Health and Lifestyle in Rural Northeast Germany: The Findings of a Rural Health Study from 1973, 1994 and 2008

How do changed living conditions in a peripheral, rural area affect the health and lifestyle of its population? The present study addresses this question. Its special feature is that it compares the findings of a survey we conducted in 2008 with those of earlier surveys conducted by our predecessors in the same communities in 1973 and 1994 (1, 2). We performed this Rural Health Study (Landgesundheitsstudie, LGS) to examine secular trends in health, health-related behavior, illness, and living conditions. As far as possible, we will compare its findings with representative data for Germany and evaluate their significance.

Methods

In this study, we evaluated survey findings from 1973, 1994, and 2008 and supplemented this evaluation with regional statistical analyses and qualitative interviews.

All of the surveys were carried out among the adult population of 14 rural, peripheral communities in northeastern Germany. The communities to be surveyed were chosen at random in 1973 from among all the rural communities of what was then the Neubrandenburg district in East Germany. Standardized paper-and-pencil questionnaires were addressed to all adults in these communities in 1973, 1994, 2004 (the pre-test), and 2008 (the main survey). After correction for qualitatively neutral missing data, the response rate of returned questionnaires in 2004/2008 was 37% (1246 respondents). The corresponding figures for the earlier surveys were 83% (3603) in 1973 and 68% (2155) in 1994.

A comparison with official registry data at the district (Bezirk) and state (Land) level reveals that the differences over time in age and sex distribution among the respondents to the surveys in 1973, 1994 and 2004/08 (Table 1) are well explained by birth and migration trends over the past four decades. A wave comparison thus seems appropriate (3). The survey data from 2004/08 were weighted according to official registry date for the population of the surveyed communities in these years. Controlling for other variables was performed with further tests of representativeness (for details, see eMethods, [4] and [5]).

Table 1

Distribution of sex, age, and educational level in the Rural Health Study in 1973, 1994 and 2004/08

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The data were analyzed with descriptive statistics and binary logistic regressions. The age-adjusted prevalences reported here were adjusted according to the age distribution of the (weighted) sample in 2004/2008. The comparisons over time that are presented here are based on cross-sectional comparisons (for further details on this and on panelization on the basis of individual data, see eMethods and [5]).

The quantitative analyses were supplemented by biographical interviews with selected inhabitants of the region and by interviews with experts, mainly the mayors of the surveyed communities. Computer-assisted data analysis with MAXQDA 2007 was performed, as well as analyses that were essentially based on the documentary method (6, 7).

Regional statistical information, cultural-historical information, and our own field observations were compiled in standardized monographs on each community. Some of this information was also evaluated in secondary analyses for an overall characterization of the study area for interregional comparisons, as well as in the context of the survey findings (8). To make interregional comparisons, we used representative data at the national level, as well as the findings of the German Socio-Economic Panel (SOEP), the microcensus of the German Federal Statistical Office, and the German Federal Health Survey (Bundesgesundheitssurvey).

Results

The first wave of the Rural Health Study was carried out in 1973 during a phase of modernization, in which the differences between urban and rural environments became less pronounced (1). Working and living conditions had already improved in largely agricultural communities, and the percentage of persons completing secondary education and vocational training had risen, particularly among women. On the other hand, many people retained their traditional health-related habits, such as a high-calorie diet (1).

The second wave was carried out in 1994, by which time rural areas had become further modernized (2): for example, the percentage of the population with more than eight years of education in school had risen from 18% to 48%. Other changes had resulted from the “transformation,” i.e., the collapse of the former German Democratic Republic. The most important of these was a vast decline in employment, e.g., a 75% drop in agricultural employment for the years 1990–93 (2).

The third wave, in 2008, was characterized by regional peripheralization with respect to living conditions, leading to all of the following:

• social-structural decoupling of part of the population;
• low added-value creation, expansion of the low-wage sector, and precarious employment;
• deteriorating infrastructure and diminishing quality of life;
• low political participation and low involvement in institutions (9, 10).

As these processes go on, the options and opportunities for rural inhabitants become narrower, and their living strategies may well be nothing more than an attempt to make the best of a bad situation (11).

Health-related behavior

O ver the entire period of the study, health-promoting behaviors became more common in most areas of health-related behavior (Table 2). The percentage of persons participating in exercise and sporting activities rose markedly (in the last survey), particularly among women, who exercised more than men (58.1% vs. 54.5%).

Table 2

Health-related behaviors: prevalences in 1973, 1994 and 2004/08

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The rural inhabitants consumed more fruit, vegetables, and dairy products than they had done in 1973 (when some of these were less available); women consumed more of each of these items than men (Table 2). On the other hand, the percentage of men who ate meat every day, or almost every day, rose to 28.5% by 2008. There was a steady decline in the percentage of persons who felt that they “had enough time for meals, in particular for the main meal of the day” (which was the evening meal for 20% of persons in 2008), as well as in the percentage of those who thought they had a healthful diet (78.7% in 2008, see Table 2).

The mean body-mass index (BMI) rose slightly between waves 2 and 3, with a rise in the percentage of obese respondents to 23.4% among women and 25.0% among men (these figures are both roughly 10% higher than those of the nationwide microcensus for 2009). Comparable findings were obtained in the Study of Health in Pomerania (SHIP), which revealed a markedly higher average BMI in the eastern German region of West Pomerania than in the nation at large (12).

The meaning of such findings for the inhabitants’ lifestyle is well illustrated by what one of our interviewees said in the qualitative part of the study: “When the money is running low, I sometimes have to make an unhealthy toast sandwich for the children. It’s not so bad if I can put some liverwurst on it” (from an unemployed single mother and former factory worker, age 45).

Smoking (Table 2) became much less common among men over the period of the study (from 61.2% to 34.6%), in accordance with the nationwide trend, but much more common among women (from 9.5% to 26.6%). By 2004/2008, the percentage of persons who had started smoking before their 16th birthday had risen to 42.3% among women and 52.7% among men, and the average age of beginning smoking was lower than that of the nation as a whole. The percentage of persons smoking more than 20 cigarettes per day had risen to 15%.

Among men, the regular consumption of beer and hard liquor declined over time; among women, the regular consumption of wine increased. Between waves 2 and 3, for example, fewer men drank large quantities of beer and/or hard liquor each day (more than 2 liters of beer daily: 3.2% to 0.5%), while more women drank up to one glass of wine daily (24.7% to 29.1%) (13). The prevalence of dangerous alcohol consumption (> 30 g of pure alcohol for men, > 20 g for women) dropped to 25.1% among men, but this figure remained significantly higher than the corresponding figure for women (Figure 1) and also well above the national figure (20.1% / 5.3%) (13). These findings were associated with an increased statewide morbidity and mortality due to alcohol-associated diseases (12).

Figure 1

The prevalence of alcohol consumption patterns in the Rural Health Study (LGS), 1994–2008, based on data from 2155 respondents in 1994 and 1246 respondents in 2004/08.

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Working conditions

With respect to working conditions in 2004/2008, the region under study was characterized by the following, compared to other regions across Germany:

• a dearth of jobs,
• a high percentage of agricultural workers,
• and a marked decline in industrial employment.

Respondents complained particularly of the fear of losing their jobs and of the hard physical labor that they had to perform (mainly in the agricultural and industrial sectors).

One respondent stated in an interview: “Some of the people who still have work seem to think they’re something special, because they’re working and all. We’d also like to work, but I just don’t get the chance” (from an unemployed female landscape designer, 48).

In 2004/08, the percentage of so-called gratification crises (perceived inadequacy of reward in relation to effort [14]) among employed people in the study region was twice as high as the national average. This was particularly true among workers in the markedly declining industrial sector, more than 40% of whom reported a gratification crisis (15).

Health and disease

For both men and women, the age-standardized percentage of persons who reported being in good or very good health was lowest in 1994 (Table 3). The increase from 1994 to 2004/08 was, however, much more pronounced in women than in men. In fact, the percentage of men reporting good or very good health in 2004/08 was slightly less than in 1973, while 17% more women reported being in good or very good health in 2004/08 than in 1973. Similar trends can be seen in nationwide age-and sex-specific health data (12).

Table 3

Subjective assessment of health as good or very good: prevalences and 95% confidence intervals, 1973–2008

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The prevalence of chronic heart diseases (Table 4) was highest in 1994, dropping thereafter in women, but only slightly in men; the age-adjusted figures for 2008 show a higher prevalence among men than among women. The prevalence of diabetes mellitus (Table 4) was four times higher among men in 2004/2008 than in 1973, and 3.5 times higher among women (Table 4). A relatively large rise among men was also observed nationwide over the same period, albeit to a lesser extent (12). The mean nationwide diabetes prevalences reported on the basis of the Current Health in Germany 2009 telephone survey (Gesundheit in Deutschland aktuell 2009, GEDA09) were markedly lower among both men and women than the corresponding figures that we obtained in the LGS 2004/08 (6–8% vs. 12–13%). The latter figures were also markedly higher than the corresponding figures of the SHIP, which covered both rural and urban areas (12). These findings are clearly related to the markedly above-average BMI among the population of our study region. The lifetime prevalence of high blood pressure also rose steadily and markedly, mainly among men, though not as much as that of diabetes did (Table 4). For more details on health and disease, see (16).

Table 4

Chronic heart diseases, diabetes mellitus, and hypertension: lifetime prevalences and 95% confidence intervals, 1973–2008

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Satisfaction

Satisfaction with individual areas of life, as well as with life overall, dropped in practically all areas from 1994 to 2004/08 in the region of the study. The areas of least satisfaction in both 1994 and 2004/08 were financial and occupational. Satisfaction with health declined with increasing age and was also below average among the unemployed and among respondents who had attended school for less than ten years. A comparison of the LGS findings with those of the SOEP (17) reveals (Figure 2) that mean job and income satisfaction in the LGS study region were both markedly lower than they were, on average, in both western and eastern Germany, not only in 1994, but also in 2004/08. Health satisfaction was also lower among LGS respondents than among SOEP respondents, although the difference was less marked than the differences in job and income satisfaction. Health satisfaction increased somewhat from 1994 to 2008 in both the SOEP (West) and the SOEP (East), but declined from 1994 to 2004/08 in the LGS (Figure 2). The smallest differences were found in reported overall life satisfaction: the LGS figures for both 1994 and 2004/08 were worse than those of the SOEP (West), but they were comparable to the SOEP (East) figures for 2004/08 and actually slightly better than the SOEP (East) figures for 1994. Thus, the overall comparison indicates markedly lower job and income satisfaction in rural northeast Germany in 1994 and 2004/08 (Figure 2).

Figure 2

Satisfaction in various areas of life in the Rural Health Study and the Socio- Economic Panel (East and West), 1994 and 2008 (mean values)

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Coping strategies

The qualitative part of the study allowed us to examine how persons in the study area dealt with their problematic living and working conditions and the ensuing consequences for health, disease, and life satisfaction.

Many interviewees complained of stress resulting from low income and joblessness, and many also complained of a decline in infrastructural resources, such as local public transportation or shopping opportunities. Some, however, said they had succeeded in developing and/or maintaining coherence and life satisfaction despite unfavorable conditions, such as joblessness, poverty, or long-distance commuting, by taking advantage of locally available opportunities, such as non-recompensed individual work (see 18 for a further description), integration, and social support from the village community (18).

One interviewee, for example, said the following: “We always have something to do. . . . I’m always needed. Even if the Job Office doesn’t have any way for me to earn money, I’m needed someplace else, and that means a lot to me. I have interests: my home, rearranging things . . . . yes, that makes life kind of enjoyable” (from the interview transcript of case L:129).

Discussion

The analyses of the survey data show that, overall, persons in the study area considered themselves to be in better health at the end of the study than at the beginning, reflecting a trend also seen in the German population as a whole. This improvement was associated with a marked rise in educational attainment and with generally positive changes in dietary habits, exercise/sporting activities, smoking, and alcohol consumption. We cannot fully exclude the possibility that, particularly with respect to health-related behavior (in all waves of the study, 1973 included), the respondents’ answers were colored by social expectations and thus more positive than they should have been.

The increased burden of certain diseases that was observed in the study may be due, in part, to improved diagnosis. It is, nonetheless, clear that the study region had a higher burden of disease than other regions, with correspondingly lower health satisfaction and overall life satisfaction.

The empirical findings provide a basis for potential theoretical explanations of parallel developments in health and lifestyle in the region. In the authors’ view, the observed regional (and also supra-regional) trends in health and disease, education, and health-related behavior, as well as the continuing rationalization of work and the associated los of jobs, are all manifestations of the modernization of living and working conditions.

On the other hand, we consider the regionally specific differences in employment, living conditions, health, burden of disease, and life satisfaction that were revealed by the LGS to be mainly attributable to the regional and peripheral nature of the study region. All of these differences present a challenge for social and health-care policy. There is a need, in the intermediate term, for the expansion of regional or national programs for the promotion of involvement in civic and cultural life, and for the connection of small communities to such programs (“active village” programs); it would also be desirable to improve the provision of health care in rural areas so that people no longer have to travel far to see a doctor. Nonetheless, as was discussed in the follow-up conferences that were held in the rural communities (19), the remediation of the structural job shortage should also remain a priority, so that the regional problems that are already evident do not become even worse.

Limitations

The study findings can presumably be extrapolated to other communities that are located in the region of the study but were not surveyed for it. We do not know, however, to what extent the already observed peripheralization can be expected to continue in the future, or whether the findings are also applicable to other peripheral regions.

Methodological limitations of this study include the declining rate of respondents over the years and the less than full comparability of the items in our survey with those of other surveys. We often had to approximate as well as we could (also because the reference data from other studies represent different areas). Inter-regional comparisons will become easier in the future if further studies on trends and needs in rural, peripheral areas will be performed in other regions besides the one that we investigated in this study.

eTable 1

Health-related behaviors: prevalences in 1973, 1994 and 2004/08

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eTable 2

Features of the qualitative sample (overview)

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For further information: see: www.hs-nb.de/ppages/elkeles-thomas/projekte/

Acknowledgement
The authors thank the German Research Foundation (Deutsche Forschungsgemeinschaft) for their support of the study entitled “Health and Lifestyle in Rural Northeast Germany”(„Gesundheit und alltägliche Lebensführung in nordostdeutschen Landgemeinden“) (DFG-FZ: EL 493/2–1) in the period 2008–2010.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 4 November 2011, revised version accepted on 13 February 2012.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Prof. Dr. med. Dipl.-Soz. Thomas Elkeles
Hochschule Neubrandenburg
Fachbereich Gesundheit, Pflege, Management
Postfach 11 01 21,D-17041 Neubrandenburg, Germany
elkeles@hs-nb.de

@For eReferences please refer to:
www.aerzteblatt-international.de/ref1612

eMethods and eTables:
www.aerzteblatt-international.de/12m285