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Health-care service provider networks are regarded as an important instrument to overcome the widely criticised fragmentation and sectoral partition of the German health-care system. The first part of this paper incorporates health-care service provider networks in the field of health-care research. The system theoretical model and basic functions of health-care research are used for this purpose. Furthermore already established areas of health-care research with strong relations to health-care service provider networks are listed. The second part of this paper introduces some innovative options for reimbursing health-care service provider networks which can be regarded as some results of network-oriented health-care research. The origins are virtual budgets currently used in part to reimburse integrated care according to §§ 140a ff. SGB V. Describing and evaluating this model leads to real budgets (capitation) - a reimbursement scheme repeatedly demanded by SVR-Gesundheit (German governmental health-care advisory board), for example, however barely implemented. As a final step a direct reimbursement of networks by the German sickness fund is discussed. Advantages and challenges are shown. The development of the different reimbursement schemes is partially based on models from the USA., (© Georg Thieme Verlag KG Stuttgart · New York.)

This paper provides a sketch of key research areas within health services research focusing on patient-centredness. The evaluation of patient-reported outcomes (PROs) is increasingly required for evaluating interventions in clinical trials and in routine health care. Often, however, it is un-clear which PROs are best suited for a particular research question. One of the most commonly used PRO is the construct of quality of life (QoL), which has become an established outcome in clinical trials and is also named as a health goal in the German Social Code of Law. The concept of patient empowerment implies that autonomy and room for manoeuver of the individual patient should be strengthened. However, it is un-clear how the concept is best operationalised. One prerequisite for patient empowerment in routine health care is the development and implementation of evidence-based patient information. Another prominent research area focuses on the role of self-help and patient organisations in health services. Topics of interest are aims and activities of self-help organisations, potentials and challenges of integrating self-help into professional health services, effects of organised self-help support on patients and barriers of use., (© Georg Thieme Verlag KG Stuttgart · New York.)

It has been shown that socio-economic status (SES) and health are closely linked to one another. Now we focus on further questions, and one of the most important ones is whether these "health inequalities" increase with time. In Germany, there is little discussion about this question and no review summarising the empirical evidence is available.This review focuses on 4 dimensions: time trends of health inequalities concerning mortality (or, respectively, life expectancy), self-rated health, smoking and obesity. First we included all empirical analyses from Germany, and all analyses from other European countries published between 2008 and 2012. Then, step-wise, 44 studies (including 5 from Germany) were selected by predefined criteria for a detailed -description of empirical results and methods.The number of publications has strong-ly increased in recent years, illustrating the growing interest in time trends of health inequalities. The empirical results of the 44 studies could be summarised in the following way: All in all, 184 empirical results are reported about time trends in health inequalities and 112 of them show increasing inequalities; decreasing inequalities are shown in 13 reports. The studies from Germany point in the same direction (i. e., most results indicate increasing health inequalities). It is also important to stress that there is great -heterogeneity concerning the methodical approaches. Some studies analyse health inequalities by individual socio-economic status (e. g., educational level), others by regional deprivation. Sometimes changes in the extent of health inequalities over time are not calculated explicitly. Some papers do not include absolute and relative measures of inequalities, but just one of them.In Germany, there is a need for more empirical studies looking at time trends of health inequalities; the available datasets should be used more often for this type of analysis. If possible, further studies should include individual SES and regional deprivation, measures of absolute and relative inequality (stratified by sex, with significance tests for time trend), and they should cover as many points in time as possible. Also, it would be important to relate the chang-es in health inequalities to the other changes in the society., (© Georg Thieme Verlag KG Stuttgart · New York.)

The German statutory health-care system is based on the principle of solidarity and thus it is committed to the objective of 'equal chances'. From an economic perspective it is also important to emphasise that scarcity of resources continuously pushes the services towards cost control and towards increasing cost-effect-iveness. There could be conflicts between the 2 objectives 'equal chances' and 'cost-effectiveness', of course, for example if measures for increasing cost-effectiveness lead to increased financial burdens of the insured. To date it has not been studied if and how this potential conflict is discussed in Germany.In a first step we searched for German publications discussing this potential conflict focusing on 3 major public health journals (Das Gesundheitswesen, Bundesgesundheitsblatt, Ethik in der Medizin) and on the internet portal "gerechte-gesundheit.de". For the main part of the paper, we looked for publications from 4 major health policy actors (Bundesärztekammer, Zentrale Ethikkommission bei der Bundesärztekammer, Deutscher Ethikrat, Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen). All papers published since the year 2000 were included in the system-atic qualitative analysis.The analyses show that the potential conflict between 'equal chances' and 'cost-effectiveness' is rarely discussed in any detail, at most in an implicit way. It would be important, though, to have an explicit discussion, supported by scientifically based analyses and recommendations. One step towards this objective could be, for example, a closer cooperation between social-epidemiologists and health--economists., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Due to demographic aging, economic evaluation of health care technologies for the elderly becomes more important. A standardised questionnaire to measure the health-related resource utilisation has been designed. The monetary valuation of the resource use documented by the questionnaire is a central step towards the determination of the corresponding costs. The aim of this paper is to provide unit costs for the resources in the questionnaire from a societal perspective., Methods: The unit costs are calculated pragmatically based on regularly published sources. Thus, an easy update is possible., Results: This paper presents the calculated unit costs for outpatient medical care, inpatient care, informal and formal nursing care and pharmaceuticals from a societal perspective., Conclusion: The calculated unit costs can serve as a reference case in health economic evaluations and hence help to increase their comparability., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: "Stratifying medicine" is a topic of increasing importance in the public health system. There are several questions related to "stratifying medicine". This paper reconsiders definitions, opportunities and risks related to "stratifying medicine" as well as the main challenges of "stratifying medicine" from the perspective of a public health insurance., Definition: The application of the term and the definition are important points to discuss. Terms such as "stratified medicine", "personalised medicine" or "individualised medicine" are used. The Techniker Krankenkasse prefers "stratifying medicine", because it usually means a medicine that tailors therapy to specific groups of patients by biomarkers. OPPORTUNITIES AND RISKS: "Stratifying medicine" is associated with various hopes, e. g., the avoidance of ineffective therapies and early detection of diseases. But "stratifying medicine" also carries risks, such as an increase in the number of cases by treatment of disease risks, a duty for health and the weakening of the criteria of evidence-based medicine., Challenges: The complexity of "stratifying medicine" is a big challenge for all involved parties in the health system. A lot of interrelations are still not completely understood. So the statutory health insurance faces the challenge of making innovative therapy concepts accessible in a timely manner to all insured on the one hand but on the other hand also to protect the community from harmful therapies. Information and advice to patients related to "stratifying medicine" is of particular importance. The equitable distribution of fees for diagnosis and counselling presents a particular challenge. The solidarity principle of public health insurance may be challenged by social and ethical issues of "stratifying medicine"., Conclusion: "Stratifying medicine" offers great potential to improve medical care. However, false hopes must be avoided. Providers and payers should measure chances and risks of "stratifying medicine" together for the welfare of the patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

The first aim of the paper is to analyse in a culture-theoretical perspective those characteristic semantic markers that permit "personalized" medicine (PM) to figure as a prestigious seminal trend of future medicine. In fact, there is evidence that the ambiguity of the favourite semantic markers of PM engenders a conception of PM that is analogous to the tailoring of services to customers. There is an air of paradox: while patients are supposed to be the key beneficiaries of PM, their genuine preferences, at present, are seriously underarticulated. The second aim of the paper is to focus attention on some highlights within the multifarious ethical discourse that accompanies the development of PM. As a result, valuable methodological options are outlined that support a consistently ethical analysis of ethical value-conflicts pertaining to the rise of PM., (© Georg Thieme Verlag KG Stuttgart · New York.)

Study Aim: This paper shows how a state-wide health-promotion intervention at primary schools can be implemented by considering the example of the programme "Join the Healthy Boat - Primary School". Additionally, it is illustrated how quality control throughout the whole process can be incorporated., Methods: To operate long-term and target-group orientated in the whole state of Baden-Württemberg, the school-based prevention programme "Join the Healthy Boat" uses a "train the trainer" model. The trainers are teachers who were instructed by the project team. In the school year 2009/10, these trainers offered quadrinominal training courses for further teachers. Every urban and rural district is covered by 1 trainer. The trainers evaluated the 6 preparatory training courses they had been given using questionnaires. The following 4 training courses the trainers offered to the teachers were reviewed by the trainers as well as the teachers using questionnaires, too. Additionally, at the end of the school year 2009/10, the teachers completed a questionnaire about their satisfaction regarding the programme itself and the work with the trainer., Results: During the school year 2009/10, 453 teachers were trained by 32 trainers. According to indications on the questionnaires about the preparatory training courses, all trainers felt themselves "very well" or "well" prepared for their task. The teachers evaluated the expertise of the respective trainer, the quality of the training courses and the satisfaction with the programme itself throughout highly., Conclusion: Based on the excellent results of the process evaluation and the programme's wide coverage, an adoption of a "train the trainer" model seems worthwhile for other school-based prevention programmes, as well., (© Georg Thieme Verlag KG Stuttgart · New York.)

It is well known that Sen's capability approach and preference utilitarianism have different distributional values. The purpose of this paper is to discuss how Sen's capability approach might be operationalised for allocation decisions and cost-effectiveness analysis in health care. The paper identifies several requirements for measuring health or well-being in line with the capability approach. Among them is the need for objective assessments of capabilities. This paper also shows that from the perspective of the capability approach a portion of productivity changes are irrelevant for allocation decisions., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Due to the increasing numbers of Muslims in Germany(1)--about 4.3 million at the moment--more Muslim patients are medicated in the practices of family doctors. Their heterogeneous cultural and religious backgrounds are nontheless unknown and unfamiliar for the treating general practitioner. Based on the daily experiences of the latter and in order to capture their development of intercultural competence, in the present study a brainwriting with general practitioners was conducted to record their spontaneous associations with Muslim patients., Methodology: Individually and without exchange 90 general practitioners (66 male, 24 female) listed subjective thoughts regarding "Muslim patients" on a prepared sheet of paper. Additionally, sex, age, number of years as physician in a private practice and the frequency of treatment of Muslim patients in their own practice were requested. The content of the notes were evaluated using MAXQDA and were clustered in the categories of "language", "company", "violence", "men"/"women", "psychosomatic medicine", "compliance", "understanding of illness", "physical examination" and "head scarf"., Results: The ideas listed show that the majority of interviewed general practitioners regarded the treatment of Muslim patients as difficult. They associate Muslim patients with communication problems, a different type of disease understanding and a fear of contact, which hampers the examination situation. Less frequently, positive associations and unproblematic examination situations were noted., Conclusions: Due to a lack of knowledge about cultural and religious contexts Muslim patients are often described by using stereotypes. This underlines the necessity to foster intercultural competences and self-reflection in daily practice and its systematic inclusion in medical education., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Since July 1st, 2009 in accord with the statuary order based on the German law for infectious diseases (Infektionsschutzgesetz), MRSA in blood and liquor have to be notified to the public health authorities. The aim of this extension of the notification to report is to improve the surveillance of nosocomial infections and the prevention of nosocomial MRSA infections. In this paper data of the notifications in the year 2011 within the MDRO-Net Rhine-Main, an association of 7 public health authorities in the region, are reported in order to investigate whether the aims of the obligation for notification could be achieved., Results: In 2011, 138 MRSA bloodstream infections, including 1 MRSA in liquor culture, were notified to the 7 health protection authorities, resulting in an incidence rate of 5.6/100,000 inhabitants. In urban regions with more hospitals available, the incidence rate was higher than in rural districts with less medical facilities (6.9 vs. 4.4/100,000 inhabitants). Only 46 (35%) of the patients with MRSA cultured in their blood had been detected via anamnesis as patients on risk for MRSA, and 59 (45%) had been screened for MRSA on admission. The incidence rate in the different hospitals was 0.041 ± 0.031/1,000 patient days (range 0-0.145/1,000 patient days)., Conclusions: For the first time, data on notification of MRSA cultures in blood specimen are published from a whole MRE Network in Germany encompassing >2.1 million inhabitants. Incidence rates per 100,000 inhabitants alone do not seem adequate to cope with the aims of the obligation for notification. Instead, reference to patient days in the respective clinic enables an external comparison to other medical institutions in the region and is a better base for discussion with these institutions on improvements of surveillance, screening and hygiene., (© Georg Thieme Verlag KG Stuttgart · New York.)

National and international epidemiological studies have shown that relevant segments of populations are - especially in the winter period - vitamin D deficient and for the entire year vitamin D intake is far too low. This also applies to pregnant women. In January 2012 the German Nutrition Society has increased the intake recommendations for vitamin D by a factor of 4. It is suggested that a sufficient supply with vitamin D has high preventive potentials with respect to several chronic diseases and will potentially reduce the incidence of preterm birth. This paper considers the evidence of associations between vitamin D deficiency and adverse pregnancy outcomes. Based on the current epidemiological knowledge which is, however, sparse there is very low evidence that vitamin D deficiency is a relevant risk factor for adverse pregnancy outcomes. This makes it even more difficult to give rationale answers to emerging questions with respect to supplementation, dosage and vitamin D diagnostic measures. An observational study with 2 or 3 large obstetric clinics should be undertaken to clarify the central question without delay., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Recent years have seen an increasing number of foreign doctors starting to practice medicine in German hospitals (or more rarely, in surgeries). In order to be granted the German license to practice medicine, doctors with a medical degree from outside the European Union have to undergo an equivalency examination. The supervisory authority for this is the examination office of the relevant federal state, which is why different procedures are being applied in the individual states. The aim of this paper is to point out the problems that frequently arise when conducting this specialist exam and to make suggestions as to how to improve the quality of the procedure., Method: 6 senior professors from the examination boards of the 4 medical schools in Baden-Wuerttemberg formed a focus group and discussed the difficulties associated with the exam, recorded problems in its actual implementation and then analysed the minutes of the meeting in a results-based manner in order to compile proposals for optimisation., Results: In view of the deficits in subject knowledge, general communication skills and specific communication skills, the difficulties of the current recognition procedure and the existing equivalency exam fall into 3 categories: structure and content of the exam, examiners and exam candidates., Conclusions: In consultation with the State Examination Office Stuttgart, some processes for optimisation have been devised, e. g., to develop a special curriculum which could be used for guidance and to recruit more examiners. The recommendations of the focus group from Baden-Wuerttemberg are an important step towards more transparency and possibly towards a Germany-wide standardisation of this exam., (© Georg Thieme Verlag KG Stuttgart · New York.)

Personal contextual factors play an essential part in the model of the International Classification of Functioning, Disability and Health (ICF). The WHO has not yet classified personal factors for global use although they impact on the functioning of persons positively or negatively. In 2010, the ICF working group of the German Society of Social Medicine and Prevention (DGSMP) presented a proposal for the classification of personal factors into 72 categories previously arranged in 6 chapters. Now a positioning paper has been added in order to stimulate a discussion about the fourth component of the ICF, to contribute towards a broader and common understanding about the nature of personal factors and to incite a dialogue among all those involved in health care as well as those people with or with-out health problems in order to gain a comprehensive perspective about a person's condition., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: 'Walkability' is mainly assessed by the NEWS questionnaire (Neighbourhood Environment Walkability Scale); in Germany this questionnaire is widely unknown. We now try to fill this gap by providing a systematic overview of empirical studies based on the NEWS., Methods: A systematic review was conducted concerning original papers including empirical analyses based on the NEWS. The results are summarised and presented in tables., Results: Altogether 31 publications could be identified. Most of them focus on associations with the variable 'physical activity', and they often report significant associations with at least some of the scales included in the NEWS. Due to methodological differences between the studies it is difficult to compare the results., Conclusion: The concept of 'walkability' should also be established in the German public health discussion. A number of methodological challenges remain to be solved, such as the identification of those scales and items in the NEWS that show the strongest associations with individual health behaviours., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Since the late 1990s several measures have been introduced in Germany to curb tobacco use and to protect non-smokers. Smoking bans in public spaces, including restaurants and pubs, are part of them. It is the aim of the paper to analyse the change in smoking prevalence and attitudes towards smoking bans in the population of Düsseldorf, Germany, over time., Methods: Random samples from the population register of the city of Düsseldorf of persons with German nationality, 18 years onwards were approached. Mail surveys were sent with up to 3 reminders in the years 1997, 1998, 2004, 2007 and 2009. Response rates were between 52% and 59% (N per date of comparison ca. 700-1 200)., Results: The number of daily smokers has declined between 1997/98 and 2009 from 33% to 21%. Likewise, the number of cigarettes smoked per day has declined. The number of respondents who favour smoking bans has increased. Rather than favouring a total ban, a partial ban is often preferred (with a zone for smokers). Whether a smoking ban is favoured depends on whether the respondent is using tobacco and whether dangers are ascribed to tobacco use and tobacco smoke. Self-rated health does not exert an impact on attitudes towards smoking bans with the exception of the most recent survey, done in 2009. Here those respondents were most often in favour of bans who considered their health as being very good. Possibly this reflects a new situation where the acceptance of smoking bans has become part of a self-perceived healthy lifestyle., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Purpose: The aim of this paper is to identify characteristics that inhibit or encourage the diffusion of novel implants in the German health care system using the example of drug-eluting stents (DES). After their introduction in the early 2000s, DES were considered as an effective innovative technology. Hypotheses that link the use of DES to characteristics on patient-level, hospital-level, regional-level as well as on state-level are generated on existing literature. These hypotheses are tested using administrative data from a German sickness fund., Methods: The analysis is based on the administrative sickness fund data of 6 777 patients with a hospital admission due to an acute myocardial infarction (AMI) and an implantation of either a DES or a bare-metal stent. The sickness fund data was merged with information on reimbursement surcharges for DES implantations, information from the German Hospital Registry and information on county level provided by the German National Statistical Office. Logistic regressions with random intercepts on hospital and county level as well as fixed effects on state level were estimated to identify characteristics that are correlated with DES use., Results: All levels do have an impact on the treatment decision whereas the patient-level is of major importance. In particular, young age, admission to a university or a privately owned hospital and a hospital located in a county with a low level of bankruptcies are positively correlated with DES use., Conclusion: Although individual characteristics are of major importance for DES use in the German health care system, characteristics at the hospital and regional level do have an impact on the use of DES. Further research on the influence of reimbursement mechanisms in the German setting is needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

According to the "Protection against Infection Act", public health services are obliged to supervise and consult the hygienic conditions not only in hospitals but also in ambulatory medical practices in Germany. Firstly, in this paper basic principles on transmission routes of pathogenic germs and general remarks on the infection control visits as well as on the special regulations (i.e., German commission on hospital hygiene and infection prevention) are described. Secondly, crucial points to be considered in all medical practices are mentioned. Finally, special issues in different practices are reported, such as dermatology, gastroenterology, gynaecology, paediatrics etc. This article aims to support the public health departments in their task to prevent infections in patients and personnel in medical practices.·, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Externalising behavior problems involve a huge developmental risk potential as they can substantially interface with the parallel process of establishing and forming identity in peer groups during adolescence while simultaneously coping with expectations regarding academic achievement and behaviour. Therefore adolescents with externalising behavior constitute a potential target audience for health promotion., Aim of the Study: The purpose of this paper is to clarify in what kind of social contexts externalising behavior problems are associated with decreased subjective health in adolescence., Method: An analysis of secondary data from the KiGGS study (Robert Koch-Institute, 2009) was undertaken. Calculations of logistic regression models for boys and girls were performed on the basis of preceding stratifications using the indicator subjective health and including relevant social demographic factors., Outcome: Externalising adolescents face a higher risk of decreased subjective health than inconspicuous adolescents of the same age group, while there is a gender-specific difference (boys OR 2.76; girls OR 1.48). The gender-specific differences in subjective health appraisal found in inconspicuous adolescents cannot be verified in adolescents with externalising behaviour. Related to social demographic predictors a classic social gradient for girls is verified whereas externalising behaviour in boys is predominantly associated from high social class and decreased subjective health. In multivariate procedures a higher odds ratio for decreased subjective health becomes apparent for adolescents who ascend or descend in relation to their education level as well as for adolescents from higher social classes who had to repeat a school year., Conclusion: Adolescents with externalising behavior frequently rate their health situation as being bad. The fact that it is primarily boys with behavior problems and boys who are intergenerational mobile educationwise who exhibit decreased psychosocial well-being, indicates that an increased context related exclusion risk (ostracism) is an essential health risk factor. Micro-groups of adolescents facing risk of being ostracised appear to be an essential target group for prevention and health promotion which so far is not being taken into consideration on the basis of school type related recommendations., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: This paper analyses on the basis of data from over 2 400 nursing homes the relationship between remuneration rates and quality for Germany. Other factors influencing this relationship are taken into account.Data about nursing homes are taken from the nursing home data base PAULA, which includes about 11 500 nursing homes., Data and Methods: Data about quality of care in nursing homes are derived from the so-called transparency reports for residential long-term care (PVTS). In a linear regression framework the different quality measures are regressed on the average nursing home price. Control variables are inter alia ownership, size and location of the nursing homes., Results: The analyses show a statistically significant positive correlation between remuneration rates and quality. Better quality is reflected in higher remuneration rates., Conclusions: The results show a significant, but in actual size low relationship between quality and remunerations rates. The results cannot be interpreted as a causal relationship. Additionally, it is not possible to explain differences in nursing home prices over federal states with differences in quality., (© Georg Thieme Verlag KG Stuttgart · New York.)

Restraints are used for several medical situations. Their use in restraining patients in psychiatric care and nursing homes is widely debated, whereas those in hospitals are rarely discussed. This is a particular cause of concern because restraints are prescribed under various circumstances in hospitals and yet they have an ambivalent character because they are viewed as a custodial measure. The aim of this paper is to examine the civil law legislation on restraints and medical reasons for employing restraints in German hospitals. I will argue that the use of restraints should only be performed after a thorough assessment of the patient and his or her wishes. As a vulnerable group, patients are dependent on clinical staff members, who must in all circumstances do their best to respect the autonomy and rights of their patients. Awareness of health-care personnel regarding the use of restraints should be increased and interdisciplinary collaboration among judges, clinicians and nurses must be bridged and enhanced in order to improve the flow and exchange of information on this very ethical and moral issue., (© Georg Thieme Verlag KG Stuttgart · New York.)

Claims data-based studies provide insight into the delivery of health care services within the statutory health insurance (SHI) system. So far discretionary decisions concerning the definition of service utilization are seldom discussed. Using claims data of 9 147 dementia patients insured with AOK Bavaria SHI fund as an example, this paper compares different definitions of service utilisation and the corresponding costs of care. In total, the different approaches do not always result in different figures. Indeed the observed variation depends on the relative frequency of equivocally interpretable services within the study sample. Based on these results it is possible to provide recommendations for future standards for claims data analyses., (© Georg Thieme Verlag KG Stuttgart · New York.)

With medical advances, acute -disease in childhood and adolescence could be substantially reduced, thus shifting the focus towards chronic and mental health problems. Currently there is a lack of studies on trends in health-related quality of life (HRQoL) and mental well-being and their determinants in the context of children's and adolescents' environment (e. g., family, school). The aim of this paper is to describe the trend in HRQoL in children and adolescents from 2006 to 2010 and to analyse factors associated with HRQoL and mental well-being of children and adolescents.Results are based on the German sample (11-, 13- and 15-year-old school children) of the international WHO Study from the 2006 (n=6 896) and 2010 (n=4 723) surveys. HRQoL was assessed by means of KIDSCREEN-10. The Strengths and Difficulties Questionnaire (SDQ), a screening instrument for mental health problems, was used as an indicator of mental health. Logistic regressions were performed to analyse the effects of covariates on HRQoL as well as on mental health problems.HRQoL remained fairly stable between 2006 and 2010 for both boys and girls. Approximately 85% of the school children report a high or normal HRQoL, whereby girls indicate a lower HRQoL than boys. Overall, 14,3% of the pupils show signs of mental health problems. The model results show that poor communication with parents, spending little time with friends, lack of perceived support from classmates and a negative attitude towards school are negatively associated with mental health.The majority of children and adolescents report a high HRQoL over time. The fact that every 7th 11- to 15-year-old shows signs of mental health problems raises concern and suggests that addressing mental health problems needs to gain more priority in public health measures., (© Georg Thieme Verlag KG Stuttgart · New York.)

The purpose of this study was to undertake an assessment and differentiated examination of the development of bullying and violence in schools between 2002 and 2010 in Germany.We examined the national German data of Health Behaviour in School-aged Children (HBSC) study in 2002, 2006 and 2010. A paper-pencil questionnaire was distributed to a representative sample (N=17 929) of 11-, 13- and 15-year-old school children. The evaluation of the data was done by descriptive statistics and logistic regression analyses, controlled by age, gender, family affluence, school type and survey year.A clear positive trend could be identified: from 2002 to 2010 the number of bullies and bully victims decreased whereas the group of the uninvolved pupils increased. There was a delay in this trend for children with low family affluence.The obvious success in the prevention of violence is shown by the decreasing rate of bullies. The paper discusses whether future prevention should focus more on victims and children with educationally deprived background., (© Georg Thieme Verlag KG Stuttgart · New York.)

This paper aims to investigate the effects of sin-gle-parent families on the health of young peo-ple. Database is the 2010 HBSC survey as well as the 2002 and 2006 data for trend analysis. Findings show that there is a weak but significant effect of single-parent families on the health and health-behaviour of young people. There has been little change in the findings between 2002 and 2010., (Georg Thieme Verlag KG Stuttgart · New York.)

The aim of the HBSC-Study is to collect data on the physical and mental health and health behaviour of children and adolescents and to gain a deeper insight into their situation and the specific environment they grow up in. The HBSC-study is an international school-based cross-sectional survey conducted in collaboration with the World Health Organization (WHO). The survey takes place every 4 years since 1982 and is based on a standardised protocol. In Germany the survey was first conducted in 1994 as a pilot study in North Rhine-Westphalia. The German sample is based on a random sample of classes in all public schools in Germany. 11-, 13-, and 15-year-old pupils are surveyed by means of a paper and pencil questionnaire. The questionnaire comprises a broad selection of -topics, including sociodemographics, health and risk behaviours, family, school and peers. The reported trends in the supplement are based on the data from surveys in 2002 (N=5.650), 2006 (N=7.274) and 2010 (N=5.005). The representative samples for each of the survey years are defined as follows: in 2002 the data is based on information collected in 4 Federal States (Berlin, Hesse, North Rhine-Westphalia, Saxony); in 2006 5 states define the German data file (Berlin, Hamburg, Hesse, North Rhine-Westphalia, Saxony). The data from the 2010 survey comprises data from 15 Federal States. The HBSC-data contributes towards a better understanding of the relationship between health and living conditions of young people. The papers in this supplement deliver important insights into the living context of young people and in doing this they provide important information about their health and the long-term effectiveness of public-health-measures., (© Georg Thieme Verlag KG Stuttgart · New York.)

For many years, the HBSC-Study has provided important insight and information on the health situation and health behaviours of young people 11- through 15 years of age living in Germany. The papers in this supplement take a first look at the trends in selected indicators of health and health behaviour of this group and draw important conclusions about the association between prevention and health promotion measures and individual health across time. This short report gives an overview on the key results and findings of the 10 papers in the supplement., (© Georg Thieme Verlag KG Stuttgart · New York.)

For the last 30 years the appropriateness of social strata concepts has been discussed controversially in Germany. It was hypothesised that changes in the social structure resulting in a greater heterogeneity of social living conditions has decreased the relevance of social strata concepts. However, socio-epidemiological research still revealed a strong social gradient, indicating that health risks are still depending on individual social background. Nevertheless, enhanced models of social stratification could be fruitful for socio-epidemiological research, particularly with respect to the objective of reducing health inequality. The 'concept of living conditions' is one of the continuative social strata approaches, which is based on a multidimensional concept of social inequality. First use of this concept provided promising results in obtaining a more precise description of health-related living conditions. In this paper, the concept is presented in more detail, spotlighting on questions about conceptual realisation as well as empirical implementation. The paper aims to encourage a wider discussion about the use of these concepts for socio-epidemiological research and medical sociological theory., (© Georg Thieme Verlag KG Stuttgart · New York.)

The data linkage of health-related primary and secondary data provides new opportunities for health services research. The advantages of both data sources can be used synergistically, in this way their disadvantages can be overcome. In the context of the evaluation of a health intervention - the integrated health services project ('Gesundes Kinzigtal') - the conditions and requirements for an individualised data linkage of primary data (survey) and claims data of a statutory health insurance are described in this paper. The integration of secondary data permits us not only to assess the intervention concerning physical activity, nutrition and social participation of elderly people ('AGil') but, above all, also to measure and analyse the program effects on the utilisation of health care services. Recommendations regarding the data linkage of primary and secondary data in health services research are derived from the results and experiences of the AGil study. Suggestions are made concerning the suitable pseudonymisation algorithm for primary and secondary data, the matching method, approaches to reduce mismatching and their validation, as well as the legal basis for such a data linkage. Overall, an individualised data linkage of primary and secondary data does not pose any technical problems. Nevertheless a couple of data protection rules have to be followed; the data linkage offers a high knowledge insight to many health and epidemiological research questions and might be the new gold standard for health services research., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose of the Study: The 9 (th) Revision of German Medical Licensing Regulations for Physicians has come into effect on October 1 (st) 2003. Social medicine was separated into the fields ""occupational health, social medicine" and the various cross-sectional modules: epidemiology, biometry, medical computer science; health economics, health-care system, public health; prevention, health promotion; rehabilitation, physical medicine, naturopathic treatment. This paper studies the realisation of teaching in the field social medicine at German medical faculties., Methods: The survey was conducted in collaboration with the German Association for Social Medicine and Prevention (DGSMP). A survey was conducted at 38 institutes of 36 German medical faculties. The written questionnaire contained mostly selection items in which chances and barriers of the field were queried with supply items. Information about time scale, general conditions and resources was aked for. On the basis of the guidelines of the DGSMP, the topics to be taught were evaluated concerning their relevance and integration into education., Results: The response rate was 68% (n=26). Social insurance, basic principles, responsibility in the Social Security Code and the different providers were judged as the most important topics. There was a strong demand for lecturing material. 82% (n=18) of the faculties wished to have specific material, for example e-learning, examples, lesson plans, curricula and also textbooks. 91% (n=19) of the faculties requested an exchange of information between the faculties concerning educational contents, motivation of students and e-learning., Discussion: The realisation of teaching is different between the faculties concerning the number of hours, teaching methods and number of students per year. The motivation of the students is one of the problems, but also the lack of acceptance within the clinic. Specific resources and exchange between the faculties are necessary concerning e-learning, which is offered at only few faculties so far, but interest for a more intensive usage exists. Potentials of social medicine are the promotion of awareness among the students and the "identification of basics for medical acts in the social security system". Social medicine offers the possibility to connect the theoretical institutes with the clinic., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose of the Study: Non-commercial investigator-initiated trials are an important part of clinical research in Germany. Academics who want to initiate clinical trials are confronted with the new and complex regulatory framework of the 12(th) Amendment to the German Drug Code. This paper studies the effects of this new regulatory framework on different important aspects of clinical trials., Methods: A total of 87 people who are engaged in planning, conducting or analysing investigator-initiated clinical trials were included in the study. The professionals are employed at university hospitals, coordinating centres for clinical trials, and contract research organisations. The survey took place using a web-based, anonymous questionnaire., Results: The interviewed professionals described a general increase of regulatory requirements and complexity in investigator-initiated clinical trials, as well as an increase in expenditure of time and total costs. However, there is also an observed improvement in the quality of clinical trials., Conclusion: The new regulatory requirements of the 12(th) Amendment to the German Drug Code have led to an increasing professionalisation in planning and conducting clinical trials in an academic environment. In particular, university hospitals have been confronted with large challenges., (© Georg Thieme Verlag KG Stuttgart · New York.)

Priority setting in medicine helps to achieve a fair and transparent distribution of health-care resources. The German discussion about priority setting is still in its infancy and may benefit from other countries' experiences. This paper aims to analyse the Danish priority setting debate in order to stimulate the German discussion. The methods used are a literature analysis and a document analysis as well as expert interviews. The Danish debate about priority setting in medicine began in the 1970s, when a government committee was constituted to evaluate health-care priorities at the national level. In the 1980s a broader debate arose in politics, ethics, medicine and health economy. The discussions reached a climax in the 1990s, when many local activities - always involving the public - were initiated. Some Danish counties tried to implement priority setting in the daily routine of health care. The Council of Ethics was a major player in the debate of the 1990s and published a detailed statement on priority setting in 1996. With the new century the debate about priority setting seemed to have come to an end, but in 2006 the Technology Council and the Danish Regions resumed the discussion. In 2009 the Medical Association called for a broad debate in order to achieve equity among all patients. The long lasting Danish debate on priority setting has entailed only very little practical consequences on health care. The main problems seem to have been the missing effort to bundle the various local initiatives on a national level and the lack of powerful players to put results of the discussion into practice. Nevertheless, today the attitude towards priority setting is predominantly positive and even politicians talk freely about it., (© Georg Thieme Verlag KG Stuttgart · New York.)

With rising costs in health care, especially in the area of pharmaceuticals, patients are expected to be more involved in managing their care. Concepts such as shared decision-making or self-management support in chronic illness have been suggested as a way to facilitate this process and to empower patients. It is unclear however, whether the self-responsible patient role outlined in these concepts aligns with the patient's needs. The aim of this paper is to examine this proposed self-responsible role with regard to the patient's medication management needs and to discuss whether self-responsibility and autonomy are suitable concepts when illness-related challenges become difficult or complex. Selected findings from a qualitative longitudinal study on medication management from the perspective of people with chronic conditions are presented. Results from interviews with 27 patients indicate that both the patient's view and the challenges people with chronic conditions face in everyday life remain a 'blind spot' in health care. Providing information to improve health literacy may not be enough; there is a need to systematically support patients in developing skills to adequately (self-)manage a chronic condition., (© Georg Thieme Verlag KG Stuttgart · New York.)

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The risk compensation scheme (RCS) in the Statutory Health Insurance (SHI) was implemented in 1994 to discourage risk selection between sickness funds. However, several expertise papers have concluded since then that the sociodemographic risk adjusters in place could not adequately curb risk selection. To minimise incentives for risk selection in the Statutory Health Insurance (SHI) further, the RCS was refined in 2009 by adding 80 diseases as additional risk adjusters. In spite of the better compensation of differences in morbidity, however, incentives for risk selection may still persist. In this study, we investigated the association of indicators such as region (number of inhabitants in the city), income, level of education and family status (children in the household) with health care costs to determine if risk selection is still attractive for sickness funds under the refined RCS., Method: The analysis is based on a 2002 cross-section survey comprising 75,122 individuals. Health expenditures were estimated using self-documented utilisation data and were standardised for age, sex and diagnoses covered by the risk adjustment scheme. We included costs for inpatient care, outpatient care, pharmaceuticals, rehabilitation, and medical devices. To assess the effects of the above-mentioned individual characteristics on health-care expenditure, regression analyses and analyses of variances were performed., Results: Full documentation was available for 52,484 individuals (69.86%). From these the variables "family status (children in the household)", "higher educational level", and "higher income" were associated with lower costs for individuals without chronic conditions. For individuals with chronic conditions, results were mixed. "Family status", "education" and "income" showed no clear association with lower or higher costs and were not statistically significant. The variable "region" was neither significantly associated with chronically ill nor for healthy individuals., Discussion: With respect to age, sex, and morbidity, individuals with high income and education and without chronic diseases apparently cause lower costs. Thus, health status, income and education remain as possible selection criteria for sickness funds in Germany. However, the refined RCS compensates for the largest proportion of cost differences between insured with and without chronic disease. Possible causes of the small but remaining differences and whether improving preventive programmes or providing awareness campaigns may be appropriate strategies to tackle this issue should be investigated in future research., (© Georg Thieme Verlag KG Stuttgart · New York.)

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by their member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. Registries in Health Services Research vary in their aims and research questions as well as in their designs, methods of data collection, and statistical analyses. This paper aims to provide both a methodological guideline for developers to ensure a high quality of a planned registry and, to provide an instrument for users of data from registries to assess their overall quality. First, the paper provides a definition of registries and presents an overview of objectives in Health Services Research where registries can be useful. Second, several areas of methodological importance for the development of registries are presented. This includes the different phases of a registry (i. e., conceptual and preliminary design, implementation), technical organisation of a registry, statistical analysis, reporting of results, data protection, and ethical/legal aspects. From these areas, several criteria are deduced to allow the assessment of the quality of a registry. Finally, a checklist to assess a registry's quality is presented., (© Georg Thieme Verlag KG Stuttgart · New York.)

This paper follows on from a previous study which assessed the relationship between socioeconomic position, empowerment and the development of psychological health in women after treatment in mother-child rehabilitation centres in Germany. The study revealed that socioeconomic position was less important for mothers caring for young children. For this reason the present study is based on a broader definition of social inequity, taking household conditions and psychosocial stressors into account. The aim of the paper is to answer the following questions: 1) To what extent does the improvement of psychological health depend on the living circumstances of the mothers? 2) What is the impact of living conditions on the success of empowerment? 3) Does the health-related impact of empowerment differ between different living conditions of the mothers? By conducting a cluster analysis on clinical data of the women (n=6094), seven different living circumstances of the mothers could be detected. Two living circumstances could be identified to be related to extremely poor health. These are 'dissatisfied single mothers with high degrees of psychosocial distress and lack of social support', and 'married mothers with conflicts within the family and self-perceived lack of appreciation'. At the end of inpatient treatment these mothers showed the highest reduction of psychological symptoms, but after six and twelve months the symptoms increased again. The results of empowerment showed that empowerment is most health-effective for mothers living in poor living conditions, but the success of empowerment here is less pronounced. As a consequence the health effect of empowerment was smaller for those mothers. The study suggests that health promotion programmes could be more effective when they explicitly take the living circumstances of their participants into account., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

Today's understanding of what health or well-being means often refers to certain ideals of activity and achievement. Lennart Nordenfelt's concept of health will be used to analyse and discuss this phenomenon. Furthermore, using the example of the ecclesiastical paper "God is a friend of life", we will explore if such conceptions of health also affect the teachings of the Christian churches., (Georg Thieme Verlag KG Stuttgart, New York.)

This paper explores the problem of dealing with normalisation in public health concepts, using the example of the relaunching of anti-aging-medicine in Germany. The analysis mainly draws upon qualitative analyses of publications of different anti-aging-medicine organisations. The German branch of anti-aging-medicine's new concepts of the nature, the morality and the self-design of aging are delineated. These are the concepts of aging as a medically controllable health risk (nature), the emphasis of the moral duty to responsible personal risk control (morality) and the self-design through individual risk profiles and prevention programmes. The analysis shows that the proposed bio-political programme cannot only be induced from biologically, societally or medically given facts, but that it is - as all public health concepts - a normative concept. It is argued that the normative aspects of public health concepts cannot be avoided but should be explicated and negotiated. This paper therefore concludes with an exploration of what there is to negotiate concerning the German anti-aging-physicians' surprisingly uncontroversial plea for a shift of emphasis from the collective right to health to a new individual duty for health maintenance in old age., (Georg Thieme Verlag KG Stuttgart. New York.)

On July 1, 2009, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2009; 71: 505-510]. This is an in-depth publication on "quality-of-life assessment in health services research". Within the context of the health sciences, quality of life (QL) encompasses the subjective well-being and functioning in the physical, psychological and social domains. QL informs about the aspects of health care that "actually get to the patient". QL is what patients primarily experience, what they talk about and what to a large degree affects the acceptance of health-care services and processes in the society. Therefore, QL can be considered as a highly important endpoint within health services research. The importance of the construct quality of life is also emphasised in German treaties on social law and utility analyses. This paper is the first account on the relations between health services research and the concept and assessment of QL. Our working group has specified key criteria for QL assessment within studies on health services research. (1) Assessment instruments need to comply with standard quality criteria (reliability, validity, sensitivity, interpretability) and the decision for a particular instrument has to be reasonably justified. (2) Study design and study population have to match with the scientific research question and the sample size has to be biometrically sound. (3) QL assessment including time points over the course of the study has to follow a standardized protocol. (4) Criteria for analysis and interpretation have to be prospectively specified. (5) Studies focusing on diagnostic/therapeutic issues need to specify standards for diagnostic criteria and related therapeutic interventions., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

This paper offers insight into the development and the standardisation of the social-pediatric screening, SOPESS. The screening was developed for assessing children's developmental stages in the context of the health examination for school entry in North Rhine Westphalia. As the cutoff date regarding age, time of school entry has been rendered flexible, health examinations are due up to six months earlier than before. The screening's theoretical basis is described, its development and standardisation are presented, and its psychometric properties reported., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

Purpose of the Study: The availability of licensed medication for children and adolescents depends on the frequency of clinical trials within this age group. In Germany legislation the framework for clinical trials was changed essentially in 2004 by the 12th amendment on the German Drug Code (AMG). This paper studies the changes in applications to the IRBs for clinical trials in adults and minors before and after implementation of the 12th amendment., Methods: In total four IRB were included in the study. All IRB were located in one German state, all were located at universities or medical schools. Two of the universities have a clinical research unit (CRU) funded by the German Ministry of Research, one of these CRUs has additionally a unit specialised on conducting trials with minors (PadNET). All data were assessed by the applications to the IRB between 2002 and 2006 and analysed by the number of applications, inclusion criteria (with minors or without) and the funding status (investigator initiated trials=IIT or funded by industry)., Results: The total number of applications was stable over the observation period (2002: 1192; 2006: 1231). The number of applications according German Drug Code showed no essential changes (2002: 484; 2006: 504). The number of applications for trials which included minors was low and remained on this low level (2002: 41; 2006: 28). Immediately before and after implementation of the amendment the number of applications increased or, respectively, decreased. IIT with minors constituted a higher proportion of all clinical trials with minors, but in total the number of IIT with minors was low., Discussion: The 12th amendment to the German Drug Code had only slight effects on the number of clinical trials in general and especially on the number of clinical trials with minors. Overall, clinical trial with minors make only a small proportion of all applications for clinical trials to the IRB in Germany. The EU regulation on medical products for children may cause an increasing number of clinical trials with minors in the future.

According to the Protection against Infection Act, public health services have been legally obliged to control the hygienic conditions in hospitals for many years. In the amendment of this act of 2001, ambulatory medical settings such as ambulatory surgical facilities, private medical practices, and dental practices have to be controlled as well. Since this increase in legal tasks has not been accompanied by an increase in staff in the public health services, new ways have had to be established to comply with these tasks. Prioritisation based on analyses of infection risks in the various ambulatory settings as well as feasible control strategies are mandatory. In most hospitals, hygienic personnel such as nurses for hospital hygiene, hygienists and standard operating procedures on hygienic measurements are available, so that new guidelines can easily be communicated between the public health department and the specialists and be implemented there. In ambulatory settings such as private practices, however, neither hygienic specialists nor appropriate organisation structures are available and time for studying guidelines and current rules is scarce. Thus, in order to achieve a maximum of hygiene in a minimum of time, public health services should offer lessons in hygiene for the personnel as well as a model of a hygiene plan and other information and facilities, that are easy to understand for non-specialists and easy to implement in practical settings. Examples of this strategy and data on its effect are given in this paper.

Periods of heightened vulnerability to weight gain have been identified, and research supports the notion that obesity has its origins in early life. Maternal overweight, maternal smoking during pregnancy, high or low birth weight, rapid growth in early infancy, and early adiposity rebound all have been implicated in the development of obesity. This paper focuses on susceptibility to increased overweight and adiposity during the prenatal period, infancy and mid-childhood, and on how factors operating in each of these periods by their timing and duration, and also whether other co-factors are present. The persistence of obesity from early childhood emphasizes the importance of understanding growth trajectories, and a developmental view on early risk factors of adiposity. A systematic review of early risk factors may help developing prevention strategies to overcome strong influences of obesogenic environments at young age.

Objective: This paper focuses on the current resolutions for quality reports of German hospitals as released in 2007 as well as on comprehensibility of these reports for patients. It is meant to analyse the textual information given by these quality reports. Its main objective was to attain a reliable assessment of their comprehensibility for patients on the basis of objective measuring methods. A further goal was to qualify eventual differences between large and small or private and public hospital operators. On the basis of the attained results conclusions on the appropriateness of the current legal situation and the existing criteria for quality reports were to be drawn., Method: The textual system part of 200 German hospital reports was analysed as published in the Internet (latest download 28th May, 2007). The selection took place by means of a controlled sample. The sample structure essentially corresponds to the German hospital system structure in terms of bed numbers and its ratio of public and private operators. The analysis measured all formal text patterns as well as technical terms by means of a computer-aided device. The readability index for each text was calculated according to all known readability formulas for the German language., Results: German hospital quality reports are readable only for those patients who dispose of above-average communicative skills. The analysed reports contain more than 10% technical terms while 17% of the chosen words and 60% of all sentences are too long. 10% of all sentences are too complex and 25% comprise more than three technical terms. To understand these texts at least an entrance qualification for higher education is required in accordance to readability indices. The texts' degree of complexity is comparable to that of philosophical papers. Most textual information given by German hospital quality reports is proven to be unreadable and incomprehensible for most patients. There are no fundamental differences concerning hospital size and operator., Conclusions: The reports' readability and comprehensibility for patients have only scarcely been considered in the current legal resolutions, and there is no undergoing process of improvement. The analysis has shown that there is in fact an urgent need for action. Future reports should therefore ensure that their textual content is formulated in a readable and comprehensible recipient-friendly manner. To enhance customer-oriented transparency within the German public health service patients should be able to fully understand what hospitals want to communicate. Therefore the further process of research will focus on the development of specific criteria for the production of textual reports. This has to be done in co-operation with patients and resident general practitioners.

The aim of this paper is to deepen our knowledge about empirical evidence of empowerment on the basis of follow-up data from mother-child rehabilitation centres. The study focusses on three questions: i) to what extent can psychological health in different socioeconomic groups be improved by the intervention?, ii) Is there an impact of social position on the success of empowerment and iii) Is there any relevance of empowerment for sustainable improvement of psychological health? The study is based on data from 6 095 patients of 39 mother-child rehabilitation centres in Germany, collected up to one year after intervention. Empowerment was assessed by two self-defined scales, measuring positive changes i) in living circumstances, such as partnership or household ('Verhältnis-Empowerment') and ii) in health-related behaviours and competencies, such as better coping with problems and higher health awareness ('Verhaltens-Empowerment'). Health status was assessed by psychological symptoms and measured by SCL-K-9, a short form of the SCL-90-R. The socioeconomic position was determined by cluster analysis, the influence of social position and empowerment for psychological health was computed by analysis of regression. Before intervention mothers from the lower class showed higher degrees of psychological symptoms. After intervention they reached higher short-term effects, but six months later psychological symptoms increased again. In particular improvement of health-related behaviours and competencies was associated with better psychological health. The highest impact on health was found among mothers from the middle and lower class. These mothers, however, showed less success in optimising health-related behaviours and competencies. Twelve months after treatment the health-related impact of empowerment decreased. The theoretical evidence of empowerment could be empirically confirmed. However, decreasing health effects of empowerment after twelve months show that supporting help after clinical intervention is necessary to maintain the positive impact of empowerment. Only small differences in empowerment between lower and middle class lead to the conclusion that terms of social class are less appropriate for the clinical sample of mothers investigated in this study.

Aim: Scientific research on empowerment so far is nearly exclusively focused on the adult population. Nevertheless, it is possible to show a link between empowerment and a) the developmental psychology concepts of resilience, b) autogenetic concepts and c) concepts of risks and resources. This paper aims to study the role of personal, familial and other social resources as well as personal autonomy for subjective health-ratings., Methods: A secondary analysis of the health data of 7,000 children and adolescents aged 10-17 years of the German health behaviour in school-aged children (HBSC) study as well as 1,700 children aged 11-17 years of the mental health module (BELLA Study) within the German health interview and examination survey for children and adolescents (KiGGS) was performed. Statistical analyses encompassed analyses of variance and linear regression., Results: Analyses of the HBSC study showed a protective effect for school-class climate as well as parental support, whereby school was associated with fewer self-reported health complaints. Analyses of the BELLA/KiGGS study showed personal, familial and other social resources as well as personal autonomy as unique predictors for a better health-related quality of life (KINDL-R). This was true even if psychological problems were observed., Conclusion: The results confirm the importance of strengthening personal, familial and other social resources as well as the principal importance of personal autonomy for coping with health risks and health impairments. Future research explicitly focussed on empowerment could relate to the role of personal resources within children's and adolescents' contact with the medical and health care system. It can be expected that strengthening personal resources benefits and improves the communication and active participation of children and adolescents within treatment-decision and -evaluation.

Breastfeeding is influenced amongst other aspects by the support of the medical staff in clinics. Therefore WHO and UNICEF have implemented the programme "ten steps to successful breastfeeding" and the certificate "Baby friendly hospital" to promote breastfeeding in clinics. When the study "Breastfeeding in Bavaria" was started only two clinics in Bavaria were certified as baby friendly. In a Bavarian region where breastfeeding rates were significantly lower than in other regions an intervention study will be conducted. The aim of the study is to educate the clinic staff in the support of breastfeeding mothers. This paper describes the aims and methods of this intervention study.

Background: The question of which factors influence return to work following medical rehabilitative measures in the case of chronic back pain is, in a social political context, of international significance. While psychosocial, socio-economic and demographic factors as well as subjective perceptions of working conditions are individually discussed, the role of social inequality has thus far received little attention., Objective: The present paper focuses on the occupational reintegration of patients with chronic dorsopathies following a medical rehabilitative intervention and aims to investigate the influence of predictor variables on successful reintegration., Methods: The re-analysis conducted was based on a three-year prospective controlled intervention study with three measurement sessions. The study comprised a sample of 289 patients aged 20 to 64 years who had undergone first-time intervertebral disc operations in the lumbar spine region. Data were collected between March 2002 and February 2005 using a standardized written questionnaire. Winkler's (1998) composite index comprising indicators of occupational position, income and education was employed as a measure of social inequality. Age and sex were also included as independent variables in a binary logistic regression analysis., Results: Of individuals undergoing rehabilitation, those from lower social classes returned to work later than those from higher social classes. Age and sex did not prove to be significant predictors of successful return to work., Discussion: The probability of successful reintegration into working life increases according to the position within the vertical structure of social class. In light of this result, it can be assumed that not only differential allocation of patients to rehabilitation interventions but also the specific contents of these interventions should be modeled on the basis of economic criteria.

The purpose of this study was to evaluate the impact of demographic changes on future health care expenditure of the German social health insurances considering the expenditures of survivors and decedents by age. The study analysed data from 269,646 members up to the age of 99 years of the AOK - one of Germany's largest social health insurers - in the State of Hesse in 2000/2001. In order to determine future health care expenditures, per-capita expenditures by age for outpatient, inpatient, rehabilitation, and nursing services of survivors and decedents (death within the next 12 months) were multiplied by the estimated number of survivors and decedents by age in Germany in 2020, 2035 und 2050. Expenditures for all ages were summed together. The paper shows that demographic changes until 2050 will lead to an increase of health care expenditures by 20% in total or less than 1% annually. Considering the future re-duction in workforce, demographic changes until 2050 will result in an estimated increase in health care expenditures per employee by about 57% (undifferentiated model). Considering the cost of survivors and decedents separately, this increase will amount to 50%. Hence, undifferentiated models overestimate the impact of demographic changes by about 10%.