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The aims of the population-based, cross-sectional survey "Study of Health in Pomerania" (SHIP) are to describe prevalences and distributions of a broad range of diseases, as well as environmental and behavioural risk factors in the region of Pomerania (North-eastern Germany). The examinations are performed in two study units by different physicians, technicians and interviewers and laboratory analyses in two separate laboratories. In addition, the study will take at least 3 years and approximately 7000 persons will be examined. Because of the design of the study a special concept of quality assurance is indispensable. In the present paper methods are presented for quality assurance and control in anthropometry, ECG, echocardiography, abdominal sonography, carotid ultrasound, sonography of the thyroid gland, blood pressure measurements as well as clinical laboratory analyses. The technical control protocols, the training programmes of the observers and methods to establish observer and method variabilities are presented by means of typical examples. The logistic, personal and technical measures for quality assurance and control require appropriate attention. The methods and procedures presented here are expected to provide an effective instrument to continually monitor the quality of medical examinations in the SHIP study.

The term assisted reproductive technologies (ART) describes all treatment procedures which include more than the natural intercourse to conceive. The most invasive procedure is intracytoplasmic sperm injection (ICSI), which was introduced in 1993. By ICSI the successful treatment of couples with severe male factor infertility, even in cases of azoospermia, became possible. In cases where only immature forms of spermatogenesis are present in the testicular tissue, pregnancies could also be achieved. The limiting factor with greatest influence on the success rate of ART procedures is the female's age. In this context the treatment of postmenopausal women by oocyte donation, as well as ooplasma donation to overcome the negative influence of the female's age on oocyte quality are extreme examples of ethically questionable ART procedures. Until now several 100,000 children worldwide have been born subsequent to ART and especially in vitro fertilisation. No increase in the malformation rate neither after IVF nor after IVF/ICSI have been reported so far. However, because of the lack of prospective controlled studies using standardised evaluation procedures and having enough statistical power to prove the security of ICSI for the newborn children, the German statutory health insurance bodies have ceased to pay ICSI costs as of July 1999. The data on the success of ICSI, the known data on the newborn and developing children and the decisions of the medical services of the German statutory health insurance bodies are presented in discussed in this paper.

Background and Aims: The paper informs about methods and field survey procedures used in the German National Health Interview and Examination Survey--Mental Health Supplement (GHS-MHS)--and provides 12-month prevalence estimates of affective, anxiety and somatoform disorders in the general population. Such data have previously not been available for Germany on a nationwide level., Methods: Findings are based on a two-stage design: In the first stage all the 7124 participants of the German National Health Interview and Examination Survey (core survey) completed the Composite International Diagnostic-Screener (CIDS) for mental disorders. In the second stage 4181 probands (all screen-positive and a random sample of 50% of the screen-negative subjects) were interviewed with the full Composite International Diagnostic Interview (DIA-X-M-CIDI) by clinical interviewers. The overall response rate was 87.6%., Results: Affective (12-months prevalence estimate: 6.3%), anxiety (9%) and somatoform disorders (7.5%) are widespread in all age groups (18 to 65 years) of the German population; women are significantly more often affected than men. The prevalence rates of somatoform and affective disorders were found to be significantly lower in the former East German Länder as compared to the former West, whereas no such difference was found with regard to anxiety disorders. All disorders resulted in considerable reduction of work productivity during the past month; affective disorders reported on average 1.3 days/month total impairment and 7.2 days/month partial impairment, indicated significantly higher reduction in work productivity than anxiety and somatoform disorders., Conclusions: Affective, somatoform and anxiety disorders are highly prevalent mental disorders (total: 17.3%) in the German population. The result of a lower morbidity of affective and somatoform disorders in former East Germany was unexpected and requires further clarification. The findings on impairment of work productivity emphasize the economic impact of psychiatric disorders on society.

The results of the German National Health Interview and Examination Survey will be of great importance for health policy and research. Therefore, internal quality management was supplemented by an external quality control which was carried out by a private company (Bernhard Schwertner Feld organisation, Augsburg). The interviewer training, sampling and response, field work and data management were included into the external quality control. For each of these four areas, measures of control and detailed check-lists were provided by the external quality control. The aim was to find sources of potential and real errors and to arrive at recommendations for internal quality management. The general concept of external quality control is briefly presented and experiences and results from the quality control of the field work are described in the present paper.

On April 26, 1986, a serious reactor accident occurred at the Chernobyl nuclear power plant. A total radioactivity of 2 x 10(18) becquerel, i.e. 3.5% of the reactor inventory were released spreading throughout Europe. Radioactive tracers were iodine 131 (with a half-life of 8 days) and caesium 137 (with a half-life of 30 years). Measurements made in Magdeburg by the Institute of Hygiene on May 5th after a heavy thunderstorm indicated a considerable radioactive contamination. Measurements revealed 75,000 bq/kg in grasses, 44,000 bq/litre in storm water and 40,000 bq/kg in garden soil, however, these high values decreased to normal by the end of 1986. The paper describes a stay in Chernobyl in 1989 and the environmental and working conditions prevailing at site. An increase of the cancer rate in the contaminated areas was not observed until 1990; however, thyroid tumours increased in children in Belorussia after that time. The current caesium load of the soils in the area is 10(6) becquerel/cubic metre. As much as 480,000 bq/kg were measured in dried mushrooms picked in the autumn of 1997. Assuming a mean natural exposure to radiation of the population in Germany of 2.4 millisievert/year (mSv/a), the additional load caused by the Chernobyl accident was 5% in 1986, falling to below 0.1% in 1996. Today, 19 nuclear power plants are operating in Germany for power generation. Radioactive substances are used in medicine, research and industry. An opinion on the safety of transports and final dumping of radioactive waste is given, based on a visit to the Morsleben final dump site. The use of nuclear energy and a percentage replacement by renewable energies are discussed from a regional and global perspective (climate protection).

A first approach to the word "social epidemiology" is provided by the two components social and epidemiology. They suggest that the social dimension of the distribution of morbidity and mortality should be analysed by means of epidemiological methods. The interest in this topic has risen considerably in recent years, but it is difficult to exactly specify the questions "social-epidemiologists" are analysing or should be analysing. That is why the "Social Epidemiology Working Group" is now reviewing the state of the art of social epidemiology discussions in the German-speaking countries. The overview shows the broad spectrum of social epidemiology topics, but also the difficulties in providing a clear definition. In a brief description of the Anglo-American discussion it is pointed out that social epidemiology have to deal with similar problems there, and that they classify their work as epidemiology rather than social epidemiology. The paper concludes with recommendations by the Working Group concerning the main topics and objectives of current socio-epidemiological research.

An instrument documenting the care process in in-patient psychiatric services within the German mental health care system has been developed (BADO). This paper reports on the development of a documentation system for all non-hospital based mental health services (day centres, community mental health centres, supported accommodation, work rehabilitation services for general adult psychiatric patients and people with substance misuse). The development process and the instrument (PC and paper and pencil version) are described. The documentation system (BADO-K) could be an important prerequisite for quality assurance in non-hospital based mental health care, and its structure ensures compatibility with the corresponding hospital-based documentation system.

The section 125 of the German Social Statute Book No. III (unemployment insurance) determines the conditions for an unemployed insured person who is unable to work due to a disease. Ascertainment of the existence of the medical conditions governed by section 125 is not only a task for the physicians of the unemployment insurance, it is also a task for the doctors of the pension insurance and of the health insurance. Hence it is very important that all medical experts of social insurances are in consensus in view of these medical requirements. In this paper the medical conditions for section 125 are described: The disease must be so serious that the unemployed insured person will be unable to return to work within the next six months. The inability to work will be continuous. In this case the unemployment insurance continues to pay unemployment benefit in spite of the inability to work until the pension insurance body agrees to pay a pension.

First of all the author gives a historical review of the importance of social work in public health service. The complementary cooperation between medical doctors and social workers is also described. The author then examines the activities of social workers in public health service on the basis of selected journals and the titles of these papers by graduates from medical "officer of health" courses of the Akademie für öffentliches Gesundheitswesen Düsseldorf. The results show that social work is still a part of counsel and care by the pubic health service. Offers for new target groups are suggested. Another important aspect is the cooperation with other interest groups such as resident doctors or institutions outside the public health office. Better presentation of the profession of social workers is also an important issue.

Secondary preventive measures to reduce cigarette smoking can be effective only if the motivation to change in the target population is taken into account. A useful model to match interventions to the readiness to change differentiates five stages: precontemplation, contemplation, preparation, action, and maintenance. In the USA, general population studies showed that 40% of smokers were in the precontemplation and contemplation stage, respectively, and 20% were in the preparation stage. In Germany, no data according to the distribution of stages among smokers are available; however, such data are necessary to plan population-based interventions. Data with respect to nicotine use, nicotine dependence, and the stages of change were assessed in a representative sample of 4075 respondents in Luebeck, a northern German city, and 46 adjoining communities in a face-to-face interview. The response rate was 70.2%. In this sample, 37.3% were cigarette smokers. Of those smokers with at least one attempt to reduce or quite smoking in the past, 76.4% were in the precontemplation, 17% in the contemplation, and 6.6% in the preparation stage. Including individuals without an attempt to reduce or quit smoking, 95.3% can be allocated to the precontemplation or contemplation stage. Nicotine-dependent smokers were in higher stages compared to smokers without dependence. Severity of dependence was not related to the stages of change. Data demonstrate that common smoking cessation programmes that require the individuals' readiness to change are inappropriate for 95% of the population. Stage-matched interventions are introduced and discussed in the paper. Compared to data from the USA smokers in Germany are more likely to be in early stages of change. Policy-based public health measures are necessary to change these findings.

This paper illustrates the possibilities and the evidential value of epidemiologic studies in combination with the pre-school screening examinations, which in Germany are mandatory for all children who are to attend school for the first time. Aspects of study design and study conduct are discussed primarily. We used two studies conducted in the city of Ulm in 1996 and in 1997. The aim of these studies was to investigate the prevalence, determinants and effects of Helicobacter pylori infection among pre-school children and their parents. Study subjects were all pre-school children in Ulm, a city in the South of Germany, who were screened for school fitness by physicians of the Public Health Service in 1996 and 1997, respectively. Infection status was determined by 13C-urea breath test. In addition, the parents of the children were asked to fill out a standardized questionnaire. In the 1997 study, the infection status of the accompanying parents was also evaluated by 13C-urea breath test. We present some selected results from the study of 1996. In total 945 out of the 1201 eligible pre-school children participated in the study (response rate = 79%). Overall, 127 children (13.4%) were infected with Helicobacter pylori. The prevalence varied between 6.1% in the children with German nationality to 44.8% in children with Turkish nationality and 24.8% in children with other nationality. In addition, we identified further determinants and investigated effects of the infection. The results of these studies demonstrate that epidemiologic studies combined with the mandatory screening examinations in pre-school children may be an important and feasible way to gain knowledge. The participation of the Public Health Service is of special advantage and allows to collect health related data in a efficient way.

This paper review examines whether there are health inequalities in terms of hospital admissions due to accidents in children and adolescents in Germany, and whether the social gradient varies according to age and gender. Analyses are based on information from a statutory health insurance North-Rhine Westphalia. The social structure of these insured persons does not correspond to the German population. Lower social positions are predominant while persons holding higher positions are under-represented and professionals are virtually absent. Data were compiled from hospitals, routinely transmitted from employers and from data collections by the insurance for accounting purposes. 47,427 records of children and adolescents below the age of 17 were included; altogether 4246 accidents were recorded. Hospital admissions following accidents showed a clear social gradient. The odds-ratio (OR) of children with an unskilled/semi-skilled background as compared to the highest occupational position considered was OR = 1.4. Social gradients differed by gender and age. The respective odds-ratio for the group below 6 years was OR = 0.9, for ages 6 to 10 OR = 2.2, and OR = 1.4 for ages 11 to 16. The interpretation of age-specific odds-ratios is impaired by low numbers of events in the highest status group. Girls had a lower rate than boys. With regard to accidents, children and adolescents who could not be classified according to their socioeconomic status were similar to the two lower status groups. These findings are comparable to results of the few international studies in this research area. They suggest the necessity of preventive efforts to reduce social inequalities in the lower status groups.

The introduction of statutory long-term care insurance into the German social security system led to connections and need of distinction between the different bodies providing benefits to severely disabled persons. In this paper, a general survey describes the different claims for these benefits based on expert assessment by the Medical Services of Statutory Health Insurance.

Faecal specimens from 1166 children and also from 143 educators in day-nurseries of Schwerin-City were analysed for intestinal parasites. Analsmeers from 1147 children and 137 educators were proved for the evidence of Enterobius vermicularis. The results are compared with those of an earlier paper covering the same subject. Résumé: The intestinal parasites found are disseminated mostly faecal-oral. These dirt- and smear infections are an indicator on hygienical short-comings in the facility concerned. There is a correlation between existing outside circumstances in the facility, infection rate of the children and subsequent exposure towards the educators. However, since reunification the quality of day-nurseries has clearly improved, the extent of investigated intestinal parasites has dropped significantly. No more can be spoken of a dangerous situation for the educators to become infected.

A study was started a) to assess the incidence self-poisoning in pre-school children and b) to evaluate the impact of an emergency set containing activated carbon and an antifoam. Cooperation was established with the regional legal sickness funds, the regional physician association, and two pharmaceutical companies. Incidence and extent of unintentional self-poisoning among pre-school children are to be determined. The impact of an emergency specimen given to parents of one year old children is evaluated. Families with children aged 1 to 4 year living in boroughs of Berlin are the population at risk. Study period for measuring the incidence is from January 1995 to June 1998. Cases are all accidents of poison ingestion by children of the at-risk-population. Intervention was performed between July 1995 and June 1996. The sets were handed out to parents of children born in 1994. 85% of the selected parents could be interviewed. It was studied whether the behaviour of parents in accidents of poisoning differed between those given an emergency set compared to those who had none. Data were mainly collected by telephone interviews. In this paper the theoretical aspects of the psychological effect of the intervention are discussed.

The structural changes in outpatient medical care in eastern Germany took place by far-reaching winding up of the outpatient departments. At the same time, many doctors from these institutions set up a practice. These changes also concerned the medical care by family doctors. It is assumed that as a result of these partly extensive changes there are also changes in the accessibility of the family doctor by outpatients. We will describe in this paper the level attained in Dresden, capital of Saxony in 1995 and 1996, from the point of view of the inhabitants. Existing problems are shown. In this connection, random samples of inhabitants of Dresden were interviewed by postal survey with questions on this subject in 1995 and 1996.

This paper reviews the ideas of Robert Koch in the context of infection surveillance of typhoid fever in Trier in 1902 and the actual epidemiological situation of infectious diseases in the world. The plan of the EC Commission for a network for surveillance and control of infectious diseases after the treaty Maastricht is presented. Definition, aim and critical points of infectious surveillance are discussed. Problem deficits in Germany associated with infection surveillance are also dealt with.

What should happen if children or adolescents refuse school? This may be due to phenomena such as school phobia, fear of school, playing truant, or a learning strike. The article demonstrates how an interdisciplinary team guided by the health authorities handles the problem of school refusal in the multifactorial field of tension of family, school and psychosocial dynamics. The present paper includes an analysis of school-related and sociological causes, a description of the legislative framework, an outline of possible treatments, as well as a discussion on aspects of prevention.

A central hypothesis in German family sociology is the observation of a disruption of family structures. If this disintegration prevails up to highest ages it must, among others, lead to an increasing inability to perform nursing care within families. The most important person in case of a need for nursing care is the spouse. The main topic of this paper is to determine whether demographic and familiar developments in Germany will increase or decrease the share of men and women at higher ages with a living spouse within the next decades. In spite of a slowly increasing share of the never-married and the divorced, on the average elderly men and women will be married to a greater and widowed to a much lesser proportion within the next decade. The Dutch LIPRO-model is used to calculate the exact numerical developments. The surprising result is primarily due to the fact that the actual high shares of the widowed are a consequence of distortions caused by the two World Wars. During the next few decades, these unusual developments will disappear even among the most elderly.

The paper starts by offering a short overview of the state of implementation of the 2nd stage of the newly introduced German Long-Term-Care-Insurance (Pflegeversicherung). It continues to present results of a detailed descriptive analysis of employee activities in (long-term-care-)nursing-homes, differentiating by severity of the patients' condition. Surprisingly nurses spend a large part of their time (40%) on other than nursing activities. The time spent with individual patients varies considerably with sex and the main diagnosis; thus significantly more time is spent on (basic and treatment-related) nursing care for male patients. Age per se does not appear to influence the time required for taking care of a patient.

For more than ten years policy makers and researchers in the field of health policy have been requesting the local health departments in Germany to focus primarily on population-oriented and structural strategies in health promotion. Based on empirical findings of a study carried out in Berlin, this article argues that several structural and organizational factors in practice influence the implementation of these strategies by the local health departments. These factors can constrain or enable the implementation of the strategies. The paper draws the conclusion that several requirements must be fulfilled for the local health departments to define themselves in health politics and policy. More than ever, the definition of their tasks and targets needs to be linked to questions of organizational change and personnel. Moreover, the local health departments should define their role more clearly in relation to the other institutions in the sector of public health and in relation to the citizens.

Regional population forecasts are on average even more uncertain than nationwide projections, due to the greater importance of migration and the unstable smaller absolute numbers. Other than national projections, local or regional calculations do normally have an explicit goal. In this paper, a projection of the population and age structure in the region of Augsburg is used to demonstrate some specific aspects of local population projections used for public health purposes. If institutions of childhood ages are to be projected the results are primarily determined by the assumptions on migration. If questions of old age are to be answered, the main factor of influence is the development in mortality. Depending on the specific alm of a local population projection, the principal insecurity about the future should be integrated by calculating confidence bands for those demographic parameters, that are most important for the specific question.

The rise of social hygiene in Mecklenburg before 1945 is described via examples of three scholars of the Rostock University (Julius Uffelmann, Hans Reiter, Werner Kollath). By contextualising this rise, the paper attempts to demonstrate both the transformation of medical items into disciplines and the change of social values of illness and health. This was accompanied by an increasing dissemination of medical-biological values and concepts, from which eugenics emerged and subsequently served as a general model for constructing a well-organised and developing society. Thus a growing number of social disciplines became subjected to these ideas.

As a further step towards quality management in environmental medicine the Hamburg Association of Panel Physicians and the Hamburg Department of Labour, Health and Welfare developed a consensus paper concerning the handling of indoor related problems. It focuses on the cooperation between environmental physicians and engineers. A critical point in the process of environmental health risk assessment is the selection of either human biomonitoring or environmental monitoring. Further well-known problems are quality of measures and process documentation. Accurate, reliable measures of individual exposure are an essential need for physicians who have to judge the potential impact of environmental contaminants on human health. The approach proposed in this paper was chosen to enable the patient and the physician to benefit from the special knowledge of environmental engineers on indoor related problems. The procedure and criteria might help to reduce misclassifications of diseases and the amount of measures with no medical relevance and to establish scientifically valid associations between health outcomes and exposures to environmental contaminants.

The Munich Community Health Service (Medical School-Service Department) conducted an alcohol prevention project in ten public secondary schools. The 423 pupils (11-17 years of age) filled in a questionnaire on alcohol and discussed it afterwards under the guidance of a school physician and a teacher using guideline information. The results of the survey are presented in this paper. Additionally, suggestions for transferring the results to conceptualize and carry out preventive measures are made. The results indicate that the first experience with alcohol occurred early in life. One-fifth of the sample had already tried alcohol at the age of six. Immediate effects of alcohol (e.g. state of drunkenness) were experienced by 35.7 percent of the sample group. Kiosks, shops, and beverage stores were named most frequently as sources for alcohol. The sources of social support varied with respect to sex and age. With increasing age of the children, parents were contacted less frequently whereas the role of peers increased. The present results supply possible paths of action for the development of successful prevention strategies, e.g. by pointing out the early age of onset as well as specific sources of alcohol acquisition.

In a state of the art paper a four step approach is made in order to investigate the question why public health research is necessary at all. 1. Expectations concerning public health research: The classical topics of public health research will continue to be relevant. Additionally, health promotion especially for low income and other risk groups should become important. For this purpose public health should try to relate to politics. Considering available resources and the quality of services goals should be determined as regulative criterias for the health system. Public health research will only remain relevant in the future if it turns from the traditional approach of public health medicine to what is called the new public health paradigm and if it adds the system approach to the population approach. 2. Target groups of public health research are policy makers and institutions as well as persons in the health care system. It has to be checked if these target groups are reached. Policy impact is more important than science impact. 3. Expectations to public health research concern the transfer of public health into other areas of science, the establishment of new institutions and teaching programmes and its inter-disciplinarity. Deficits exist in the selection of relevant topics and in the innovative power of projects. 4. Proposals for further public health actions refer to politically dominant issues which are to be defined by consensus conferences.

The term "epidemiological absenteeism trend"-especially as used in Germany-was defined by Wagner in 1977 and has since entered the sickness-absence discussion as an outcome indicator of medical rehabilitation. In its key concepts, the term refers to the fact that although there is a constant trend in absenteeism over time, individuals show changes in absenteeism from one measurement to the next. Evaluations of those individuals who have very high (or low) absence rates change to a higher degree than do those of individuals with mean scores on the absenteeism index; nevertheless, the summation of all deviations will be zero. In evaluating absence reduction due to rehabilitation, this fact must be considered. Because people who take part in medical rehabilitation show high absenteeism before they start its intervention, there will be--according to Wagner's absenteeism trend--a higher rate of reduction in sickness absence in the time following rehabilitation than there will be for people with medium scores. This paper investigates the hypothesis that the epidemiological absenteeism trend is identical with Galton's discovery--roughly 100 years before Wagner's definition--generally referred to as "reversion". Galton developed this term as the fundamental concept for regression and correlation. It can be shown that the absenteeism trend does not give a special description of sickness-absence but is rather the results of applying regression analysis. With the help of the statistical method of log linear modelling, a re-analysis of Wagner's data is performed in which the term epidemiological absenteeism trend is not necessary. In consequence, it is argued that this term should be abandoned or given a new meaning.

Subject of this paper is methadone-maintenance given by the office-based physicians in Germany within the framework of the statutory health insurance (SHI). Results of a survey of the associations of SHI-accredited physicians are presented, comprising the number of substituted patients, the distribution of indications and the number of physicians engaged in this field. The increasing trend in the number of substituted patients continues, although less steeply. Strongholds of methadone maintenance are still the cities of Hamburg, Berlin, and Bremen, where the highest rates of substituted patients were found in relation to the resident population. The method of data-gathering used trends to overestimate the number of substituted patients. Comparing the determined numbers with different data sources, the actual number of addicts who are substituted in the longer term at the cost of the SHI is estimated to be 10 000 patients.

In Germany, the discussion on the pros and cons of rationing health care services in the statutory health insurance funds has just begun, but it will probably be of great importance in the years to come. Until now, it is mainly a political discussion with only very few researches participating. In order to enhance the matter-of-factness in this controversial debate, the experiences in the USA with rationing health care services are summarised, and in the second part a more general discussion is added on different forms and consequences of rationing. The present discussion in Germany is outlined in the third part of the paper. In our own evaluation two arguments are stressed: Firstly, the central argument that rationing of health care services is inevitable because health care costs are "exploding", has as yeb no firm empirical and theoretical basis. Secondly rationing by taking medically useful benefits from the schedule of benefits in the statutory health insurance funds is not compatible with the ethical principles governing these funds.

This paper deals with the establishment of the National Breastfeeding Committee at the Robert-Koch-Institut and its activities. As the highest level scientific and advisory board for the German Federal Health Ministry the institute obtained permission from the state authorities to carry out a survey of the local health offices. A finding of this survey was that the different health offices apparently place different priorities on advising mothers in regard to breastfeeding. Some health offices offer medical counselling and others indicate that their counselling is carried out by non-medical personnel. In some cases the health offices reported a supply but no demand. We believe that the public health services should at least provide information on breastfeeding counselling in the community and on training opportunities for counsellors. The National Breastfeeding Commission will collect such information and provide it to the health offices and also give advice in the case of problems with regard to breastfeeding.

Self-help groups strengthen an individual's sense of autonomy and self-determination, and help to recover from diseases and other health-related problems. Participants mutually support each other within the group to promote a healthier approach to socio-psychological issues; they also conduct activities outside the group, especially counselling services for peers dealing with similar problems. In recent years, the number of groups throughout Germany rosen to approximately 60,000. The groups are mainly supported by self-help clearinghouses which have sprung up in many regions of western and eastern Germany over the last few years. This paper provides an overview of the development of self-help groups as well as the current state of support and funding in this area. Furthermore, it describes in detail the work performed by clearinghouses and the possibilities for cooperation with these new "liaison institutions".

In this paper, we present the first study on the inter-rater reliability of a standardised examination of functional disability, employed by the medical service of the German statutory health insurance system ("Medizinischer Dienst der Krankenversicherung", MDK). 215 elderly adults (mean age 84) living in 6 nursing homes in Munich were included in the study. They were assessed by three medical students and two nurses of the respective nursing homes using the standardised questionnaire of the MDK. Inter-rater reliability of both a summary judgement of disability and of single items, such as impairments in activities of daily living, was assessed by kappa-coefficients. Inter-rater reliability was higher for the overall assessment of disability (kappa = 0.82 between nurses, kappa = 0.57 between medical students) than for most single items. Reliability was particularly low for some items on mental status (such as "restlessness") or perceptions (particularly visual perception) which require clearer definition. This pattern was consistently observed for the two types of comparisons (inter-students, nurse-nurse) and for different subgroups of the study population.

Court decisions of the Federal Court for Problems of Social Welfare (Bundessozialgericht) make health insurance pay for unconventional methods under certain circumstances. Physicians of the Health Insurance Medical Service (MDK) have to examine whether these conditions are fulfilled in a special case. The specific problems they encounter there are being described in this paper. Hermeneutic differences can be noticed. To guarantee the quality of medical care, which is the duty of the statutory health insurances, seems to be difficult in the case of "unconventional" medical methods.

The concept of "disease of civilization" is commonly used for a variety of conditions. It implies a criticism of the "modern" way of life. This criticism and the strategies put forward to prevent diseases of civilization are correlated to the specific historical context in which they are formulated. The paper analyses three positions characterising different periods in 20th century German history: In the Weimar Republic, representatives of paediatrics and social hygiene asked for the expansion of public health care programmes according to the principles laid down by the Weimar constitution. During the time of National Socialism, more radical measures were propagated by exponents of hygiene and psychotherapy, aiming at a fundamental restructuration of society in accordance with the Nazi ideology. After 1945, strategies focused on the individual: Physical exercise, abstinence, and individual psychotherapy were propagated to prevent or treat the consequences of life in modern society.

In two counties (Dithmarschen and Nordfriesland) of the Federal State of Schleswig-Holstein (in the northern part of Germany) the cancer mortality rates, especially those of stomach and colon cancer, were evaluated for the time period 1980-1991. For this purpose the corresponding death certificates collected in these counties were analysed. The counties were subdivided into 16 and 17 smaller areas, respectively. The age-adjusted mortality rates were calculated and the obtained data scaled into eight sections, which were graphically mapped over the smaller areas of the two counties. The frequency of these cancer mortality rates reflects a wide range of distribution pattern in the smaller areas of the two counties, which greatly differ from the cancer mortality values calculated for the two counties as a whole. In comparison with the frequency of stomach cancer mortality for men published in the German Cancer Atlas in 1984 it could be demonstrated that this cancer mortality further decreased in these counties. However, in some smaller areas of these counties, especially in rural areas, the mortality rates of stomach cancer in men were still rather high. The opposite seems to be reflected regarding the frequency of colon cancer mortality. Here higher frequencies of mortality were seen in the small cities of these counties. We suggest that a more subtile cancer mortality mapping can be performed easily without any risk of hurting the requirements of personal data securities, because cancer mortality data are already continuously evaluated by a trained staff at the offices of statistical affairs. These data may be transferred and used for cancer mortality mapping as described in the present paper. In order to guarantee that there will be no violation of personal data secrecy the cancer mortality mapping must be restricted to cancer sites with high frequencies of mortality. All published data should be supervised by an official with special knowledge of the requirements of personal data protection. This study underlines the necessity for higher resolution (smaller areas) in cancer registries as essential prerequisite for systematical exploration of the origins of cancer mortality and as a basis for preventive measures.

Health impact assessment (HIA) is defined in this paper as the adequate coverage of health aspects within the context of environmental impact assessment. HIA is a typical task for the public health service. A project on HIA undertaken by the North Rhine-Westphalian Research Compound for Public Health found out that presently the opportunity to use HIA for preventive health purposes is still largely neglected. However, in a survey local health departments expressed great interest in receiving HIA-training. A workable concept and supporting tools are both necessary prerequisites for the practice of HIA becoming routine. This paper presents a ten step HIA-conceptl. Supporting tools are presently under development and testing.

Public Health is a social innovation of the modes how society deals with health risks before and after their occurrence. In this paper the essence of this innovation is sketched out with regard to the four stages of the Public Health Action Cycle (assessment, policy formulation, assurance, evaluation). Based on both literature surveys and own research findings several critical aspects of innovation are identified at each of these stages. At present, the bottle-neck of the intended social innovation seems to be the implementation, stabilisation, and generalisation of interventions.

This article is based on a study using different approaches to examine the links between urban development on the one hand and health promotion on the other. The background and basic concepts underlying this study are briefly explained. Programmatic papers from both spheres of approach result in the basic thesis that both urban development and health promotion are aiming at improving the quality of life in city districts (objective conditions of living and subjective feeling tone, i.e. subjective well-being) in the overall sense of a health-promoting general policy. Because of these common goals cooperation between both spheres is hypothesised. However, the study as a whole shows (especially an analysis of the documents of the files of the sanitation committee) that this is not so. To understand this finding better the freedom of both parties concerned to act as they should, is analysed, namely, that of the sanitation committee and of the regional health and environmental office. It becomes evident that in both these spheres the requisite monitoring capacities, such as legal support, finances, information service and counselling activities, are fundamentally lacking or indeed limited. Hence, there are limited chances of success in the spheres of health promotion and preventive care by means of sanitation of city districts. Finally, the authors point to long-term trends and developments that would make a future approach between the two spheres mandatory and (at least partially) possible.

In a period of transition from industrial to post-industrial society with its focus on the service and information sector the nature of work is changing as well as the impact of work on human health. This paper describes leading concepts which were developed in social sciences to better account for this impact, especially so the so called job strain model. Moreover, it gives a selective, but representative review of recent empirical findings based on these concepts with coronary risk and disease as main outcome criteria. Finally, the paper discusses practical implications with regard to public health: preventive measures which aim at structural rather than individual intervention. The main focus of these measures is on work organisation and manpower policy.

This paper gives a short presentation on some of the difficulties a public health officer has to face concerning questions of town-planning. The focus is on giving an expert opinion on development plans. It may be said that the public health service and "health" often play minor roles in town planning. The article presents some suggestions for a change of this situation.

According to the Federal law concerning the prevention and control of epidemics (Bundes-Seuchengesetz) and according to the third enforcement law about the standardisation of the public health system (Dritte Durchführungsverordnung zum Gesetz über die Vereinheitlichung des Gesundheitswesens) it is incumbent upon the local Public Health Authorities to supervise the sewage treatment plants within their respective administrative district. In practice, that task is hardly ever realised since it is often not clear exactly which hygienic aspects should be checked and what the benefit of such supervision could be. The following paper is an attempt to make suggestions how to carry out such supervising activities in practice. Furthermore, the paper shows the results of the 1993 supervising activities in the sewage treatment plants in the Limburg-Weilburg area. This is illustrated on the basis of the checklist which has been developed at the public health office of Limburg.

An irresponsible "approval on request" in favour of waste incineration written by a consulting committee of the German Federal Board of Physicians has meanwhile been widely distributed both nationally and internationally. The aim of this politically motivated paper is to dramatically increase the present number of 49 waste incinerators in Germany. It is our duty to warn of this intention. Health problems are known to exist both in workers at waste incinerators and in humans living in their vicinity. Furthermore, in the long run negative impact also to ecosystems should be expected from the emissions. Health problems in patients living downwind of waste incinerators repeatedly have been reported on by physicians. "Lack of statistical significance", often used as counter-argument, is only due to absence of funding of comprehensive epidemiological studies in Germany. Analyses of soil samples reveal the pollution from waste incineration. Considering the pre-load of the region, additional emissions caused by waste incineration and other sources have to be assessed. The application of preventive limit values is imperative. The presently used "limit values", being about 100 times too high, bear an unacceptable risk. Therefore, reliable regional registers of emissions have to be established immediately. Limit values continuously have to be adjusted to the progress of scientific knowledge. In this respect it is imperative to consider that the actual composition of emissions is unknown; isolated risk assessment of single compounds underestimates the total risk; the negative impact, e.g. of dioxins, on both the immune and hormone systems occurs at concentrations 100 times lower than those causing carcinogenic effects; the assumption of "threshold values" is obsolete; a considerable lack of knowledge exists about accumulation in food webs and in ecosystems; the demand of preservation of natural, geogenic situations is indispensable in assessments of soil and water pollution. Essential prerequisites for risk assessments of emissions from waste incineration are 1. actual, continual and comprehensive qualitative and quantitative analytical knowledge of the composition of emissions; 2. region-specific meteorologic dispersion models of the emissions; 3. evaluation of the complex mixtures in emissions for their kinetics in and toxicity for ecosystems and humans. Neither of these demands is so far fulfilled. Facing these problems, the present propagation of waste incineration must be stopped. As an alternative, efforts to optimize waste-avoiding and recycling concepts considerably have to be reinforced, and low-risk procedures, like compost and other decomposing methods, hydrogenation or freeze-griding of plastics, have to be widely promoted.

While looking for enough living quarters for the town people regional planners are often confronted with high levels of noise due to traffic, highways and railways near the planning area. This may change or even stop the procedure of town planning. Generally, health authorities--who are more or less involved in the process of planning--should take the chance to demand compatibility of special planning with health care regarding noise. However, most guidelines on health-compatible noise levels are not legally binding. This paper describes the variety of health problems accompanied by moderate to high levels of noise. In regions with traffic noise problems efforts should be directed at maximum health compatibility coupled to highly imaginative planning. It is suggested that levels of noise of 55 dB(A) (daytime) and of 45 dB(A) (nighttime) should be tolerated near to the building. This would ensure tolerable levels of noise of 35 dB(A) (daytime) and of 30 dB(A) (nighttime) in the dwellings. Examples of different arrangements of buildings are shown. They demonstrate that these tolerable noise levels could even be observed in areas with traffic problems. It mostly depends on the planner's imagination whether the need for dwelling houses in problem areas could be met in keeping with health demands.

In 1990 in Germany for the first time more than 100,000 cases of enteric infections (mostly salmonella enteritidis) were registered. The incidence is still increasing. As only one of ten cases is reported the yearly overall loss to general economy is estimated up to DM 600,000,000. Many hypotheses on causes were suggested but none could be verified (e.g. mass-breeding of animals, modernistic habits of eating and drinking, introduction of microwave-cooking, deterioration of hygiene in kitchens, insufficient cooling of food). This paper reports on the result of retrospective interviews with regard to food- and kitchen-hygiene of persons suffering from salmonellosis during an epidemy in Lübeck in autumn 1990. As no systematic violations of rules of hygiene could be detected we concluded that in future prevention and research should again be concentrated especially on the control of animal feed imports, poultry breeding, cooling and technical processing of eggs and garbage-sanitation. In Sweden consistent elimination of infected poultry stock showed effect. In the Federal Republic of Germany more drastic steps in regard of planed EC-Guidelines on the control of zoonoses are demanded.

The spectrum of diseases affecting today's children and adolescents has changed. Today's urgent health problems are no longer acute and infectious disorders but much rather psychosomatic and chronic disorders. However, the present health delivery system has not adapted its structure to this changed spectrum of disease. This paper reports on a study carried out by the project "Health Risks and Structures of Medical and Mental Health Care." The project belongs to the North Rhine-Westphalian Consortium for Public Health, and the study was carried out in cooperation with the Special Research Unit 227: "Prevention and Intervention in Childhood and Adolescence." Results show that a small proportion of adolescents actually consult general practitioners. Inadequate cooperation between medical and mental health care services as well as insufficient links between these services and the life world of adolescents have led to a situation in which the use of professional assistance meets with barriers. As a result, adolescents continue to avoid visiting a physician even when they have already become ill. For this reason, there is an increasingly strong need to consider how to change the structures of medical and mental health care. Proposals are developed that meet the needs of adolescents and are oriented toward the requirements arising from the changing spectrum of disease.

This paper presents update fundamentals of the legislation and the current status of the supervision of hospitals by the public health service of Nordrhein-Westfalen. Based on this, a hospital check list is proposed by the department for the supervision of hospitals with the District Officer at Arnsberg.

The situation of the elderly during the Third Reich has hitherto been neglected by research. This paper deals with the living conditions and the fate of the aged in institutional homes in Saxony. Those no longer able to care for themselves were subjected to the aggressive social and military goals pursued by the National Socialists and were victimized in the organisation of medical care. Many conditions contributed to the destruction of their lives: not only the emptying of homes for the elderly to make room for military hospitals, disorienting relocation programmes, and the murderous "T4" programme, but also the death of children during the war, the destruction of property and the loss of a home due to forced dislocation.

This paper presents the different concepts of realisation of the currently existing counselling institutions in Germany and ambulances for environmental medicine. It is based on the specific conceptual papers, reports of the ambulances and an inquiry with 20 counselling institutions and ambulances conducted especially for this purpose. From the noted special characteristics a typology of the "ambulance approach" is derived especially with regard to its place in larger institutions, theoretical concepts, specific contents, way of working, diagnostic as well as counselling requests, and usage frequencies. Basic differences exist between research and service projects and between the more general environmental medical services, the special wards in the framework of larger clinical departments (e.g. in dermatology, gynaecology and neurology) and the resources of the departments of occupational medicine. In addition, definite differences exist concerning the number of personnel and equipment, analytical and diagnostical possibilities, data assessment, data documentation, data processing and reporting. Current efforts of standardisation of documentation are presented as well as concepts for a better connection of environmental medical ambulances with physicians' private offices, hospitals, public administrations and laboratories.

In Germany the quality of drug therapy suffers from the lack of transparency of an overloaded drug market, from the turnover-oriented information strategies of the pharmaceutical industry and from the lack of prescribing transparency and quality control of the individual doctor. After an analysis of the present deficient situation in the area of drug therapy the following paper discusses strategies to improve structure as well as process quality. It also stresses the necessity of implementing a legal framework to analyse individual patients' records aimed at controlling the quality of therapy. Because of problems with confidentiality continuous patient record linking is not allowed although it is a precondition for an adequate control of the patients progress and the quality of results.

This paper provides projections of incident cases of malignant neoplasms in Saarland, Germany, between 1988 and 2002. The analyses are based on population forecasts by the National Statistical Office and on age-cohort analyses of cancer incidence data from the population-based cancer registry of the Saarland. Due to dramatic demographic changes and increasing age-specific cancer incidence rates, the average yearly number of total incident cases of malignant neoplasms is projected to increase by 63.1% between 1983-1987 and 1998-2002 in men, with the strongest increase projected for colon cancer (+114.6%). In women, a modest increase (+7.1%) is projected for all malignant neoplasms, with stronger increases for colon cancer (+50.1%), lung cancer (+44%) and breast cancer (+27.4%), whereas decreasing annual numbers of cases are projected for cervical cancer (-51.6%), stomach cancer (-18.5%) and endometrial cancer (-10.2%). The results provide a quantitative basis for health care planning in the Saarland. They may also serve as a rough guide for other parts of Germany for which reliable cancer incidence data are not available.