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Many governments increased the retirement age in response to population ageing. Against this backdrop, it remains unclear whether the development in healthy life years can keep pace with the increase in working life years and whether people with lower socio-economic status are left behind. We investigated time trends in healthy life years and healthy working life years and how trends differ between educational groups in Germany. Temporal trends in partial life expectancy between age 30 and 69 were assessed using data from the German Socio-Economic Panel (GSOEP, N=40,150) of three educational groups. Based on this, education-specific (Un)Healthy Life Expectancy ((U)HLE) and (Un)Healthy Working Life Expectancy ((U)HWLE) were calculated using the Sullivan method. Health is assessed on the basis of two health indicators: the physical and the mental score of health-related quality of life (p/mHRQoL). Both has been shown to be important indicators for working-age health. With respect to pHRQoL, HLE increased among men and women with higher educational attainment while it decreased in men with lower educational level. HWLE increased stronger in men and women with higher than with lower educational attainment. UHWLE increased strongest in persons with lower educational attainment. In terms of mHRQoL, HLE increased in all educational groups except for the group of women with lower educational attainment. UHLE decreased among men and women with middle and higher educational level. HWLE increased in all groups, with increases being strongest among higher educated individuals. UHLE increased in women with lower educational attainment but decreased in men and women with higher educational level. We found polarising trends, with healthy life years and healthy working years developing less favourably among people with lower than with higher educational level. This applies to both the physical and mental component of HRQoL. The study shows that people with lower educational level are less able to keep pace with the prolonged working life from a health perspective and that more effective prevention is needed to stop the widening of health inequalities in working age.

Due to substantial improvements in prevention and therapy, stroke incidence and mortality rates have decreased during the last decades, but evidence is still lacking on whether all socioeconomic groups benefited equally and how the length of life affected by stroke developed over time. Our study investigates time trends in stroke-free life years and life years affected by stroke. Special emphasis is given to the question whether trends differ between income groups, leading to decreasing or increasing social inequalities. The analyses are based on claims data of a German statutory health insurance company of the two time periods 2006-2008 and 2014-2016. Income inequalities and time trends in incidence and mortality risks were estimated using multistate survival models. Trends in stroke-free life years and life years affected by stroke are analysed separately for income groups by applying multistate life table analyses. Stroke incidence and mortality risks decreased in men and women in all income groups. While stroke-free lifetime could be gained in men having higher incomes, improvements in mortality counterbalanced decreasing incidences, leading to increases in life years affected by stroke among men of the lower and higher income group. Among women, no significant changes in life years could be observed. Changes in stroke-affected life years occur among men in all income groups, but are more pronounced in the higher income group. However, irrespective of the income group the proportion of stroke-affected life years remains quite stable over time, pointing towards constant inequalities. Further research is needed on whether impairments due to stroke reduced over time and whether all socioeconomic groups are affected equally.

Lung Cancer (LC) is one of the most common malign diseases worldwide. So far, it is unclear if the development of LC incidence and mortality leads to morbidity compression or expansion and whether these developments differ by socioeconomic characteristics. This study analyses time trends in social and gender inequalities in life years with and without LC in Germany. The study is based on data of a large German statutory health insurance provider (N = 2,511,790). Incidence and mortality risks were estimated from multistate survival models. Trends in life years with and without LC were analysed using multistate life table analyses. All analyses were performed separately for gender, time period (2006-2009 and 2014-2017), and income group (<60% and ≥60% of the German average income). Among men, declining LC incidence rates resulted in gains of life years free of LC and declining LC- affected life years and led to a relative compression, which was strongest in men with higher incomes. Among women, a clear increase in life years with LC led to an expansion of the lifespan affected by LC. This expansion was mainly driven by increasing incidence rates in women with low incomes. Overall, income inequalities in LC increased in both genders. Our analyses reveal that developments in the length of life affected by LC differed substantially by gender and income and led to widening health inequalities over time. Public health efforts should mainly focus on vulnerable groups to reduce the persisting social inequalities in LC.

Introduction Cancer is a major public health challenge in Germany with significant socioeconomic inequalities in incidence and mortality. However, there is only limited research on the incidence of diagnosis-specific cancers and related inequalities among socioeconomic groups within the working-age population. This study aims to address this gap by analysing how the incidence of common cancers depends on individual- and area-level socioeconomic characteristics among working-age women and men.  Methods Using a prospective cohort design based on anonymised German statutory health insurance data, this study examined a cohort of 2.23 million individuals aged 25–67 years over a five-year period (2015–2019). Individual socioeconomic position was assessed using educational attainment and occupational skill levels, while area-level deprivation was determined using a composite socioeconomic index. Incidence rates were estimated per 100,000 person-years at risk, age-standardised to the 2013 European standard population. Hazard ratios were calculated using multilevel Cox proportional hazards models. Results The analysis revealed 50,276 newly diagnosed cancer cases during the study period. Lower education, lower occupational skill levels and higher area-level deprivation were associated with a higher incidence of stomach, lung, colorectal, prostate, breast and cervical cancer, but a lower incidence rate of malignant melanoma of the skin. After mutual adjustment of the socioeconomic indicators, higher hazard ratios of lung cancer were found for men with lower educational (HR = 2.8, 95%CI:2.3–3.5) and occupational skill levels (HR = 2.8, 95%CI:2.3–3.5) and for women with lower education (HR = 2.3, 95%CI:1.7–3.1). Lower occupational skill levels in both sexes (women HR = 0.6, 95%CI:0.5–0.7; men HR = 0.7, 95%CI:0.6–0.9) and lower educational levels in men (HR = 0.7, 95%CI:0.6–0.8) were independently associated with a lower risk of malignant melanoma. For area-level deprivation, we observed a higher risk of stomach (women 1.6, 95%CI:1.2-2.0; men HR = 1.3, 95%CI:1.1–1.6) and lung cancer (women HR = 1.3, 95%CI:1.1–1.5; men HR = 1.5, 95%CI:1.3–1.7) in more deprived areas, even after adjusting for individual-level socioeconomic characteristics. In contrast, a higher risk of skin melanoma was observed in less deprived areas after individual-level socioeconomic adjustments (women and men HR = 0.6, 95%CI:0.5–0.7). Conclusions Our findings suggest that strategies to prevent cancer in the working-age population should take more account of the unequal structural conditions in which people work and live. The study shows that area-level socioeconomic deprivation has explanatory power for unequal cancer risks beyond the individual characteristics of socioeconomic position.

Background Lung Cancer (LC) is one of the most prevalent cancer diseases. Due to the lack of databases which allow the combination of information on individual socioeconomic status (SES) and cancer incidence, research on social inequalities in LC among the German population is rare. The aim of the study is to analyse time trends in social inequalities in LC in Germany. Methods The analyses are based on data of a large statutory health insurance provider. The data contain information on diagnoses, occupation and education (working age), and income (full age range) of the insurance population. Trends were analysed for two subpopulations (retirement age and working age) and stratified by sex. The analyses are based on incidence rates and proportional hazard models spanning the periods 2006–2009, 2010–2013 and 2014–2017. Results Incidence rates declined in men but increased in women. For men, inequalities were strongest in terms of income and the decline in incidence was most pronounced in middle- and higher-income men. Among women at retirement age, a reversed income gradient was found which disappeared in the second period. The educational gradient among the working-age population decreased over time due to the trend towards increasing incidence among individuals with higher education. Declining gradients were also found for occupational position. Conclusion The findings reveal considerable inequalities in LC and that trends vary with respect to SES, sex and age. Widening income inequalities were found in the retired population, while educational and occupational inequalities tend to narrow among the working-age population.

PurposeWe examined changes in the burden of depressive symptoms between 2006 and 2014 in 18 European countries across different age groups.MethodsWe used population-based data drawn from the European Social Survey (N = 64.683, 54% female, age 14–90 years) covering 18 countries (Austria, Belgium, Denmark, Estonia, Finland, France, Germany, Great Britain, Hungary, Ireland, The Netherlands, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland) from 2006 to 2014. Depressive symptoms were measured via the CES-D 8. Generalized additive models, multilevel regression, and linear regression analyses were conducted.ResultsWe found a general decline in CES-D 8 scale scores in 2014 as compared with 2006, with only few exceptions in some countries. This decline was most strongly pronounced in older adults, less strongly in middle-aged adults, and least in young adults. Including education, health and income partially explained the decline in older but not younger or middle-aged adults.ConclusionsBurden of depressive symptoms decreased in most European countries between 2006 and 2014. However, the decline in depressive symptoms differed across age groups and was most strongly pronounced in older adults and least in younger adults. Future studies should investigate the mechanisms that contribute to these overall and differential changes over time in depressive symptoms.

Cancer mortality has declined in recent decades, but—due to a lack of national individual-level data—it remains unclear whether this applies equally to all socioeconomic groups in Germany. Using an area-based approach, this study investigated socioeconomic inequalities in cancer mortality and their secular trends on a German nationwide scale for the first time. Official cause-of-death data from 2003 to 2019 were linked to the district-level German Index of Socioeconomic Deprivation. Age-standardised mortality rates for all cancers combined and the most common site-specific cancers were calculated according to the level of regional socioeconomic deprivation. To quantify the extent of area-based socioeconomic inequalities in cancer mortality, absolute (SII) and relative (RII) indices of inequality were estimated using multilevel Poisson models. On average, cancer mortality was 50% (women) and 80% (men) higher in Germany’s most deprived than least deprived districts (absolute difference: 84 deaths per 100,000 in women and 185 deaths per 100,000 in men). As declines in cancer mortality were larger in less deprived districts, the socioeconomic gap in cancer mortality widened over time. This trend was observed for various common cancers. Exceptions were cancers of the lung in women and of the pancreas in both sexes, for which mortality rates increased over time, especially in highly deprived districts. Our study provides first evidence on increasing socioeconomic inequalities in cancer mortality on a nationwide scale for Germany. Area-based linkage allows to examine socioeconomic inequalities in cancer mortality across Germany and identify regions with high needs for cancer prevention and control.

Musculoskeletal diseases (MSDs) are a major predictor of early retirement. Against the backdrop of the extension of working life, we investigated time trends and educational inequalities in years spent in the labour market free of MSD. Based on German statutory health insurance data (N = 3,405,673), total life years free of MSD (Healthy Life Expectancy, HLE) and years spent in the labour force free of MSD (Healthy Working Life Expectancy, HWLE) were estimated for three periods (2006–2008, 2011–2013, 2016–2018) using multistate analyses. Educational inequalities (8 to 11 vs. 12 or more years of schooling) are reported for 2011–2013. HLE decreased slightly over time in all genders. HWLE in women increased, while it remained rather constant in men. Over time, the share of years in the labour force spent free of MSD declined continuously. People with lower education had lower HLE and HWLE than individuals with higher education. With respect to musculoskeletal diseases, the increase in disease-free working life years cannot keep pace with the extension of working life, resulting in an increasing proportion of years spent in impaired musculoskeletal health in the labour market. Effective prevention strategies are needed, focusing especially on individuals with lower educational attainment.

Background Acute myocardial infarction (MI) remains a frequent health event and a major contributor to long-term impairments globally. So far, research on social inequalities in MI incidence and mortality with respect to MI severity is limited. Furthermore, evidence is lacking on disparities in the length of life affected by MI. This study investigates social inequalities in MI incidence and mortality as well as in life years free of MI and affected by the consequences of mild or severe MI. Methods The study is based on data of a large German statutory health insurance provider covering the years 2008 to 2017 ( N  = 1,253,083). Income inequalities in MI incidence and mortality risks and in life years with mild or severe MI and without MI were analysed using multistate analyses. The assessment of MI severity is based on diagnosed heart failure causing physical limitations. Results During the study period a total of 39,832 mild MI, 22,844 severe MI, 276,582 deaths without MI, 15,120 deaths after mild MI and 16,495 deaths after severe MI occurred. Clear inequalities were found in MI incidence and mortality, which were strongest among men and in severe MI incidence. Moreover, substantial inequalities were found in life years free of MI in both genders to the disadvantage of those with low incomes and increased life years after mild MI in men with higher incomes. Life years after severe MI were similar across income groups. Conclusions Social inequalities in MI incidence and mortality risks led to clear disparities in the length of life free of MI with men with low incomes being most disadvantaged. Our findings stress the importance of primary and secondary prevention focusing especially on socially disadvantaged groups.

Background Cancer is one of the main causes of a high burden of disease and one of the strongest contributors to earlier mortality among lower socioeconomic groups in Germany. Therefore, studying socio-economic inequalities in cancer incidence is of high relevance from a public-health and health-equity lens. The aim of this study was to examine in more depth time trends in socioeconomic inequalities in cancer incidence and the related potential for reducing the incidence of specific cancers across Germany. Methods We used epidemiologic data from the Centre for Cancer Registry Data at the Robert Koch Institute and official population statistics for Germany from 2008 to 2019. To analyse trends in socioeconomic inequalities in cancer incidence, we used an ecological study design and linked the cancer registry and population data with the German Index of Socioeconomic Deprivation at district level. We calculated standardised cancer incidence rates for the most common cancers by area-level socioeconomic deprivation and estimated the Slope and Relative Index of Inequality (SII, RII) to determine the extent of area-level socioeconomic inequalities in the risk of cancer. In a what-if analysis, counterfactual scenarios were used to calculate how much lower cancer incidence could be if socioeconomic inequalities in incidence were reduced or eliminated. Results Due to less favourable trends of cancer incidence in more deprived areas, socioeconomic inequalities in cancer incidence has widened to the detriment of residents in highly deprived areas. This was observed for all cancers combined and for several common cancers such as stomach, colorectal and lung cancer among both women and men. In 2017–19, total cancer incidence was 18% (women: RII 1,18) and 49% (men: RII 1,49) higher in the most than in the least deprived area. Reverse inequalities were observed for skin melanoma in both sexes and female breast cancer, the lowest incidence being among residents of highly deprived districts. For 2017–19, the what-if analysis showed that the annual number of newly diagnosed cancers cases would be 9,100–76,000 cases fewer if the socioeconomic gap in cancer incidence between districts could be narrowed or eliminated. Conclusions In Germany, socioeconomic inequalities in cancer incidence have widened in recent decades. Tackling cancer risks in deprived areas could reduce those inequalities and the burden of cancer overall. Our study emphasises the growing importance of structural approaches in cancer prevention for reducing health inequalities in Germany.