Gender inequalities in psychological distress have been found in various populations, including occupational groups and countries. There is a lack of studies that compare regions in a uniform operationalisation of distress and integrate occupational groups. 67,641 participants from 36 countries of the European Working Conditions Survey 2021 were analysed. High psychological distress was operationalized using the WHO-5 Well-Being Index. Using predicted probabilities and multilevel regression analysis, gender inequalities between countries, regions and occupational subgroups were calculated. Across most countries, women reported higher psychological distress. The magnitude of gender differences varied between countries, regions and occupations. However, overlapping confidence intervals limit the conclusiveness of the results. When stratifying for both region and occupation type, in the Southern European region and in blue-collar low-skilled occupations gender inequalities were highest. In the significant interaction model, white-collar occupations in Western Europe and blue-collar low-skilled occupations in Southern Europe had the highest gender inequalities. This study demonstrates heterogeneity in the magnitude of gender differences in high psychological distress across Europe and occupational groups. White-collar high-skilled occupations in Western Europe and blue-collar low-skilled occupations in Southern Europe were identified as vulnerable groups. The findings underscore the importance of considering regional patterns when addressing gender-based mental health inequalities in the European workforce.

While the individual health benefits of education are well-established, the population-level health returns of educational expansion remain underexplored. This study examined how Germany's educational expansion over two decades has been associated with population health changes. Using data from the German General Social Survey (ALLBUS) spanning 2004-2023 (N = 33,956 aged 20+), we calculated the Prevented Fraction for the Population (PFP) for poor self-rated health, estimating the proportion of poor health cases prevented by higher education in the population over time. Higher education was associated with a reduced risk of poor health that remained relatively constant, whereas the prevalence of higher education doubled over time. Thus, overall PFP increased from 6.5

Background: Disability indicators are commonly associated with poorer mental health, yet this is partly contradicted by the "disability paradox." A research gap persists in utilizing both the objective operationalization of officially recognized disability status and the subjective operationalization of self-reported health-related restrictions to assess their associations with depressiveness. Investigating the impact of varying degrees of disability severity is also needed. Objective: Assessing and comparing the association of subjective and objective measures of disability regarding depressiveness. Methods: This cross-sectional study analysed the data set of the German Ageing Survey (DEAS) 2023 including 4811 participants. Analysis of covariance (ANCOVA) and post-estimated adjusted contrasts were employed to investigate the association between disability measures (objective status and subjective health restrictions, both scaled categorically) and a depression score while controlling for the covariates gender, education, employment status (each categorically scaled) and age (continuously scaled). To examine the interaction between disability status and health restrictions on depressiveness, the interaction term disability status*health restrictions was added along the covariates in their association with depressiveness. Results: Both recognized disability status and greater subjective health restrictions were significantly associated with increased depressiveness (p<.05). Keeping all other covariates constant, the model using health restrictions as independent variable accounted for a larger proportion of variance of depressiveness (13.92%) than using degree of disability (9.60%). No clear gradient effect was observed in 10% increments of disability degree; however, participants with a degree of over 50% reported lower depressiveness than those with a degree under 50%. Individuals with both acknowledged disability and strong subjective restrictions showed the highest depressiveness, the interaction term was not statistically significant. Conclusions: A comprehensive understanding of depressiveness in disability necessitates the consideration of both officially recognized status and subjective health restrictions.

Abstract Background Education has been a well-established indicator of health. Against the background of educational expansion, little is known on how the temporal rise in educational attainment is affecting health trends. This study mainly examines the mediation effect of educational expansion on the trends of limitations in daily activity as measured by the global activity limitation indicator (GALI). Methods The study utilized data from the German Health Update survey (GEDA) using five waves between 2008 and 2024. Predicted probabilities and trends of (severe) limitation in daily activities were estimated using logistic regression analyses. Educational inequalities in the rates of limitation in daily activities in the five waves as well as their development over time were examined using the slope and relative indices of inequalities (SII, RII). Causal mediation analyses were applied to examine how educational expansion influenced the temporal development of (severe) limitations. All analyses were stratified by gender and three age groups. Results The results reveal significant disparities in severe limitations in daily activities, particularly widening among the middle-aged group. The findings show divergent trends in limitation across age groups: older individuals have experienced considerable improvements, while younger individuals have experienced an increase in severe limitations over time. In both cases, educational expansion was found to have a positive mediating effect on the temporal development of (severe) limitations, reducing the exacerbation in younger individuals and contributing to the improvement in older individuals. Conclusion Educational expansion appears to have a positive influence on health trends, which reinforces the need for continued educational reforms. More focus is needed on younger individuals to explore factors behind their declining health. Additionally, addressing widening educational inequalities, particularly among middle-aged adults, is crucial for narrowing the gap between educational groups. Social challenges and the digital divide could be important contextual factors to address this development.

BACKGROUND:People with functional limitations may be lonelier than those without functional limitations, as health-related constraints can restrict social participation. However, this relationship might also vary depending on the type of loneliness considered and the age of the individual. Consequently, this study examines differences in emotional and social loneliness according to functional limitation status and across age groups. METHODS:Population-based data from 3,984 participants aged 40 and older from the 2023 German Aging Survey were analyzed. Emotional and social loneliness were measured using the De Jong Gierveld Loneliness Scale, and functional limitations were assessed using the Global Activity Limitation Indicator (GALI). Analysis of variance examined differences across age groups and functional limitation severity. RESULTS:Results showed that participants with functional limitations generally reported progressively higher levels of both types of loneliness compared to those without functional limitations. Emotional loneliness showed consistent patterns across age groups, with progressive increases from no functional limitations to moderate functional limitations to severe functional limitations. In contrast, social loneliness displayed a significant interaction with age group, where middle-aged adults (40-65 years) showed much stronger progressions in social loneliness according to functional limitation severity as compared to older adults (66+). CONCLUSIONS:These findings suggest that functional limitations are generally associated with increased loneliness, but that the extent varies by both type of loneliness and age group. The stronger differences in social loneliness among middle-aged adults indicate that functional limitations may have particularly pronounced social implications earlier in the life course. Middle-aged adults with functional limitations thus represent a particularly psychosocially vulnerable group.

BACKGROUND:There is strong evidence that persons with disabilities are at greater risk of social exclusion in various areas of life. However, the role of employment for perceived social exclusion (PSE) among persons with disabilities has not yet been sufficiently researched. OBJECTIVE:This study addresses this gap by analyzing the mediating role of employment on the relationship between disabilities and PSE in women and men of later working age (40-64 yrs.). METHODS:We used a pooled data set from the 2014-2023 survey waves with 11,680 observations from the German Ageing Study (DEAS), a nationally representative longitudinal study of Germans over the age of 40. The Global Activity Limitation Indicator (GALI) was used as a measure of disability. PSE was measured with a scale developed by Bude and Lantermann covering four statements such as "I feel like I do not really belong to society". We performed logistic regression analyses and counterfactual-based causal mediation analyses. RESULTS:For men with severe disabilities, employment accounted for almost half of the difference in PSE between individuals with and without severe disabilities. For women with severe disabilities, the effect of employment was less pronounced, accounting for 15.0% of the difference. While employment rates increased between 2014 and 2023 regardless of disability status, the employment-gap between persons with and without disabilities persisted. CONCLUSIONS:The inclusion of individuals with disabilities into the labor market while promoting self-determined work remains an important social policy goal in Germany.

Purpose Return to work is one of the most important aims in the context of psychosomatic rehabilitation. Studies from outside of Germany have reported that high self-efficacy positively influences time to return to work. In this study, the impact of self-efficacy on return to work was investigated after inpatient treatment in a psychosomatic rehabilitation facility of those with mental health disorders.Methods In a longitudinal study, the participants ( N =180) were asked about their return to work self-efficacy, depression symptoms, length of employment prior to rehabilitation, and other demographic variables. Insurance data were used to calculate time to return to work after 12 months. Cox regression analyses were used to identify relevant factors. Additionally, pre-post analyses and correlative relationships regarding self-efficacy and depression were conducted.Results Higher return to work self-efficacy and longer employment prior to rehabilitation increased the chance for return to work. The treatment showed changes in depressiveness ( d =0,97) and return to work self-efficacy ( d =|0,36|).Conclusion In the course of psychosomatic rehabilitation, self-efficacy is important in the process of return to work among employees with mental health disorders.

Previous research indicates that women report more psychosomatic complaints at work compared to men. However, there is a lack of research examining this gender gap across different occupational subgroups and over time. The study utilized data from the nationwide German Employment Survey of the Working Population on Qualification and Working Conditions conducted in 2005/2006, 2011/2012, and 2017/ 2018. First, gender differences in psychosomatic complaints were analysed within the occupational subgroups categorized as white-collar high-skilled, white-collar low-skilled, blue-collar high-skilled and blue-collar low-skilled workers. Second, gender stratified time trends of psychosomatic complaints were analysed. A total of 58,759 participants were included in the analysis. Women consistently reported significantly higher levels of psychosomatic complaints compared to men across all years examined. The largest differences were observed in white-collar high-skilled occupations. From 2005/2006 to 2011/2012, gender differences increased; from 2011/2012 to 2017/2018, they stagnated. The study revealed that women experience more psychosomatic distress at work than men in all occupational subgroups and time points. White-collar high-skilled workers showed the highest gender gap in psychosomatic complaints. The gender gap widened from 2005/2006 to 2011/2012 and remained stable from 2011/2012 to 2017/2018. Future research should investigate the reasons and implications of this phenomenon, especially considering the increasing proportion of high-skilled white-collar workers, where the gender gap is most evident.

Die Wiedereingliederung in das Arbeitsleben ist eines der wichtigsten Ziele der psychosomatischen Rehabilitation. Internationale Studien zeigten, dass eine hohe Selbstwirksamkeitserwartung die Zeit bis zur Rückkehr zur Arbeit positiv beeinflussen kann. In dieser Studie wurde der Einfluss von Selbstwirksamkeitserwartung auf die Rückkehr zur Arbeit nach einer stationären psychosomatischen Rehabilitationseinrichtung für Erwerbstätige mit psychischen Störungen untersucht. In einer retrospektiven Längsschnittstudie wurden die Teilnehmenden (N=180) einer Rehabilitation zu ihrer arbeitsplatzbezogenen Selbstwirksamkeitserwartung, zur Depressivität, zur Dauer der Beschäftigung vor der Rehabilitation und zu anderen demografischen Variablen befragt. Die Versicherungsdaten wurden zur Berechnung der Zeit bis zur Rückkehr zur Arbeit nach 12 Monaten herangezogen. Mit Hilfe von Cox-Regressionsanalysen wurden relevante Prädiktoren ermittelt. Weiterführend wurden korrelative Zusammenhänge und Prä-Post-Analysen hinsichtlich der Selbstwirksamkeit und Depressivität durchgeführt. Eine höhere arbeitsplatzbezogenen Selbstwirksamkeitserwartung und eine längere Beschäftigungsdauer vor der Rehabilitation erhöhten die Chance auf eine schnellere Rückkehr zur Arbeit. Die Behandlung zeigte Veränderungen in der Depressivität (d=0,97) und der arbeitsplatzbezogenen Selbstwirksamkeitserwartung (d=|0,36|). Im Verlauf der psychosomatischen Rehabilitation könnte die arbeitsplatzbezogene Selbstwirksamkeitserwartung für den Prozess der Wiedereingliederung bei Beschäftigten mit psychischen Störungen ein relevanter Faktor sein.

Previous studies have found some evidence for worsening health trends in working age adults. This study aims to further investigate the time trends in self-rated health among workers and explore the potential role of changes in job activities and working conditions in explaining these trends. Data from the BIBB/BAuA Employment Surveys conducted in 2006, 2012, and 2018 were analyzed (N = 53,747, age 15+). The study variables included self-rated health as the dependent variable, and time period, age, gender, education, working hours, physical work activities, cognitive work activities, ergonomic working conditions, environmental working conditions, work intensity, work control, and work support as predictors. Logistic regression and mediation analyses were employed to study the associations between these variables and self-rated health over time periods. The findings revealed a significant deterioration in self-rated health among workers over the study period, alongside an aging and more educated workforce. Additionally, several working conditions and work activities underwent changes, with work becoming generally less physically demanding and more cognitively and psychosocially demanding. The changes in job activities and working conditions partly explained the negative trends in self-rated health, with work control and environmental conditions being most important. In conclusion, worsening trends in self-rated health among the working population were found. While changes in the world of work (especially perceived work control and hazardous environmental conditions) contribute to these trends, they constitute only part of the explanation. Further research is needed to identify further intermediary determinants driving these trends and develop targeted interventions to promote worker health and well-being.

This study aimed to identify distinct patterns of health complaints among German workers and investigate their associations with socioeconomic factors. Latent class analysis was performed on data from the BIBB/BAuA Employment Survey, which included 19,320 employed respondents aged 15 years and above. The analysis considered 21 physical and psychological health complaints, such as headache, back pain, fatigue, irritability, and depressiveness. The identified health complaint classes were compared via sociodemographic indicators, including age, gender, occupation, working hours, and education. Four classes of health complaints were identified: “Low Overall Complaints” (low prevalence of all complaints; 40

PURPOSE:Based on theoretical and empirical work on the significance of school education for health, this study examines the influence of educational expansion on self-rated health (SRH) and the development of social and health inequalities between educational groups among young adults in Germany. METHODS:We used data from the German Socio-Economic Panel study from 1995 to 2020, focusing on individuals aged 25-39 years. Health was measured using the single item 'self-rated health'. Social inequalities between educational groups were examined in terms of professional position, unemployment rates and household income. Logistic regression analyses were applied to examine health trends. The Relative and Slope Index of Inequality (RII/SII) were calculated to examine the development of social and health inequalities. The influence of school education, professional position, unemployment rates and income on the health trends was analysed using causal mediation analysis. RESULTS:We found a beneficial effect of educational expansion on SRH of young adults. At the same time, social and health inequalities have increased between educational groups in terms of relative and absolute measures of inequalities. The deterioration in health of young adults with low education could be partly explained by the increase in low-skilled jobs and low incomes. CONCLUSIONS:Our findings suggest that a high educational attainment is becoming increasingly important for success in the labor market and good SRH. Young adults with a low level of education are becoming a smaller but increasingly vulnerable group, which poses challenges for future prevention.

Early onset type 2 diabetes (T2D) is increasingly recognized as a significant public health concern, leading to more severe complications and a greater decline in quality of life compared to T2D diagnosed later in life. This can have a profound impact on the workforce. Social status—whether assessed vertically through levels of income, education or job position or horizontally through occupational groups—can play a critical role in the risk of developing early onset T2D. While research focusing on vertical socioeconomic inequalities related to T2D is abundant, there is currently no study that combines both vertical and horizontal perspectives to explore vulnerable groups. We aim to combine the vertical and horizontal approaches to examine vulnerable groups within the employed population regarding early onset T2D. Using data from the largest statutory health insurance provider in the state of lower Saxony, Germany for the year 2019 “Allgemeine Ortskrankenkasse Niedersachsen” (AOKN), we examined education and income inequalities in early onset T2D among nine occupational sectors using logistic regression analyses (N = 365059). Age and gender adjusted prevalence rates as illustrated by predicted probabilities were displayed to compare rates of early onset T2D among different education and income levels and occupational groups. Regression tree analysis was used to examine intersectionality between the vertical (levels of income and education) and the horizontal (occupational sector) dimensions in order to determine the most vulnerable groups. Both vertical and horizontal inequalities in early onset T2D exist within the employed population. On the one hand, disparities in education and income were present across various occupational sectors. On the other hand, significant differences in T2D prevalence could be observed within the same education and income levels across different sectors. Notably, affiliation to occupational sector was the primary factor influencing vulnerability to early onset T2D, followed by educational attainment. Individuals with low education working in the “Transport, logistics, protection and security” and “Health, social work, teaching, and education” sectors were among the most vulnerable. It is important to simultaneously examine both vertical and horizontal dimensions of inequalities to identify vulnerable groups within the workforce. Future research should adopt this approach while also exploring other populations and health outcomes.

Diabetes prevalence is steadily increasing in Europe. This study aims to compare diabetes prevalence and the existence of related socioeconomic inequalities between 19 European countries. Using data from The European Social Survey (ESS), there were 31,178 participants (53.06% women) aged 25+ years from Austria, Belgium, Czechia, Denmark, Finland, France, Germany, Hungary, Ireland, Lithuania, Netherlands, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland and the United Kingdom. Education level and employment were used as indicators of socioeconomic inequalities. Logistic regression analyses were calculated to predict diabetes by controlling for age and gender. Differences in the effect size of education on diabetes prevalence between countries were then further examined. Overall diabetes prevalence in Europe was reported to be 6.12%, and was higher in participants from Eastern and Southern Europe than in Northern and Western Europe. Additionally, men in Western and Northern Europe had a higher risk of reporting having diabetes compared to women. Employment was identified as a protective factor against diabetes development across all European regions. Moreover, individuals with a tertiary level of education had a lower risk of reporting having diabetes in most European regions except for the Eastern region. Participants with lower education levels and the unemployed ones had a higher chance of reporting having diabetes. This was found across all European regions except for some countries from the Eastern region.

Objective: Cardiac donation after circulatory death has increased in utilization with results comparable to donation after brain death in adult patients undergoing heart transplantation. However, its use in adult congenital heart disease (ACHD) is not well studied. We aimed to characterize outcomes of cardiac donation after circulatory death in an ACHD population. Methods: Utilizing the United Network for Organ Sharing database, patients with ACHD who underwent heart transplantation between January 2020 and January 2024 were identified. Those with any prior heart transplant or undergoing multiorgan transplant were excluded. Kaplan-Meier survival analysis and Cox regression were used for group survival comparisons. Results: A total of 420 adult patients with congenital heart disease undergoing heart transplant met inclusion criteria with 36 patients receiving donation after circulatory death grafts. Circulatory death grafts were from a similar median distance (273 vs 222 miles) but had longer ischemic times (4.7 vs 3.8 hours) and higher use of ex situ perfusion devices (66.7% vs 5.7%; P < .001). Kaplan-Meier analysis demonstrated significantly worse 90-day survival after transplant in the donation after circulatory death group (log-rank P = .039) but no difference on landmark analysis for survivors after 90 days (log-rank P = .43). Conclusions: Early results of circulatory death grafts compared with brain death grafts in adult patients with congenital heart disease undergoing heart transplantation have demonstrated worse early survival but similar midterm survival following 90 days. Attention should be placed on improving outcomes during the perioperative period to effectively utilize this potential expanded donor pool in ACHD.

Most studies devoted to the psychological consequences of congenital heart disease (CHD) have dealt with consequences in terms of psychopathology. We wanted to consider two specific aspects of body image, “Rejecting body evaluation” and “Vital body dynamics”. We examined body image of CHD-patients as compared with the general population, the stability of body image of patients over time, and the relationship of body image with disease severity. The study combined a longitudinal (panel-) and a case-control design. The findings were based on a long-term study of CHD-patients with two surveys about 15 years apart with N = 244 who participated in both. The control group consisted of the same number of cases matched by age, gender and education drawn from a national survey designed to examine body image in the general population. More men than women were classified into the group with severe CHD. Body image differences between CHD-patients and controls were found only in men, but not in women, and they emerged primarily in terms of vitality. The two dimensions of body image turned out as moderately to strongly stable over time, relationships between disease severity and body image emerged only for perceived vitality. Contrary to expectation, effects of age and sex were largely absent. The body image of men turned out to be more affected by congenital heart disease than women. Body image is not stable, but it is changing with increasing age, and disease severity is affecting body image only in terms of the perception of physical performance.

BACKGROUND:The adverse effects of perceived excessive workload (work overload), as one major source of work stress, on health and work performance are well-documented; however, studies that examine how work overload has changed over time are lacking. This study aims to examine the time trends in work overload across and within socioeconomic groups in Germany. METHODS:Data from the BIBB/BAuA Employment Surveys of 2006, 2012, and 2018 are used, with response rates between 44% and 14%. Work overload is operationalized by two indicators: qualitative overload (overload due to work difficulty) and quantitative overload (overload due to work amount). Logistic regression models are employed to examine the changes in work overload over time and by socioeconomic subgroup. RESULTS:The results indicate that qualitative overload remained relatively stable over time, with minor increments among workers with a lower educational level. Conversely, quantitative overload increased substantially in the entire sample and in all subgroups. The rise in quantitative overload was especially pronounced among workers with a lower educational level, who also reported increasing levels of qualitative overload. CONCLUSIONS:These findings show that perceived work overload has increased over time in Germany, but mostly regarding work quantity. The study highlights the public health need for managing workload to alleviate stress and enhance health and well-being in the workplace.

Evidence suggests a deterioration of health-related quality of life (HRQL) after breast cancer diagnosis and therapy. This study examines sociodemographic and health-related factors that could be associated with the HRQL of working women with breast cancer during the first five years after primary surgery. Second, it explores potential vulnerable groups with respect to HRQL using decision tree analyses. Women diagnosed with breast cancer who had paid work at diagnosis were recruited at 11 breast cancer centers in the Hannover region, Germany, after primary surgery. Assessments took place four times. 455 patients completed mailed questionnaires at 3 weeks after primary surgery. Women were followed up at 6 months, 1 year and on average 5 years after primary surgery. The physical and mental wellbeing dimensions of HRQL were examined through the Short-Form health survey-12. Potential associations between HRQL and health and sociodemographic factors were examined using multiple linear regression. Classification tree analyses were applied to define specific vulnerable groups. Mastectomy (ß=-2.49; CI:-4.67, -0.30) and chemotherapy (ß=-4.25; CI:-7.04, -1.46) as health related factors were significantly associated with poorer physical wellbeing at 3 weeks and 6 months after primary surgery, respectively. Returning to work (RTW) after having been on sick leave was strongly associated with better HRQL as illustrated by higher sum scores for physical (at 3 weeks: ß=6.21; CI:3.36, 9.05; at 6 months: ß=5.40; CI:3.01, 1.80; at 1 year: ß=8.40; CI:5.31, 11.49) and mental wellbeing (at 6 months: ß=6.03; CI:33.25, 8.81; at 1 year: ß=7.71; CI:4.85, 10.58) until 1 year after primary surgery. However, its significant effect was no more apparent at 5 years after primary surgery. At that stage, income was mostly associated with physical (ß=0.002; CI:0.0002, 0.003) and mental wellbeing (ß=0.002; CI:0.0005, 0.003) with higher summary scores for higher income especially in women aged ≤ 61 years. In addition, living with a partner appeared to be an important positively associated factor with better mental wellbeing in women with breast cancer (at 6 months: ß=3.68; CI: 0.72, 6.63; at 5 years: ß=2.85; CI:0.39, 5.32) and the first splitting node that defined vulnerability at 5 years. HRQL in breast cancer appears to be a multidimensional phenomenon associated with disease, treatment and social factors. A special focus should be drawn to women with lower income and those not living with a partner when planning rehabilitation programs and strategies that aim to improve the long term HRQL in breast cancer. As RTW appeared to be positively associated with HRQL, future research should examine potential causal relationships between RTW and HRQL in breast cancer in order to provide evidence needed to plan prevention strategies that aim to improve HRQL after breast cancer.

We examined trends in severe functional limitations among working and non-working adults in Germany (ages 40-65). Four population-based samples of 11,615 participants were used, spanning the time periods 2002-2021. The overall prevalence of severe limitations was found to be 12.8% in the sample, but also varied from 10 to 20% according to occupational group. Over time, severe limitations were found to have increased, from 10.6% in 2002 to 13.2% in 2021. Logistic regression analysis showed that severe limitations increased significantly in certain subgroups, including working women with a low skilled white collar occupational group, working men with a low skilled blue collar occupational group and, particularly, among the whole non-working population, whereas limitations remained largely the same in the other groups, including most of the working population. In terms of expectancies, overall working life expectancy increased. Along with this increase, healthy (non-severely limited) working life expectancy increased, but this trend was accompanied by a clear increase in unhealthy working life expectancy (severely limited). Thus, although severe limitations have increased in some groups in the working-age adults, people today can expect to work more years free from severe limitations than before. In the future, potentials to increase working life expectancy may come to an end, as severe limitations increased strongly in the non-working population, which could limit the prospects for a further increase in the proportion of the population in employment. Further studies are needed to investigate the potential impact of the increasing prevalence of severe limitations on the population's ability to work.

The objective of universal health care systems is to achieve equality in the use of health services at the same level of care need. This study evaluates the relationship of socioeconomic position with the frequency of doctor visits in subjects with and without chronic diseases in Germany and Spain. The dependent variables included number of consultations and if a medical consultation occurred. The socioeconomic factors were income and education. The magnitude of the relationship between socioeconomic position and medical consultation frequency was estimated by calculating the percentage ratio using binomial regression and by calculating the difference in consultations by analysis of the covariance, in the case of number of visits. Statistically significant findings according to education were not observed. The percentage ratio in the medical consultations among those with lower and higher income was 1.03 (95% confidence interval [CI] 1.01-2.88) in Germany and 1.11 (95% CI 1.03-1.20) in Spain among subjects with any of the studied chronic conditions. Also, in Germany the difference in the average number of consultations comparing lower income subjects with higher was 3.98 (95% CI 2.40-5.57) in those with chronic conditions. In both countries, there were no differences in the frequency of doctor visits according to education. However, a pro-inequality trend exists in favor of subjects with lower income.