: the COVID-19 collateral damage study

BackgroundReports about the influence of the COVID-19 pandemic on the number of hospital admissions and in-hospital mortality during the first wave between March and May 2020 showed conflicting results and are limited by single-center or limited regional multicenter datasets. Aim of this analysis covering all German federal states was the comprehensive description of hospital admissions and in-hospital mortality during the first wave of the COVID-19 pandemic.Methods and resultsWe conducted an observational study on hospital routine data (§21 KHEntgG) and included patients with the main diagnosis of acute myocardial infarction (ICD 21 and ICD 22). A total of 159 hospitals included 36,329 patients in the database, with 12,497 patients admitted with ST-elevation myocardial infarction (STEMI) and 23,832 admitted with non-ST-elevation myocardial infarction (NSTEMI). There was a significant reduction in the number of patients admitted with STEMI (3748 in 2020, 4263 in 2019 and 4486 in 2018; p < 0.01) and NSTEMI (6957 in 2020, 8437 in 2019 and 8438 in 2020; p < 0.01). These reductions were different between the Federal states of Germany. Percutaneous coronary intervention was performed more often in 2020 than in 2019 (odds ratio 1.13, 95% confidence interval [CI] 1.06–1.21) and 2018 (odds ratio 1.20, 95% CI 1.12–1.29) in NSTEMI and more often than in 2018 (odds ratio 1.26, 95% CI 1.10–1.43) in STEMI. The in-hospital mortality did not differ between the years for STEMI and NSTEMI, respectively.ConclusionsIn this large representative sample size of hospitals in Germany, we observed significantly fewer admissions for NSTEMI and STEMI during the first COVID-19 wave, while quality of in-hospital care and in-hospital mortality were not affected.Graphical abstractAdmissions for STEMI and NSTEMI during the months March to May over 3 years and corresponding in-hospital mortality for patients with STEMI and NSTEMI in 159 German hospitals. (p-value for admissions 2020 versus 2019 and 2018: < 0.01; p-value for mortality: n.s.)

Health-Economic Evaluation of the German Osteoporotic Fracture Prevention Program in Rural Areas (OFRA): Mobility and Falls Prevention Classes, Examination of Bone Health, and Consultation on Safety in the Living Environment

BackgroundFragility fractures are one of the leading causes of disability in older adults. Yet, evidence for effectiveness and cost-effectiveness of preventive approaches combining bone health and fall prevention is rare.ObjectiveTo conduct a health-economic evaluation of the German osteoporotic fracture prevention program in rural areas (OFRA).DesignSecondary cluster–randomized intervention study based on routine data.ParticipantsAll districts in five federal states in Germany were cluster-randomized as intervention or control districts. OFRA was offered to community-living (a) women aged 75–79 years or (b) women and men aged 70–84 years with a prior fragility fracture in the intervention districts. Individuals who meet these criteria in the control districts were assigned to the control group.InterventionOFRA comprised mobility and falls prevention classes, examination of bone health by bone density measurement, and consultation on safety in the home living environment.Main MeasuresWe measured health-care costs and effectiveness in terms of time to fragility fracture or death within 1 year after initial contact, based on health insurance claims data. Implementation costs were recorded by the intervention performers. We calculated an incremental cost-effectiveness ratio (ICER) and employed the net-benefit approach to construct a cost-effectiveness acceptability curve (CEAC).Key ResultsThere were 9408 individuals in the intervention group and 27,318 in the control group. Mean time to fragility fracture or death (difference: 0.82 days) and health-care costs (difference: 111.73€, p < .01) were reduced, but mean intervention costs (difference: 260.10€) increased total costs (difference: 148.37€, p < .001) in the intervention group. The ICER per fracture-free year of survival was 66,094.63€. The CEAC showed no acceptable probability of cost-effectiveness at a reasonable willingness to pay.ConclusionOFRA showed reduced rates of fragility fractures, but had high implementation costs, resulting in an unfavorable ICER. The cost-effectiveness of OFRA may improve with a longer follow-up.

Prevalence trends of type 1 and type 2 diabetes in children and adolescents in North Rhine-Westphalia, the most populous federal state in Germany, 2002-2020

AimsTo estimate the prevalence and temporal trends of type 1 and type 2 diabetes mellitus in children and adolescents (type 1 diabetes: 0–19 years, type 2 diabetes: 10–19 years) in North Rhine-Westphalia (NRW), Germany, from 2002 to 2020. MethodsThe NRW Diabetes Registry records new cases based on three data sources (median completeness of ascertainment 99% for type 1 diabetes, 94% for type 2 diabetes). We determined age- and/or sex-standardized prevalence estimates (95% confidence intervals) per 100,000 individuals. Differences in age and sex, as well as time trends, were examined by Poisson regression. Furthermore, joinpoint regression was used to evaluate changes in prevalence trends over time. ResultsAt the end of 2020, the estimated type 1 diabetes prevalence was 247.1 (240.3; 253.9) with an annual increase of 2.9% (2.7%; 3.1%). The type 2 diabetes prevalence was 12.7 (10.6; 14.9) and increased by 6.4% (5.6%; 7.3%) per year. The prevalence trends were not uniform over the total period and flattened considerably in recent years. ConclusionsThe prevalence of type 1 and type 2 diabetes has increased significantly but at a lower rate in recent years. Continued surveillance of the prevalence is essential for the planning of health care resources and prevention measures.

Physical Activity and Stress of Children and Adolescents during the COVID-19 Pandemic in Germany-A Cross-Sectional Study in Rural Areas.

Although infection with SARS-CoV-2 appears to be less dangerous for children and adolescents, research indicates that the measures to contain the COVID-19 pandemic have had and continue to have negative effects on children’s and adolescents’ mental health and physical activity (PA). Due to the different health policies, country-specific studies as well as studies in different phases of the pandemic are important to obtain a differentiated picture of the effects of the pandemic. This study set out to investigate children’s and adolescents’ PA, stress, and well-being as well as the associations between these two variables during a phase of a gradual decline in measure to contain the pandemic in Germany. For this purpose, 1293 children and adolescents in a rural area of a federal state in Germany were investigated. The results indicated that children and adolescents felt sadder and less well during this period than children and adolescents before the pandemic. Results also revealed that they were more physically active than children and adolescents before the pandemic as well as in the second lockdown but less active than in the first lockdown. Both well-being and sadness were positively associated with the PA. The study contributes to a more comprehensive understanding of the situation of children and adolescents during the COVID-19 pandemic.

The Stress Barometer: Validation of a Bio-Psycho-Social Brief Screening Instrument of Pandemic Stress Reaction.

BackgroundTo capture the psychosocial impact of the SARS-CoV-2 pandemic, a model based on the International Classification of Functioning, Disability, and Health (ICF) was developed during the first lockdown in Germany in April 2020. FACT-19, the questionnaire for the assessment of pandemic stress load, measures (1) pre-pandemic stress, (2) pandemic stress, and (3) contextual factors (functioning as facilitators or barriers). Derived from this model, the stress barometer as a brief screening instrument captures these factors. The purpose of this study is a preliminary validation of the instrument.MethodThe stress barometer was applied in conjunction with the Symptom-Checklist SCL-90-S at the beginning of the first lockdown in psychosomatic and psychotraumatological care in two federal states in Germany. The sample consists of n = 341 (68.6% female) from 18–73 years of age (M = 49.36, SD = 11.4).ResultsThe structure of the short screening was examined in the overall sample using an exploratory factor analysis [Chi2 (78) = 875.720, KMO = 0.688]. The results indicate a four-factor-structure that explains 59.5% of the total cumulative variance. The factors of the stress barometer correlate with the Global Severity Index (GSI, measured by SCL-90-S) with moderate to weak effects: pre-pandemic stress (rs = 0.431, p < 0.001, n = 295), pandemic stress (rs = 0.310, p < 0.001, n = 298), distal facilitator (rs = −0.155, p < 0.001, n = 312), and proximal barriers (rs = 0.232, p < 0.001, n = 312).DiscussionThe results indicate the suitability of the stress barometer to complement the measurement of the impact of pandemics with an ICF-oriented approach, taking into consideration pre-pandemic stress as well as interactions with facilitators and barriers. Further analysis will be necessary for a revision of the items of the scale.

Knowledge of Symptoms of Acute Myocardial Infarction, Reaction to the Symptoms, and Ability to Perform Cardiopulmonary Resuscitation: Results From a Cross-sectional Survey in Four Regions in Germany.

BackgroundIschemic heart disease affects 126 million individuals globally which illustrates the importance of finding ways to decrease mortality and morbidity in case of an acute myocardial infarction (AMI). Since knowledge of symptoms, correct reaction to symptoms, and ability to perform cardiopulmonary resuscitation (CPR) decreases the time from symptoms-onset to reperfusion, which leads to lower AMI mortality, we aimed to examine those factors and identify predicting variables in regions with low and high AMI mortality rates.MethodsWe conducted a cross-sectional online survey including 633 respondents from the general population in four federal states in Germany with low and high AMI mortality and morbidity rates. We used uni- and multivariable regressions to find health-related and sociodemographic factors associated with knowledge, reaction to symptoms, and skills in CPR.ResultsOut of 11 symptoms, the mean of correctly attributed AMI symptoms was 7.3 (standard deviation 1.96). About 93% of respondents chose to call an ambulance when witnessing an AMI. However, when confronted with the description of a real-life situation, only 35 and 65% of the participants would call an ambulance in case of abdominal and chest pain, respectively. The predicting variables for higher knowledge were being female, knowing someone with heart disease, and being an ex-smoker compared to people who never smoked. Higher knowledge was associated with adequate reaction in the description of a real-life situation and ability to perform CPR. Prevalence ratio for being able to perform CPR was lower in females, older participants, and participants with low educational level. About 38% of participants state to know how to perform CPR. Our results indicate rather no difference regarding knowledge, reaction to AMI symptoms, and ability to perform CPR among different regions in Germany.ConclusionsKnowledge of symptoms and first responder reaction including skills in CPR is inadequate when confronted with the description of a real-life situation. Educational health campaigns should focus on conveying information close to real-life situations. Interventions for enhancing ability to perform CPR should be compulsory in regular intervals. Interestingly, we found no difference regarding the factors in regions with high and low AMI mortality rates in Germany.

Digital breast tomosynthesis plus synthesised mammography versus digital screening mammography for the detection of invasive breast cancer (TOSYMA): a multicentre, open-label, randomised, controlled, superiority trial.

Two dimensional (2D) full-field digital mammography is the current standard of breast cancer screening. Digital breast tomosynthesis generates pseudo-three dimensional datasets of the breast from which synthesised 2D (s2D) mammograms can be reconstructed. This innovative approach reduces the likelihood of overlapping breast tissues that can conceal features of malignancy. We aimed to compare digital breast tomosynthesis plus s2D mammography with digital screening mammography for the detection of invasive breast cancer. TOSYMA was a randomised, open-label, superiority trial done at 17 screening units in two federal states of Germany. Eligible participants were women aged 50-69 years who had been invited to participate in a population-wide, quality-controlled mammography screening programme. Women were randomly assigned (1:1) to digital breast tomosynthesis plus s2D mammography or digital mammography alone using block randomisation (block size of 32), stratified by site. The primary endpoints were the detection rate of invasive breast cancer and invasive interval cancer rate at 24 months, analysed in the modified full analysis set, which included all randomly assigned participants who underwent either type of screening examination. Ten examinations, corresponding to a second study participation, were excluded. Analyses were done according to the intention-to-treat principle. Interval cancer rates will be reported in the follow-up study. Safety was assessed in the as-treated population, which included all participants who were randomly assigned. This trial is registered with ClinicalTrials.gov, NCT03377036, and is closed to accrual. Between July 5, 2018, and Dec 30, 2020, 99 689 women were randomly assigned to digital breast tomosynthesis plus s2D mammography (n=49 804) or digital mammography (n=49 830). Invasive breast cancers were detected in 354 of 49 715 women with evaluable primary endpoint data in the digital breast tomosynthesis plus s2D group (detection rate 7·1 cases per 1000 women screened) and in 240 of 49 762 women in the digital mammography group (4·8 cases per 1000 women screened; odds ratio 1·48 [95% CI 1·25-1·75]; p<0·0001). Adverse events and device deficiencies were rare (six adverse events in each group; 23 device deficiencies in the digital breast tomosynthesis plus s2D group vs five device deficiencies in the digital mammography group) and no serious adverse events were reported. The results from this study indicate that the detection rate for invasive breast cancer was significantly higher with digital breast tomosynthesis plus s2D mammography than digital mammography alone. Evaluation of interval cancer rates in the follow-up study will further help to investigate incremental long-term benefits of digital breast tomosynthesis screening. Deutsche Forschungsgemeinschaft (German Research Foundation).

Digitalization of Business Processes in Federalist Environments: The Introduction of E-Invoicing in Germany

In this article we will analyze the government-driven introduction of e-invoicing in Germany. The decision to digitalize the invoicing processes in Germany is based on an EU guideline that instructs all member states to switch to electronic invoicing (e-invoicing) within their administrations. The European Union thus aims to achieve a facilitation of trade across inner-European borders, as well as more transparency for the fiscal authorities. Germany, as a member state, has made e-invoicing mandatory for all national administrations, since 27 November 2020. At the same time the federal states of Germany have their own jurisdiction, which presents unique problems for the introduction of standardized solutions. For this study, several experts, representing the different stakeholders of invoicing processes were interviewed. The results are showing that while the interest in e-invoicing solutions is high among all stakeholders of invoicing processes, the implementation in the German market comes with a unique set of challenges that are putting the success of e-invoicing in Germany at risk. The government-driven digitalization of processes is therefore heavily impacted by the fact whether a country has a federal structure or not.

An environmental information system for the exploration of energy systems

The transition to renewable energy sources requires extensive changes to the energy system infrastructure, ranging from individual households to the national scale. During this transition, stakeholders must be able to make informed decisions, researchers need to investigate possible options and analyse scenarios, and the public should be informed about developments and options for future infrastructure. The data and parameters required for this are manifold and it is often difficult to create an overview of the current situation for a region of interest. We propose an environmental information system for the visualisation and exploration of large collections of heterogeneous data in the scope of energy system infrastructure and subsurface geological energy storage technologies. Based on the study area of Schleswig-Holstein, a federal state in Germany, we have set up a virtual geographic environment integrating GIS data, topographical models, subsurface information, and simulation results. The resulting application allows users to explore data collection within a unified context in 3D space, interact with datasets, and watch animations of selected simulation scenarios to gain a better understanding of the complex interactions of processes and datasets. Based on the cross-platform game engine Unity, our framework can be used on regular PCs, head-mounted displays, and virtual reality environments and can support domain scientists during assessment and exploration of the data, encourages discussions and is an effective means for outreach activities and presentations for stakeholders or the interested public.

Non-melanoma skin cancer among ethnic German immigrants (resettler) from the former Soviet Union: a cohort study from 1990 to 2007

BackgroundUV radiation is a significant risk factor for non-melanoma skin cancer (NMSC). Ethnic Germans (resettlers) who immigrated to Germany from the former Soviet Union may have had a relatively high UV light exposure and thus a higher risk of developing NMSC. We compared the incidence of NMSC in a resettler cohort with the general population of the Saarland (Federal state of Germany) in relation to tumour location.MethodsAll new NMSC cases (resettler cohort and total population) between 1990 and 2007 were retrieved from the Saarland cancer registry and classified according to sex, histology, and location. The classification used for tumour location approximated the previous UV exposure. Age-standardized incidence rates (ASR) for the general population and standardized incidence ratios (SIR) for resettlers compared to the general population were calculated and modelled using Poisson regression.ResultsSex-specific overall SIR indicated a significant increase in female resettlers (SIR 1.31 (95% CI 1.02–1.67)) which can mostly be attributed to an increased incidence of squamous cell carcinoma. The regression analysis showed that among resettlers the risk of developing tumours in UV-exposed skin areas was 2.16 (95% CI 1.35–3.45) higher compared to the general population.ConclusionsFemale resettlers have a higher risk to be diagnosed with NMSC than the general German population. Based on the observed distribution of tumour location, it is suspected that UV exposure contributed significantly to this risk.

Effect of agri-environment schemes (2007–2014) on groundwater quality; spatial analysis in Bavaria, Germany

Degradation of groundwater quality and contamination of drinking resources is one of the most widespread and harmful impacts of over-fertilisation in agriculture. As part of the Common Agricultural Policy (CAP), agri-environment schemes (AES) have as main objective the protection and management of the farm environment, including groundwater quality. In this article a spatial econometric model is applied to evaluate the impact of AES on groundwater nitrate concentrations. Bavaria, a federal state of Germany, is used as a case study, due to the findings of high nitrate concentrations in the groundwater. A significantly negative effect is found between AES expenditures focusing on grassland management and nitrogen concentrations, while AES focusing on crop management, organic farming and preservation of cultural landscape did not show a significant effect. The assessment of other factors such as cereals and forage showed a statistically positive effect on nitrate concentrations. However, loam soil texture, rainfall, and residential area were found to negatively affect nitrate concentrations.

Sixteen ways to adapt: a comparison of state-level climate change adaptation strategies in the federal states of Germany

Climate change adaptation (CCA) to reduce or prevent negative climate change impacts and, in some cases, maximize potential benefits is a complex challenge demanding multi-level policy action. In federalist systems, sub-national governments are among key actors for enabling adaptation and their clear commitments can increase collaboration and innovation at the local level. Germany serves as a particularly insightful case for observing the variance among sub-national approaches due to its role as a “leader” in CCA at the national level. This paper provides the first systematic assessment of all sixteen state adaptation strategies in Germany and examines how German states are fostering adaptation, the extent to which their approaches vary, and which patterns have emerged. Based on a qualitative document analysis of over 30 documents, this assessment focuses on five indicators synthesized from literature climate policy analyses and on barriers and facilitating factors of adaptation. Results find that German state strategies are often non-committal sets of recommendations and identify three clusters displaying different degrees of institutionalization and guidance. While federalism allows for flexibility among state responses, the absence of federal mandates and policy standards allows some states to fall behind while others continue to develop their strategies to foster adaptation. These sixteen diverse approaches each have implications for adaptation governance at other levels.

Slowing dementia symptoms – a qualitative study on attitudes and experiences of general practitioners in Germany

Background There is currently no cure for dementia but general practitioners (GPs) have therapeutic options available to counteract the progression of mild cognitive impairment, including drug and non-drug treatment. So far, few studies have investigated treatment strategies preferred by GPs. Objectives This study aimed to gain an overview of GPs’ attitudes towards influencing the progression of dementia, their involvement regarding dementia prevention and perceived effective approaches. It also elucidated the challenges experienced by GPs and desired optimisation measures towards reinforcing secondary prevention. Methods Between June 2020 and March 2021, 64 semi-standardised interviews amongst GPs were conducted in all federal states of Germany. Thirty interviews were carried out in person and 34 by phone. The data were analysed according to qualitative content analysis. Results Many interviewees see great importance in secondary dementia prevention and believe they could make an effective contribution, some of them using non-drug approaches. GPs play a role in guiding patients and relatives towards support services. Some doctors consider drug treatment as the only option towards influencing the progression of dementia, showing low expectations on self-efficacy. Interdisciplinary collaboration is a frequent challenge, which often conflicts with a coherent treatment strategy. Conclusion Many GPs feel confident about influencing the progression of dementia and believe they can intervene effectively, using various (non-drug) treatment measures and referrals to support services. GPs perceive challenges, including obstacles in interdisciplinary collaboration and negative impacts after drug administration. To improve the conditions for GP intervention, it depends on expanding interdisciplinary collaboration and care strategies.

Evaluation of the Thuringian Bovine Johne's Disease Control Program-A Case Study.

Simple SummaryParatuberculosis, or Johne’s Disease, occurs worldwide, causing a granulomatous enteritis in ruminants. Control programs, which operate mainly on a voluntary basis, have been established in several regions. In Thuringia, a federal state of Germany, a voluntary control program was firstly established in 2003 and revised in 2008 and 2015. This study aimed at evaluating the results achieved in voluntary Johne’s Disease control in Thuringia between 2015 and 2020. By the end of 2020, a total of 67 dairy herds with approximately 33,000 dairy cows and 87 suckler herds keeping approximately 6000 cows of beef breeds were enrolled, representing 35% or 16% of the population, respectively. In affected herds, the program focused on prevalence reduction by hygienic measures to break the infection cycle, annual testing for the detection of animals shedding the infectious agent and culling of these animals. A certification pathway was established based on a testing period of 3 years without positive results, and 58 herds were certified as ‘non-suspect’ with respect to Johne’s Disease. Analyzing the annual calf mortality rate in enrolled dairy farms revealed that herds that had been certified as ‘non-suspect’ regarding Johne’s Disease had a lower calf mortality rate than herds that were not enrolled in the program.The Thuringian Johne’s Disease (JD) Control Program provides a voluntary approach to JD control in Thuringia, a federal state of Germany. The program has three objectives: reduce the level of infection when present; reduce the spread of JD to uninfected herds; and facilitate the certification and protection of herds that are non-suspect with respect to JD. The program offers pathways for the management of affected herds and for certification of herds with continuing negative tests. After the control stage (CS), a certification stage of at least 3 consecutive years with continuing negative results in the annual whole-herd test has to be passed until a herd can be certified as ‘non-suspect’ with respect to JD. This study focused on calf mortality in relation to JD herd status. In a longitudinal study, the association of annual calf mortality rate of a total of 93 dairy herds (13 ‘non-suspect’; 26 in control stage; 54 not enrolled) over 10 consecutive years with JD herd status was investigated using a generalized mixed linear model with repeated measures. Non-suspect herds had a lower calf mortality rate compared with other farms. We conclude that establishing JD control measures lowers the calf mortality rate.

General digital competences of beginning trainees in commercial vocational education and training

Against the background of digital transformation processes that are currently changing the world of work, this paper examines general digital competences of beginning trainees in commercial vocational education and training (VET) programs. We are particularly interested in factors influencing digital competence profiles. From survey data including N = 480 trainees in one federal state in Germany, we were able to identify three different competence profiles (based on the trainees’ self-assessment of their general digital competence). Initial descriptive analysis reveals differences between competence profiles of different training professions (industrial clerks and retail salespersons reach higher competence levels than salespersons). However, regression results indicate that these differences can be explained by differences in school leaving certificates. Contrary to prior empirical evidence, we find no significant effect of trainees’ gender. Finally, the frequency of certain private digital activities (e.g. using office programs, conducting internet searches) affects digital competence profiles. Implications for both VET programs and further research are discussed.

The role of schools in transmission of the SARS-CoV-2 virus: quasi-experimental evidence from Germany

Abstract This paper considers the role of school closures in the spread of the SARS-CoV-2 virus. To isolate the impact of the closures from other containment measures and identify a causal effect, we exploit variation in the start and end dates of the summer and fall school holidays across the 16 federal states in Germany using a difference-in-differences design with staggered adoption. We show that neither the summer closures nor the closures in the fall had a significant containing effect on the spread of SARS-CoV-2 among children or a spill-over effect on older generations. There is also no evidence that the return to school at full capacity after the summer holidays increased infections among children or adults. Instead, we find that the number of children infected increased during the last weeks of the summer holiday and decreased in the first weeks after schools reopened, a pattern we attribute to travel returnees.

Voices from the Lagers in Germany

This paper traces the everyday realities of refugees living in camps in certain federal states of Germany during the ongoing COVID-19 crisis. It provides a systematic analysis of refugees’ testimonies and demonstrates that they have not received similar levels of care and protection as German citizens, and that their movement has become increasingly regulated. Drawing on Achille Mbembe’s notion of ‘necropolitics’, I argue that the German State has treated refugees’ lives as less liveable than those of their own citizens during the pandemic, as was the case before it broke out. Much scholarship has explained the notion of refugee camps in various ways, but there has been less discussion of Lagers (camps) as a site where colonial oppression persists outside the temporal and spatial contexts of former colonies. Data are drawn from archived data sets and testimonies that refugees uploaded to websites of various refugee activist groups.

How Does Health Literacy Modify Indicators of Health Behaviour and of Health? A Longitudinal Study with Trainees in North Germany.

Background: Health literacy (HL) is a resource that can help individuals to achieve more control over their health and over factors that influence health. In the present follow-up study, we have investigated the extent to which HL in trainees changes over time and whether or to what extent HL influences health behaviour and health. Methods: In 2017, we performed a baseline survey (T0) of trainees from six different branches, who were contacted through vocational colleges in four northern federal states in Germany. The survey was repeated at the midpoint of their training in 2019 (T1). Demographic data were surveyed, together with information on HL (HLS-EU-Q16), health behaviour and on health status (psychological well-being, subjective health status). Multivariate regression analyses were performed in SPSS 26. Results: Three hundred and ninety-one (391) data sets were evaluated, with a follow-up rate of 27%; 79% of the trainees were female. The mean age was 21.2 years. Over all subjects, the mean HL increased over time ( (SD): 11.9 (2.9) to 12.2 (2.9), p = 0.070). This increase was only statistically significant for the health service trainees ( (SD): 12.1 (2.8) to 12.5 (2.9), p = 0.019). Relative to persons with adequate HL, the odds ratio over time for impaired psychological well-being was increased by 230% in persons with inadequate HL (OR: 3.3, 95% CI: 1.70–6.32, p < 0.001). For persons with problematical HL, the corresponding increase in odds ratio was 110% (OR: 2.1, 95% CI: 1.30–3.38, p = 0.002). Relative to persons with adequate HL, trainees with inadequate HL exhibited a significant increase in odds ratio of 2.8 over time for poor or less good subjective health status (OR: 2.8, 95% CI: 1.23–6.33, p = 0.014). Conclusions: We observed a positive longitudinal association between HL and health. A significant increase in HL was observed in trainees in the health service. Thus the study shows that the concept of HL may provide a potential preventive approach for trainees.

Inequality of Educational Opportunities and the Role of Learning Intensity

Over the 2000s, many federal states in Germany shortened the duration of secondary school by one year while keeping the curriculum unchanged. The quasi-experimental variation arising from the staggered introduction of this reform allows me to identify the causal effect of increased learning intensity, the ratio of curricular content covered per year, on Inequality of Educational Opportunity (IEOp), the share in educational outcome variance explained by predetermined circumstances beyond a student’s control. Findings show that higher learning intensity aggravated IEOp due to parental resources becoming more important through support opportunities like private tuition, adapting to an intensified educational process. The effect is stronger for mathematics/science than for reading, implying the existence of subject-dependent curricular flexibilities. My findings underscore the importance of accounting for distributional consequences when evaluating reforms aimed at increasing educational efficiency and point to the role of learning intensity for explaining changes in educational opportunities influencing social mobility.

Enhancing implementation of a standardized initial assessment for demand management in outpatient emergency care in Germany: a quantitative process evaluation

BackgroundInadequate assessment of the severity and urgency of health problems is one of the factors contributing to unnecessary emergency department visits. A software-based instrument for standardized initial assessment (SmED) aims to support healthcare professionals and steer patients to the appropriate source of care. The aim of this study was to evaluate the implementation process of SmED based on the point of view of users in order to facilitate sustainable implementation.MethodsA quantitative process evaluation on the basis of a paper-based questionnaire was carried out alongside the implementation of SmED in 26 outpatient emergency care services within 11 federal states in Germany. Healthcare professionals who worked with SmED either at the joint contact points of the outpatient emergency care service and the emergency departments of hospitals ("Joint Counter", German “Gemeinsamer Tresen”) or at the initial telephone contact points of the outpatient emergency care service (116117) were invited to participate in the survey.Results200 users of SmED completed the questionnaire comprising the five scales: Intervention effectiveness/efficacy, Interprofessional context/occupational Interest, Individual Context, Organisational Framework Conditions, and Medical Context. Several individual characteristics were related to the implementation process of SmED. Female and younger healthcare professionals and participants with less than five years of professional experience tended to evaluate the implementation process as more positive. Factors related to the Individual Context and to the Medical Context were associated with the reported use of SmED (p = 0.004 and 0.041, respectively).ConclusionThe involvement of healthcare professionals, particularly more experienced professionals, in the implementation of SmED may help to facilitate sustainable implementation. In addition, training of potential user prior and during the implementation process and the adaption of Organisational Context factors are crucial.Trial registration The study was registered at the German Clinical Trials Register prior to the start of the study (DRKS00017014).