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

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.It is well established that employment grade, educational level, and household income are important predictors of mortality [1], cardiovascular risk factor levels and morbidity [2,3]. The international research supports an inverse association between socioeconomic status and cardiovascular disease [4-6]. More recently, the impact of socioeconomic factors throughout life course has been examined [7,8].An ongoing debate in the field of inequality and health focuses on two as yet unproven extensions of this association, which can be phrased as research questions:1. Is individual health status associated with individual income and (particularly) with income inequality at aggregate (e. g. regional) level? [9]2. If there is indeed an association between income inequality and health status, does it operate via a psychosocial pathway (stress due to perceptions of relative disadvantage and the psychological consequences of inequality) [9,10]; or via a ？