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Background: There is a growing awareness of the need to adequately integrate sex and gender into health-related research. Although it is widely known that the entangled dimensions sex/gender are not comprehensively considered in most studies to date, current publications of conceptual considerations and guidelines often only give recommendations for certain stages of the research process and - to the best of our knowledge - there is a lack of a detailed guidance that accompanies each step of the entire research process. The interdisciplinary project "Integrating gender into environmental health research" (INGER) aimed to fill this gap by developing a comprehensive checklist that encourages sex/gender transformative research at all stages of the research process of quantitative health research. In the long term this contributes to a more sex/gender-equitable research., Methods: The checklist builds on current guidelines on sex/gender in health-related research. Starting from important key documents, publications from disciplines involved in INGER were collected. Furthermore, we used a snowball method to include further relevant titles. The identification of relevant publications was continued until saturation was reached. 55 relevant publications published between 2000 and 2021 were identified, assessed, summarised and included in the developed checklist. After noticing that most publications did not cover every step of the research process and often considered sex/gender in a binary way, the recommendations were modified and enriched based on the authors' expertise to cover every research step and to add further categories to the binary sex/gender categories., Results: The checklist comprises 67 items in 15 sections for integrating sex/gender in quantitative health-related research and addresses aspects of the whole research process of planning, implementing and analysing quantitative health studies as well as aspects of appropriate language, communication of results to the scientific community and the public, and research team composition., Conclusion: The developed comprehensive checklist goes beyond a binary consideration of sex/gender and thus enables sex/gender-transformative research. Although the project INGER focused on environmental health research, no aspects that were specific to this research area were identified in the checklist. The resulting comprehensive checklist can therefore be used in different quantitative health-related research fields., (© 2024. The Author(s).)

Background: Physical and social neighbourhood characteristics can vary according to the neighbourhood socio-economic status (SES) and influence residents' perceptions, behaviours and health outcomes both positively and negatively. Neighbourhood SES has been shown to be predictive of mental health, which is relevant for healthy ageing and prevention of dementia or depression. Positive affectivity (PA) is an established indicator of mental health and might indicate a positive emotional response to neighbourhood characteristics. In this study, we focussed on the association of neighbourhood SES with PA among older residents in Germany and considered social integration and environmental perceptions in this association., Methods: We used questionnaire-based data of the ongoing population-based Heinz Nixdorf Recall Study for our cross-sectional analysis, complemented by secondary data on social welfare rates in the neighbourhood of residents' address. PA was assessed using the Positive and Negative Affect Schedule (PANAS) in 2016. Linear regression models were performed to estimate the associations and adjusted for socio-demographic variables., Results: Higher social welfare rates were associated with lower PA scores. The strongest negative association from the crude model (b = -1.916, 95%-CI [-2.997, -0.835]) was reduced after controlling for socio-demographic variables (b = -1.429, 95%-CI [-2.511, -0.346]). Social integration factors (b = -1.199, 95%-CI [-2.276, -0.121]) and perceived environmental factors (b = -0.875, 95%-CI [-1.971, 0.221]) additionally diminished the association of social welfare rates with PA in the full model (b = -0.945, 95%-CI [-2.037, 0.147])., Conclusion: Our results suggest that neighbourhoods have an influence on the occurrence and the extent of PA. Public health interventions that address socio-economic disadvantage in the neighbourhood environment could be an effective and far-reaching way to reduce the risk of depression and depressive symptoms due to low PA in older residents., (© 2022. The Author(s).)

Background: Having destinations within walking distance can encourage older people to walk. Yet, not all destinations may be equally important. Little is known about the types of destinations fostering older adults' walking for transport in small and medium-sized towns and rural communities. The aim of this study was to explore the associations between the availability of different destinations and walking for transport among older adults living in communities with less than 100,000 inhabitants., Methods: Between May and September 2019, self-reported data from 2242 older adults (≥ 65 years) living in the Metropolitan Region Northwest (Germany) were collected within the project AFOOT - Securing urban mobility of an aging population. Data from 2137 study participants were eligible for this analysis. Logistic regression models were used to investigate the relationship between the perceived destination availability of 19 different destinations within a 20-min or 10-min walk from home, respectively, and the engagement in walking for transport. Crude and adjusted models were run separately for each destination and distance category. Exploratory subgroup analyses examined the associations between the availability of destinations within a 20-min walk from home and walking for transport stratified by gender, use of a walking aid, and car availability., Results: The availability of each of the investigated destinations within a 20-min walk and of nearly all of these destinations within a 10-min walk from home was significantly positively associated with walking for transport in crude models. Most associations remained significant after adjustment for covariates. The strongest associations were found for the availability of small stores, pharmacy, and bakery. The availability of a bus stop showed the weakest associations and was not significantly associated with walking for transport after adjustment for covariates., Conclusions: The provision of local amenities within walking distance may be a promising approach to foster older adults' walking for transport in smaller communities with less than 100,000 inhabitants and to enable active and healthy aging in place. Further quantitative and qualitative research is needed to validate these findings and to better understand older adults' walking behavior., (© 2022. The Author(s).)

Background: Daily vegetable intake is considered an important behavioural health resource associated with improved immune function and lower incidence of non-communicable disease. Analyses of population-based data show that being female and having a high educational status is most strongly associated with increased vegetable intake. In contrast, men and individuals with a low educational status seem to be most affected by non-daily vegetable intake (non-DVI). From an intersectionality perspective, health inequalities are seen as a consequence of an unequal balance of power such as persisting gender inequality. Unravelling intersections of socially driven aspects underlying inequalities might be achieved by not relying exclusively on the male/female binary, but by considering different facets of gender roles as well. This study aims to analyse possible interactions of sex/gender or sex/gender related aspects with a variety of different socio-cultural, socio-demographic and socio-economic variables with regard to non-DVI as the health-related outcome., Method: Comparative classification tree analyses with classification and regression tree (CART) and conditional inference tree (CIT) as quantitative, non-parametric, exploratory methods for the detection of subgroups with high prevalence of non-DVI were performed. Complete-case analyses (n = 19,512) were based on cross-sectional data from a National Health Telephone Interview Survey conducted in Germany., Results: The CART-algorithm constructed overall smaller trees when compared to CIT, but the subgroups detected by CART were also detected by CIT. The most strongly differentiating factor for non-DVI, when not considering any further sex/gender related aspects, was the male/female binary with a non-DVI prevalence of 61.7% in men and 42.7% in women. However, the inclusion of further sex/gender related aspects revealed a more heterogenous distribution of non-DVI across the sample, bringing gendered differences in main earner status and being a blue-collar worker to the foreground. In blue-collar workers who do not live with a partner on whom they can rely on financially, the non-DVI prevalence was 69.6% in men and 57.4% in women respectively., Conclusions: Public health monitoring and reporting with an intersectionality-informed and gender-equitable perspective might benefit from an integration of further sex/gender related aspects into quantitative analyses in order to detect population subgroups most affected by non-DVI., (© 2021. The Author(s).)

Background: Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration., Methods: The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis., Results: The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status., Conclusions: To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.

Background: Behavioural interventions may increase social inequalities in health. This study aimed to project the equity impact of physical activity interventions that have differential effectiveness across education groups on the long-term health inequalities by education and gender among older adults in Germany., Methods: We created six intervention scenarios targeting the elderly population: Scenarios #1-#4 applied realistic intervention effects that varied by education (low, medium high). Under scenario #5, all older adults adapted the physical activity pattern of those with a high education. Under scenario #6, all increased their physical activity level to the recommended 300 min weekly. The number of incident ischemic heart disease, stroke and diabetes cases as well as deaths from all causes under each of these six intervention scenarios was simulated for males and females over a 10-year projection period using the DYNAMO-HIA tool. Results were compared against a reference-scenario with unchanged physical activity., Results: Under scenarios #1-#4, approximately 3589-5829 incident disease cases and 6248-10,320 deaths could be avoided among males over a 10-year projection period, as well as 4381-7163 disease cases and 6914-12,605 deaths among females. The highest reduction for males would be achieved under scenario #4, under which the intervention is most effective for those with a high education level. Scenario #4 realizes 2.7 and 2.4% of the prevented disease cases and deaths observed under scenario #6, while increasing inequalities between education groups. In females, the highest reduction would be achieved under scenario #3, under which the intervention is most effective amongst those with low levels of education. This scenario realizes 2.7 and 2.9% of the prevented disease cases and deaths under scenario #6, while decreasing inequalities between education groups. Under scenario #5, approximately 31,687 incident disease cases and 59,068 deaths could be prevented among males over a 10-year projection period, as well as 59,173 incident disease cases and 121,689 deaths among females. This translates to 14.4 and 22.2% of the prevented diseases cases among males and females under scenario #6, and 13.7 and 27.7% of the prevented deaths under scenario #6., Conclusions: This study shows how the overall population health impact varies depending on how the intervention-induced physical activity change differs across education groups. For decision-makers, both the assessment of health impacts overall as well as within a population is relevant as interventions with the greatest population health gain might be accompanied by an unintended increase in health inequalities.

Background: The implementation of a theoretical intersectionality framework into quantitative data analyses is gaining increasing interest in health research. The substantive foundation of intersectionality was established in the U.S., based on the claim of black feminists to broaden the scope of contemporary gender studies by considering the intersection between sex/gender and race/ethnicity more firmly. The aim of our scoping review with particular emphasis on sex/gender was to assess how intersectionality-informed studies in epidemiological research considered different social dimensions in their multivariable and multivariate analyses., Methods: Following the PRISMA Extension for Scoping Reviews (PRISMA-ScR), we conducted a literature review in PubMed. Three distinct health-related fields were brought into focus: diabetes representing a frequent chronic disease, smoking as a wide-spread behavioural health determinant and physical activity as a central target for health promotion. Initially, we compared which and how different social dimensions were accounted for and how inter-categorical and intersectionality-informed analyses were conducted. Further, we assessed sex/gender sensitivity by comparing operationalisation of sex/gender, how sex/gender theories were used and which central theoretical sex/gender concepts were referred to when aiming at explanation of (intersectional) sex/gender differences., Results: Our results suggest, that intersectionality-based analyses within the three selected health-related fields are mainly conducted in the U.S. and focused on the intersection between sex/gender and race/ethnicity by using them jointly as subgrouping variables and as parts of interaction terms in regression analyses. Income and education as proxies for social class as well as age are mainly used for adjustment in quantitative analyses. Other approaches for calculating interactions (i.a. synergy-index, CART-analysis) are an exception. Even though sex/gender was considered in every included study and Gender was the most frequent theoretical sex/gender concept referred to when theoretically explaining sex/gender differences, it was exclusively operationalised as binary and solution-linked sex/gender variables were hardly considered in quantitative analyses., Conclusion: The systematic integration of solution-linked variables indicating modifiable aspects of sex/gender-related living conditions and disadvantages could improve sex/gender sensitivity as part of intersectionality-based quantitative data analysis in health research.

Backround: Meta-analysis of the impact of public smoking bans on children's exposure to secondhand smoke (SHS) exposure at home., Methods: The electronic databases of PubMed, Web of Science, PsycINFo, ASSIA, CINAHL were searched. German public health journals not captured by these databases and grey literature were considered in addition. Studies were included when they reported children's SHS exposure at home in relation to smoke-free legislation by measuring exposure before and after the introduction of a public smoking ban. Studies had to provide results on exposure prevalences of children aged below 18 years. Language of publications was restricted to German and English. Details of the included studies (n = 15) were extracted by one author and checked for accuracy by a second author. Given the exposure prevalences before and after the introduction of a smoke-free legislation, a random-effects meta-analysis of relative risks (RR) was conducted. Results were presented in a forest plot., Results: Meta-analysis showed that the overall effect was a decreased exposure to SHS in the children's homes after introduction of a public smoking ban (RR = 0.72; 95% CI = 0.62-0.83). Only two of the 15 studies indicated an increased exposure. Sensitivity analyses considering the type of smoke-free legislation, children's age group and study quality did not substantially alter the result., Conclusion: The assumption of a displacement of smoking into homes with children due to smoke-free legislation in public places could not be confirmed. Additional research is needed to analyse long-term trends.

Background: Physical activity is one of the most important contributors to healthy aging. Public health strategies aiming to promote physical activity among older adults are increasingly being implemented. However, little is known about their impact on social inequalities. Purpose of the study was to analyze whether and how studies of interventions consider effects on social inequalities in physical activity among older adults., Methods: Nine electronic databases were searched to identify quantitative studies evaluating the effects of interventions on self-reported or objectively measured physical activity among the general population of older adults (≥50 years). English and German language peer-reviewed journal articles published between 2005 and 2015 were included. Using the PROGRESS-Plus framework, data on whether and how social factors were considered both for describing participants' baseline characteristics and for measuring intervention effects were systematically extracted. Studies examining differential intervention effects by at least one PROGRESS-Plus factor were quality assessed. Results were presented in narrative synthesis., Results: Fifty-nine studies were included. Beside age and sex, 44 studies used at least 1 further PROGRESS-Plus factor for the description of participants' baseline characteristics. When measuring intervention effects, 22 studies considered PROGRESS-Plus factors as control variables. Eleven studies reported having analyzed potential effects on inequalities by testing interaction effects, stratifying effect analyses, or exploring associations between PROGRESS-Plus factors and increases in physical activity following an intervention. Effects were most often analyzed by gender/sex (n = 9) and age (n = 9), followed by education (n = 3), marital status (n = 2), and race/ethnicity (n = 2). Five studies pointed to gender/sex- or age-specific intervention effects, indicating that some interventions affect males and females, and younger and older individuals differently., Conclusions: Many studies evaluating the effects of interventions on physical activity among older adults have not exploited the potential for assessing effects on social inequalities so far. There is an urgent need for systematic application of appropriate methodological approaches and transparent reporting of social inequalities-related findings which can provide important indications for the design of those interventions most likely to be effective across all social groups of older adults., Trial Registration: PROSPERO registration number: CRD42015025066.

Background: The context of the close neighbourhood environment in which children live has gained increasing attention in epidemiological research. This study aimed to investigate if contextual neighbourhood socioeconomic position (SEP) was independently associated with overweight in young children aged 5-7 years while simultaneously considering a wide range of individual socioeconomic determinants and known risk factors for overweight., Methods: Objectively measured body mass index (BMI) data from 3499 children (53 % boys and 47 % girls) from three surveys between 2004 and 2007 clustered in 18 school enrolment zones in the city of Munich, Germany, were analysed with hierarchical logistic regression models. An index of neighbourhood SEP was calculated with principal component analysis using aggregated data. Individual socioeconomic data, maternal BMI, and birth weight were collected with parental questionnaires. We analysed how much of the between neighbourhood variance of overweight was attributable to individual factors and how much was explained by neighbourhood SEP., Results: The prevalence of overweight, including obesity, was 14.1 %. In the final adjusted model low neighbourhood SEP was independently associated with overweight (odds ratio (OR) = 1.42, 95 % confidence interval (CI) = 1.00-2.00) compared to high neighbourhood SEP. On the individual level low parental education (OR = 1.99, 95 % CI = 1.49-2.65) or middle parental education (OR = 1.50, 95 % CI = 1.16-1.95) compared to high parental education and nationality of the child other than German (OR = 1.53, 95 % CI = 1.17-1.99) compared to German nationality were independently associated with overweight., Conclusions: Whereas individual determinants were the main drivers in explaining between neighbourhood variance, neighbourhood SEP additionally explained differences in overweight between neighbourhoods. Thus, considering neighbourhood context in intervention planning could result in more effective strategies compared to measures only focusing on individual determinants of overweight.

Background: Public health strategies to promote physical activity among older adults are increasingly being implemented. However, it is not known whether these interventions are equally effective among all social groups of the older adult population. The objectives of the proposed systematic review are to (1) describe the extent to which effects on social inequalities are considered in studies evaluating the effectiveness of interventions to promote physical activity among older adults, (2) describe the methods used for measuring these effects, and (3) assess the implications of the equity related findings for health promotion research and practice., Methods/design: MEDLINE, PsycINFO, CINAHL, CENTRAL, Physical Education Index, Social Science Citation Index, ASSIA, Sociological Abstracts, and IBSS databases as well as the German language journal Prävention und Gesundheitsförderung will be searched to identify experimental or observational quantitative studies evaluating the effects of interventions on self-reported or objectively measured physical activity among the general population of older adults (≥ 50 years). English or German language peer-reviewed journal articles published since 2005 will be included. Data on whether and how several social factors are considered for both the description of baseline characteristics of participants and for measuring intervention effectiveness will be extracted. The quality of studies will be assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results will be presented in a narrative synthesis. If feasible, harvest plots will be used to synthesize evidence about how intervention effects vary between different social groups., Discussion: This systematic review will provide evidence on what is known about the effects of interventions on social inequalities in physical activity among older adults, which is a prerequisite for the prioritization of those interventions most likely to be effective across all social groups of this target population. Therefore, the results of this review will be of major interest to researchers, policy makers, and practitioners in the area of physical activity promotion for older adults., Systematic Review Registration: This protocol has been registered with the PROSPERO international prospective register of systematic reviews (PROSPERO 2015 CRD42015025066).

Background: Children with a low socioeconomic position are more affected by mental difficulties as compared to children with a higher socioeconomic position. This paper explores whether this socioeconomic pattern persists in the prosperous German city of Munich which features high quality of life and coverage of children mental health specialists that lies well above the national average and is among the highest in Europe., Methods: 1,265 parents of preschool children participated in a cross-sectional health survey. They were given a self-administered questionnaire (including socioeconomic variables) and the 'Strengths and Difficulties Questionnaire (SDQ)', a well-established method to identify mental difficulties among children and adolescents. Prevalence estimates for the 'SDQ-Total Difficulties Score' were calculated, with a special focus on differences by parental (resp. household) socioeconomic position. The association between parental education, household income, single parenthood, nationality, and parental working status on one hand, and their children's mental health on the other, was explored using multivariable logistic regression models. The coverage of mental health specialists per 100,000 children aged 14 or younger in the city of Munich was also calculated., Results: In Munich, the distribution of mental health difficulties among children follows the same socioeconomic pattern as described previously at the national level, but the overall prevalence is about 30% lower. Comparing different indicators of socioeconomic position, low parental education and household income are the strongest independent variables associated with mental difficulties among children (OR = 2.7; CI = 1.6 - 4.4 and OR = 2.8; CI = 1.4 - 5.6, respectively)., Conclusions: Socioeconomic differences in the prevalence of childhood mental difficulties are very stable. Even in a city such as Munich, which is characterized by high quality of life, high availability of mental health specialists, and low overall prevalence of these mental difficulties, they are about as pronounced as in Germany as a whole. It can be concluded that the effect of several characteristics of socioeconomic position 'overrules' the effect of a health promoting regional environment.

The objective of this study was to examine whether duration of exclusive breastfeeding is associated with elevated weight gain in infants during the first two years of life. In this prospective cohort study 2624 healthy term neonates were followed from birth to age 2 years in 4 German study centres. Data on breastfeeding and potential confounders were gathered by questionnaires. Data on anthropometric measures at birth and age 2 years were obtained from routine standardised medical check up documentation. Odds ratios for the association between breastfeeding and weight gain until age 2 years (> or = 90th sex-specific percentile of the cohort) were calculated by logistic regression, adjusting for age at introduction and composition of solid food, maternal BMI, maternal smoking during pregnancy, socioeconomic status, study centre, birth order and, in unstratified analysis, sex. Children exclusively breastfed for less than 6 months had a greater risk of elevated weight gain at the age of 2 years than children breastfed for 6 months and more (OR (95% CI): 1.65 (1.17, 2.30)). Duration of exclusive breastfeeding was inversely associated with the risk of elevated weight gain in a strongly duration-dependent way. Those infants who were exclusively breastfed 1 month at the most had twice as often elevated weight gain (OR (95% CI): 1.99 (1.34, 2.97)) compared to infants breastfed at least 6 months. Our data show that exclusive breastfeeding protects against elevated weight gain during infancy which may be the first step on the pathway of obesity development.

The dietary intake of certain fatty acids might contribute to the development of atopic diseases like allergic rhinitis and asthma. We investigated the association between the ratio of n-6 and n-3 fatty acids in serum phospholipids and hay fever or allergic sensitisation in adults. Data from a population based cross-sectional study on respiratory health including measurement of fatty acids in serum phospholipids of 740 adults between 20 and 64 years of age were analysed. We could not find any significant association between n6/n3-ratio of fatty acids in serum phospholipids and hay fever or allergic sensitisation neither in the total population nor in the sub-population stratified by sex. Since no previous study on fatty acid intake confirmed the n6/n3-ratio hypothesis and this study did not find any association between the n6/n3-ratio in serum-phospholipids and hay fever or allergic sensitization, we conclude that the n6/n3- ratio hypothesis is not confirmed although biological plausible.