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Open Access Research article

Health inequalities in Germany: do regional-level variables explain differentials in cardiovascular risk?

Juergen Breckenkamp1, Andreas Mielck2 and Oliver Razum1*

Author Affiliations

1 Department of Epidemiology and International Public Health, School of Public Health, University of Bielefeld, POB 10 01 31, 33501 Bielefeld, Germany

2 Institute of Health Economics and Health Care Management, GSF – National Research Center for Environment and Health, POB 11 29, 85758 Neuherberg, Germany

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BMC Public Health 2007, 7:132  doi:10.1186/1471-2458-7-132

Published: 1 July 2007



Socioeconomic status is a predictor not only of mortality, but also of cardiovascular risk and morbidity. An ongoing debate in the field of social inequalities and health focuses on two questions: 1) Is individual health status associated with individual income as well as with income inequality at the aggregate (e. g. regional) level? 2) If there is such an association, does it operate via a psychosocial pathway (e.g. stress) or via a "neo-materialistic" pathway (e.g. systematic under-investment in societal infrastructures)? For the first time in Germany, we here investigate the association between cardiovascular health status and income inequality at the area level, controlling for individual socio-economic status.


Individual-level explanatory variables (age, socio-economic status) and outcome data (body mass index, blood pressure, cholesterol level) as well as the regional-level variable (proportion of relative poverty) were taken from the baseline survey of the German Cardiovascular Prevention Study, a cross-sectional, community-based, multi-center intervention study, comprising six socio-economically diverse intervention regions, each with about 1800 participants aged 25–69 years. Multilevel modeling was used to examine the effects of individual and regional level variables.


Regional effects are small compared to individual effects for all risk factors analyzed. Most of the total variance is explained at the individual level. Only for diastolic blood pressure in men and for cholesterol in both men and women is a statistically significant effect visible at the regional level.


Our analysis does not support the assumption that in Germany cardiovascular risk factors were to a large extent associated with income inequality at regional level.