Ungleichheit in Gesundheit und Gesundheitsausgaben

Einleitung / Introduction

Stigmatization can occur as a side effect of certain diseases and manifest from perceived Stigmatization experiences (such as perceived social exclusion) to objective stigma practices (such as discrimination in the workplace). However, it is not as simple as that: Stigmatization in health care is not only related to specific diseases – appearances (e.g., hair loss), social attributions (e.g., gender-related) or even health care utilization (e.g., COVID-19 vaccination) may play a role. Despite an existing stock of theoretical literature and isolated and scatted initiatives focussing on distinct indications (such as HIV), the overall consequences of Stigmatization for the German context remain blurry. To address this gap, this research project aims to investigate the burden of Stigmatization in German health care in a comprehensive and multi-perspective manner.

Methode / Method

We developed a Stigmatization index for the German healthcare setting to identify relevant Stigmatization areas and to examine the current state of knowledge. The relevant fields in our Stigmatization index is based on an initial internet query, followed by a discussion and adjustment within our research team. For validation and improvement purposes, the currently identified status of the Stigmatization map will be presented to and discussed with experts. To examine the current state of research, we are conducting 1) a systematic literature review and 2) a systematic internet search for each relevant field of the map to identify grey and additional literature.

Ergebnisse / Results

The Stigmatization index comprises 124 indicators so far, covering health-related stigma referring to specific conditions plus appearance-related, gender-related, and healthcare utilization-related Stigmatization. The systematic literature review leads to 1,253 results, and during title and abstract screening, most of the results were excluded.

Zusammenfassung / Conclusion

We are planning to present first results on the burden of Stigmatization in Germany. With the presented approach, we will identify areas that are well-studied as well as data gaps. Also, we will be able to assess the existing evidence quality in the field. With this research project, we are providing a first overview by systematically recording what is known about Stigmatization in German health care, what consequences arise from it, and where is still a need for action.

AutorInnen

Laura Naumann, Vandage GmbH

Alena Zeitler, Vandage GmbH

Eva-Maria Kuczwalska, Vandage GmbH

Julian Witte, Vandage GmbH

Einleitung / Introduction

Die Verbesserung der Bevölkerungsgesundheit sowohl in ihrem Niveau als auch hinsichtlich der Verteilungsgerechtigkeit (Equity) ist ein wichtiges Ziel von Gesundheitssystemen. Die Bewertung der Leistungsfähigkeit von Gesundheitssystemen (Health System Performance Assessment, HSPA) ist ein Instrument zur evidenzbasierten Politiksteuerung und betrachtet verschiedene Dimensionen eines Gesundheitssystems, z. B. Zugang zu oder Qualität der Versorgung, Bevölkerungsgesundheit, Effizienz. Zum ersten Mal wurde ein systematisches und umfassendes HSPA für das deutsche Gesundheitssystem durchgeführt, welches auch die Dimension Bevölkerungsgesundheit mit Analysen zur Verteilungsgerechtigkeit umfasst.

Methode / Method

Der konzeptionelle Rahmen für die Pilotierung eines HSPA für Deutschland wurde in einer vorangegangenen Machbarkeitsstudie entwickelt. Die Auswahl der Indikatoren orientierte sich an international etablierten HSPA-Initiativen und der Datenverfügbarkeit für Deutschland. Die Dimension Bevölkerungsgesundheit wird über zehn Indikatoren wie z. B. im Bereich der Gesundheit von Müttern und Neugeborenen, vermeidbaren Sterblichkeit, Infektionskrankheiten und Krebsvorsorge erfasst. Die Indikatoren werden im Hinblick auf ihre Entwicklung im Zeitverlauf (2000-2020), im internationalen Vergleich (u. a. mit den Nachbarländern Österreich, Dänemark, Frankreich) sowie nach verschiedenen Gerechtigkeitsaspekten (z. B. Alter, Geschlecht) ausgewertet.

Ergebnisse / Results

Insgesamt liegt das deutsche Gesundheitssystem im Hinblick auf die Verbesserung der Bevölkerungsgesundheit im Vergleich zu ausgewählten europäischen Ländern im Mittelfeld und zeigt somit Verbesserungsbedarfe und mögliche Handlungsfelder für gesundheitspolitische Maßnahmen auf. Im Zeitverlauf zeigt sich eine Verbesserung der Bevölkerungsgesundheit in Deutschland. Bei Betrachtung der Verteilungsgerechtigkeit werden gesundheitliche Ungleichheiten deutlich. Der Indikator P.1 Vermeidbare Sterblichkeit umfasst Todesfälle, welche als durch Gesundheitsversorgung (bzw. durch Prävention oder Behandlung) vermeidbar gelten. Im Jahr 2018 lag die durch Prävention vermeidbare Sterblichkeit bei 156 Todesfällen pro 100.000 Einwohnern. Dabei zeigten sich deutliche Unterschiede zwischen Männern und Frauen (219 vs. 96 Todesfälle). Auch für den Indikator P.6 Neuerkrankungen bei ausgewählten Infektionskrankheiten zeigen sich deutliche Unterschiede nach Geschlecht. Im Jahr 2020 lag bspw. die Neuerkrankungsrate für Syphilis bei 17 pro 100.000 Männer und bei 1 pro 100.000 Frauen.

Zusammenfassung / Conclusion

Die Messung der Bevölkerungsgesundheit in Deutschland anhand von zehn Indikatoren zeigt Bereiche mit Verbesserungsbedarfen und gesundheitliche Ungleichheiten auf.

AutorInnen

Katharina Achstetter, Technische Universität Berlin

Miriam Blümel, Technische Universität Berlin

Matthias Haltaufderheide, Technische Universität Berlin

Philipp Hengel, Technische Universität Berlin

Reinhard Busse, Technische Universität Berlin

Einleitung / Introduction

In South Asian countries, parents prefer a male child over a female child for socioeconomic and cultural reasons. Because of son preference, we assume parents allot more attention to first-born children than the second-born when the gender of the second-born is female. This discriminatory parental attention results in a differential health outcome for first-born children. We show how the presence of a second-born female in the family affects the health and nutritional outcomes of first-born children. We also show that a female child does not tempt parents to spend more on diversified food items, non-food expenditures, and education, even though those families are part of large intervention programs like Feed the Future. This research mainly contributes to the literature on son preference and its implication on child health outcomes by unveiling the gender-discriminatory household preferences based on the second child’s gender.

Methode / Method

To analyze the impact of the second-born’s gender on the anthropometric outcomes of first children, we have used an OLS regression framework assuming that the gender of second-born children in a family is random. To examine whether improved financial status helps to reduce women’s disadvantage at the household level, we used the Difference-in-Difference (DiD) and the Difference-in-Difference-in-Difference (DDD) framework. We have utilized two waves of Bangladesh Integrated Household Survey data from 2011/12 and 2018/19, before and after the Feed the Future Program.

Ergebnisse / Results

We show the Individual and household-level impact of son preference. We found that height-for-age z (haz) of first-born children (any gender) of age 5-19 is 0.087 standard deviations higher if he/she has a second-born sister. The presence of a second-born sister significantly reduces the probability of severe stunting of a first-born boy child by around 3.4 percentage points. The DDD estimate shows that the families from Feed the Future (FTF) program area with second-born females significantly loses 0.32 in household dietary diversity score. Using the DiD approach, we found a significant increase in non-food expenditure due to the FTF program. But DDD estimate shows that this increase doesn’t sustain households with a second-born female.

Zusammenfassung / Conclusion

This research causally informs us of the direct implication of daughter neglect, which many families are unaware of. Specifically, the results will help fight lower growth and malnutrition incidences among girls in the Bangladeshi rural community. It will help to reduce intra-household gender discrimination by promoting extra care for Bangladeshi female children who are lower in birth order. Large intervention programs should be designed to benefit all households, regardless of sibling gender composition.

AutorInnen

Khalid Imran, CGS, University of Cologne

Daniel Wiesen, MIG, University of Cologne

Einleitung / Introduction

Older adults with rare diseases (RDs) face unique barriers to treatment since issues related to “older adult populations” and “RD populations” are compounded by specificities inherent to the two populations. As a result, older adults with RDs experience two compounding barriers to access: barriers related to advanced age as well as barriers related to RDs. Our objective is to extract available evidence on implicit or explicit discriminatory actions towards older adults with RDs.

Methode / Method

We extracted evidence on discrimination in four major categories by systematically searching for evidence in the PubMed via Medline, Cochrane and Embase databases. We searched for evidence and followed PRISMA guidelines in the screening process. Two reviewers independently screened the 1705 results and applied a predefined set of inclusion and exclusion criteria for both title and abstract screening as well as full text screening. Ultimately, 50 articles were deemed eligible for inclusion in the final study. The inter reviewer Kappa coefficient between the reviewers was 0.95 and disagreement was resolved in discussion.

Ergebnisse / Results

We found results clustered into four major categories: ethical discussions (11 articles), regulatory frameworks (22 articles), societal preferences (11 articles) and RD Patients’ experience (6 articles). Equity principles form the core of the ethical discussions. While some of these ethical discussions seem to justify discrimination towards RD patients or older adults, hardly any consensus exists. On the other hand, evidence gauging societal preferences tries to justify discriminatory actions using societies’ little consideration of rarity. Furthermore, the heterogeneous standards that characterize most regulatory frameworks reveal methodological biases against (older) persons with RDs. In the RD patients’ experience cluster, our review reveals that older RD patients face disproportionately bigger hurdles—especially at primary care level – in comparison to younger RD patients.

Zusammenfassung / Conclusion

We conclude that the RD population is not homogenous and that older adults with RDs face unique problems with less willingness from society and payers to address their specific unmet needs. To address equity-related challenges of older adults with RDs, regulatory and reimbursement frameworks need to account for those needs. For a more holistic evaluation approach, it is important for health care systems and regulatory bodies to better understand these equity issues in order to integrate them into their reimbursement decisions and appraisals. Future studies should address equity issues that specifically concern older adults suffering from RDS. This is indeed a field in which our review failed to uncover much evidence from.

AutorInnen

Jean Pierre Uwitonze, Universität Bern

Lize Duminy, Universität Bern

Rudolf Blankart, Universität Bern