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Background Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers’ access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.

Background Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models. Methods In Germany’s largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasi-experiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex. Results SIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC. Conclusion The results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.

Social survey data on those aged 80 years or older is sparse. Based on a representative sample, this paper validates a multidimensional model proposed for understanding of quality of life (QoL) in very old age. Towards this goal, this paper estimated levels and heterogeneity of personal and environmental resources, well-being, autonomy, and perceived appreciation by society in the population of the very old in Germany. Next, the contribution of personal and environmental resources to QoL outcomes and overlap between these outcomes was estimated using a multivariate approach. Results were based on a representative survey on QoL of the very old in North Rhine-Westphalia, Germany’s most populous state. The survey included comprehensive information on socio-demographics, health, social and personal QoL resources including objective testing of cognitive function. The sample comprised 1,863 individuals (mean age 86.5 years, range 80–102 years), including 211 individuals residing in non-private dwellings. Interviews with proxy informants were conducted for 176 individuals that were willing to participate but could not conduct the interview themselves due to limited ability to communicate (PLC). Pronounced differences were found for PLC with respect to environmental and personal resources and QoL outcomes. Pronounced differences were also found both with respect to lower observed levels of QoL outcomes (e.g., autonomy) and predictors of QoL outcomes (e.g., effect of negative “external” appreciation on subjective well-being). Contrary to the deficit-oriented model of old age, a high degree of autonomy was observed. However, substantial and consequential negative “external” appreciation of very old age was also apparent.

Background If voter turnout reflects social or health inequalities, then these inequalities can reduce equal political representation. Research suggests that poor health impedes voting and contributes to low turnout, especially among the oldest-old (80 years and older). Therefore, we examine the determinants of voting behaviour in more detail, with a special focus on the role of health status among the oldest-old. Methods The analysis was based on a population-based sample of older adults living in Germany’s largest federal state, North Rhine-Westphalia (n = 1826). The outcome was participation in the last federal election. As determinants, we included subjective, functional, mental, and cognitive health; mobility; institutional living; education; social embeddedness; party attachment; habituation; and conformist attitudes. We used logistic regression models to calculate odds ratios and 95% confidence intervals. Results The overall turnout rate was 84.6% (95%-CI:82.9–86.3), which shows that most of the oldest-old participate in elections. Results from logistic regressions revealed that lower formal education and limitations in functional, cognitive, and mental health were associated with lower odds of voting; while habituation, party attachment, and partnership were associated with higher odds of voting. Conclusion Most of the oldest-old in Germany participate in elections. Still, our results hint at the existence of important inequalities in turnout rates. Given that older adults constitute an increasing share of the electorate, and that those who are less likely to vote are often among those most directly affected by political decisions, all individuals who are willing and able to participate in elections should be given the necessary support to actually do so.

Recourse to a purported ideal of societal homogeneity has become common in the context of the refugee reception crisis - not only in Japan, as Leppold et al report, but also throughout Europe. Calls for societal homogeneity in Europe originate from populist movements as well as from some governments. Often, they go along with reduced social support for refugees and asylum seekers, for example in healthcare provision. The fundamental right to health is then reduced to a citizens' right, granted fully only to nationals. Germany, in spite of welcoming many refugees in 2015, is a case in point: entitlement and access to healthcare for asylum seekers are restricted during the first 15 months of their stay. We show that arguments brought forward to defend such restrictions do not hold, particularly not those which relate to maintaining societal homogeneity. European societies are not homogeneous, irrespective of migration. But as migration will continue, societies need to invest in what we call \"globalization within.\" Removing entitlement restrictions and access barriers to healthcare for refugees and asylum seekers is one important element thereof.

Germany has experienced different forms of immigration for many decades. At the end of and after the Second World War, refugees, displaced persons and German resettlers constituted the largest immigrant group. In the 1950s, labor migration started, followed by family reunification. There has been a constant migration of refugees and asylum seekers reaching peaks in the early 1990s as well as today. Epidemiological research has increasingly considered the health, and the access to health care, of immigrants and people with migration background. In this narrative review we discuss the current knowledge on health of immigrants in Germany. The paper is based on a selective literature research with a focus on studies using representative data from the health reporting system. Our review shows that immigrants in Germany do not suffer from different diseases than non-immigrants, but they differ in their risk for certain diseases, in the resources to cope with theses risk and regarding access to treatment. We also identified the need for differentiation within the immigrant population, considering among others social and legal status, country of origin and duration of stay. Though most of the studies acknowledge the need for differentiation, the lack of data currently rules out analyses accounting for the existing diversity and thus a full understanding of health inequalities related to migration to Germany.

Late-life depression (LLD) is a common disorder, especially in the age group of 80 years and older. The aim of this analysis is the longitudinal evaluation of predictors of LLD in a population-representative sample. In the NRW80+ study, participants (age≥80 years) representative for the German state of North Rhine-Westphalia were comprehensively characterised at two time points (baseline: 2017 (n = 1863); follow-up/FU: 2019/2020 (n = 912)). Recruitment was based on 55 randomly selected community registries. The interviews were conducted by computer-assistance. We analysed data from 680 participants who were either cognitively unimpaired (CU) according to the DemTect test, had mild cognitive impairment (MCI) or dementia and had depression scores available at baseline as well as FU. Depression symptoms were assessed by the 'Depression in Aging Scale' (DIA-S). In previous analyses, 21 variables collected at baseline were identified in a data-driven procedure and divided into four different areas (function, values/lifestyle, autonomy/satisfaction and biological/somatic variables). To predict depressive symptoms at FU (DIA-S score ≥2/4), binary regression analyses were carried out for each diagnostic group with the four areas at baseline as predictors. Among the 680 participants, 79.0% were CU, 13.2% had MCI and 7.4% had dementia. There were significant group differences for the presence of depressive symptoms at FU between the different diagnostic groups (CU: 19.6%, MCI: 31.2%, dementia: 30.0%; p = 0.016). The binary regression analyses for the CU group indicated that the psychological variables (autonomy/satisfaction) explained the highest variance for depressive symptoms at FU (Nagelkerke's R  = 0.149). Contrary, in the MCI group, the biological-somatic variables explained 29.7% (Nagelkerke's R  = 0.297) and values/lifestyle variables 32.1% of the variance at FU (Nagelkerke's R  = 0.321), which was significantly higher than the variance explained by the autonomy/satisfaction model (Nagelkerke's R  = 0.224). The dementia diagnosis group did not show any significant regression models. For the longitudinal prediction of depressive symptoms, psychological variables contribute most significantly in the CU group, whereas in the MCI group, biological-somatic and values/lifestyle variables are more relevant. This could lead to new perspectives in prevention of LLD.

Background Late‐life depression (LLD) is a common disorder, especially in the age group of 80 years and older. The aim of this analysis is the longitudinal evaluation of predictors of LLD in a population‐representative sample. Methods In the NRW80+ study, participants (age≥80 years) representative for the German state of North Rhine‐Westphalia were comprehensively characterised at two time points (baseline: 2017 (n = 1863); follow‐up/FU: 2019/2020 (n = 912)). Recruitment was based on 55 randomly selected community registries. The interviews were conducted by computer‐assistance. We analysed data from 680 participants who were either cognitively unimpaired (CU) according to the DemTect test, had mild cognitive impairment (MCI) or dementia and had depression scores available at baseline as well as FU. Depression symptoms were assessed by the ‘Depression in Aging Scale’ (DIA‐S). In previous analyses, 21 variables collected at baseline were identified in a data‐driven procedure and divided into four different areas (function, values/lifestyle, autonomy/satisfaction and biological/somatic variables). To predict depressive symptoms at FU (DIA‐S score ≥2/4), binary regression analyses were carried out for each diagnostic group with the four areas at baseline as predictors. Results Among the 680 participants, 79.0% were CU, 13.2% had MCI and 7.4% had dementia. There were significant group differences for the presence of depressive symptoms at FU between the different diagnostic groups (CU: 19.6%, MCI: 31.2%, dementia: 30.0%; p = 0.016). The binary regression analyses for the CU group indicated that the psychological variables (autonomy/satisfaction) explained the highest variance for depressive symptoms at FU (Nagelkerke's R2 = 0.149). Contrary, in the MCI group, the biological‐somatic variables explained 29.7% (Nagelkerke's R2  = 0.297) and values/lifestyle variables 32.1% of the variance at FU (Nagelkerke's R2  = 0.321), which was significantly higher than the variance explained by the autonomy/satisfaction model (Nagelkerke's R2  = 0.224). The dementia diagnosis group did not show any significant regression models. Conclusion For the longitudinal prediction of depressive symptoms, psychological variables contribute most significantly in the CU group, whereas in the MCI group, biological‐somatic and values/lifestyle variables are more relevant. This could lead to new perspectives in prevention of LLD.

IntroductionIn many countries, including Germany, newly arriving refugees face specific entitlement restrictions and access barriers to healthcare. While entitlement restrictions apply to all refugees who seek protection in Germany during the first months, the barriers to access depend on the model that the states and the municipalities implement locally. Currently, two different models exist: the healthcare voucher model (HcV) and the electronic health card model (eHC). The aim of the study is to analyse the consequences of these two different access models on newly arrived refugees’ realised access to healthcare.Methods and analysisThe random assignment of refugees to municipalities allows for a quasi-experimental design by comparing realised access to healthcare among refugees in six municipalities in North Rhine-Westphalia which have implemented HcV or eHC. We compare realised access to healthcare using ambulatory care sensitive conditions and health expenditure as outcome indicators, and use of emergency care, preventive care, psychotherapeutic or psychiatric care, and of therapeutic devices as process indicators. Results will be adjusted for aggregated information on age, sex, socioeconomic structure of the municipalities and density of general practitioners or specialists.Ethics and disseminationWe cooperated with local welfare offices and the statutory health insurance for data collection. Thereby, we were able to avoid recruiting large numbers of refugee patients immediately after arrival while their access and entitlement to healthcare are restricted. We developed an extensive data protection concept and ensured that all data collected are fully anonymised. Results will be published in peer-reviewed journals and summarised in reports to the funding agency.

On 23 June 2016, the citizens of the United Kingdom (UK) voted in favour of the so-called ‘‘Brexit’’ when they were asked in a referendum if they wanted their country to remain in or leave the European Union (EU). Driven by the good intention of making the most out of the inevitability of Brexit, some prominent figures of the UK public health community are arguing that now is the time to start working in favour of a ‘‘soft’’ Brexit rather than oppose the Brexit as a block.