BMJ OpenFor peer review only 16 1 women.24 Unemployment and the changes in the labour market may...

For peer review only

Psychosocial stressors related to German reunification in

1989/1990 and the development of cardiovascular risk

factors and cardiovascular diseases in the former German

Democratic Republic

Journal: BMJ Open

Manuscript ID: bmjopen-2015-008703

Article Type: Research

Date Submitted by the Author: 07-May-2015

Complete List of Authors: Bohley, Stefanie; Institute of Medical Epidemiology, Biostatistics and Informatics, Kluttig, Alexander; Institute of Medical Epidemiology, Biostatistics and Informatics, Werdan, Karl; Department of Medicine III, Nuding, Sebastian; Department of Medicine III, Greiser, Karin Halina; Division of Cancer Epidemiology, Kuss, Oliver; German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University, Institute of Biometrics and Epidemiology

Markus, Marcello; Institute for Community Medicine, Schmidt, Carsten; Institute for Community Medicine, Völzke, Henry; Institute for Community Medicine, University Medicine Greifswald Krabbe, Christine; Institute for Community Medicine, Haerting, Johannes; Institute for Biometrics and Epidemiology, German Diabetes Center,

<b>Primary Subject Heading</b>:

Cardiovascular medicine

Secondary Subject Heading: Epidemiology

Keywords: Cardiac Epidemiology < CARDIOLOGY, EPIDEMIOLOGY, SOCIAL MEDICINE

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Psychosocial stressors related to German reunification in 1989/1990 and the 1

development of cardiovascular risk factors and cardiovascular diseases in the 2

former German Democratic Republic 3

4

Stefanie Bohley1 (Corresponding Author) 5

Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-6

University Halle-Wittenberg 7

Magdeburgerstraße 8, 06112, Halle (Saale), Germany 8

E-Mail: [email protected] Telephone: +49 345 557 35 79 9

10

Alexander Kluttig1, Karl Werdan2 , Sebastian Nuding2 , Karin Halina Greiser3 , Oliver 11

Kuss4, Marcello Ricardo Paulista Markus5 , Carsten Oliver Schmidt5 Henry Völzke5 , 12

Christine Krabbe5, Johannes Haerting1 13

14

1 Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-15

University Halle-Wittenberg, Halle (Saale), Germany 16

2 Department of Medicine III, Martin-Luther-University Halle-Wittenberg, Halle 17

(Saale), Germany 18

3 Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg, 19

Germany 20

4 Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz 21

Institute for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany 22

5 Institute for Community Medicine, University of Greifswald, Greifswald, Germany 23

24

25

Keywords: Psychosocial stressors, Cardiovascular diseases, Cardiovascular risk 26

factors, Social Change, German Reunification 27

28

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Abstract 1

Objectives: 2

The aim of this study was to examine the relationship between changes in 3

psychosocial stressors associated with German reunification and cardiovascular 4

effects. We hypothesised that higher levels of psychosocial stress related to German 5

reunification, were associated with an increase in cardiovascular risk factors and 6

cardiovascular diseases. 7

Design: Cross-sectional data from two cohort studies in East Germany were used: 8

Cardiovascular Disease, Living and Ageing in Halle Study (CARLA) and Study of 9

Health in Pomerania (SHIP). 10

Setting: Two populations in the eastern part of Germany. 11

Participants: CARLA study: 1.779 participants aged 45 to 83 at baseline (812 12

women), SHIP study: 4.308 aged 20 to 79 at baseline (2.193 women). 13

Primary and secondary outcome measures: Psychosocial stressors related to 14

reunification were operationalised by the Reunification Stress Index (RSI; scale from 15

0 to 10). This index was composed of questions that were related to changes in 16

psychosocial stressors (occupational, financial, and personal) after reunification. To 17

examine the associations between the RSI and each stressor separately with 18

cardiovascular risk factors and CVD, regression models were used. 19

Results: RSI was associated with CVD in women (RR=1.15, 95% CI=1.00-1.33). 20

Cardiovascular risk factors were associated with RSI for both men and women with 21

strongest associations between RSI and diabetes in women (RR=1.10, 95% CI=1.01-22

1.20) and depressive disorders in men (RR=1.15, 95% CI =1.07-2.77). The change in 23

occupational situation related to reunification was the major contributing psychosocial 24

stressor. We observed a strong association with CVD in women who experienced 25

occupational deterioration after reunification (RR=4.04, 95% CI =1.21-13.43). 26

Conclusion: Psychosocial stressors changed during reunification and have favoured 27

cardiovascular risk factors and CVD. The associations were stronger in women than 28

in men. An explanation for these findings could be that women were more often 29

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affected by unemployment after reunification. Morbidity and mortality follow-up of 1

both cohorts could enhance the results. 2

3

Strengths and limitations of this study 4

• This study is the first to analyse psychosocial stressors that changed through 5

a transition with direct reference to cardiovascular outcomes on an individual 6

basis. 7

• Furthermore, both studies are representative samples and the assessment of 8

the data are highly standardized and in agreement with other German and 9

international studies. 10

• Regarding the study population, we cannot rule out the possibility of a 11

selection bias. 12

• The analysis faces the usual restrictions of a cross-sectional design: to 13

determine the causality, a longitudinal design would be required. 14

• Additionally, we cannot exclude that outcomes like depressive disorders or 15

hypertension already persisted before reunification. Therefore, the direction of 16

causality cannot be established for most of the outcomes. However, the 17

exposure RSI refers to a fixed event in the past (German reunification) so we 18

can assume a chronological order of exposure and disease outcomes MI and 19

stroke. 20

21

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Introduction 1

Mortality from cardiovascular diseases (CVD) has decreased in the last century in 2

European countries. However, an east-west gradient of higher mortality in central and 3

eastern European countries is still present.1,2 After the epochal process of the 4

societal transition starting in 1989/90 in Central and Eastern Europe and the former 5

Soviet Union, these discrepancies increased enormously.3-6 Studies have described 6

possible causes for the increase in cardiovascular mortality after the collapse of the 7

socialist and communistic regimes.7-9 Some authors have particularly emphasized 8

the importance of psychosocial stressors on the increase in cardiovascular mortality 9

after the social change.10-13 10

It has been repeatedly shown that psychosocial stressors (e.g. job strain, social 11

isolation, depression, critical life events) can contribute to the development of CVD.14 12

The political, social, and economic changes in the German Democratic Republic 13

(GDR), the so-called “reunification”, brought serious changes in requirements and 14

fully modified the societal environment of the inhabitants. Reunification was a 15

population-based critical life event, which entailed other critical life events.15,16 16

The implications of psychosocial stressors during the process of a social transition as 17

a form of social change are still unclear. As such, some researchers requested 18

further investigations to better understand the links between social change, 19

psychosocial stressors, health behaviour, and the resulting impacts on health.6,11 The 20

aim of this study was to examine the relationship between changes in psychosocial 21

stressors associated with German reunification and cardiovascular effects. We 22

hypothesised that higher levels of psychosocial stress related to this critical life event, 23

i.e. reunification, were associated with an increase in cardiovascular risk factors and 24

CVD. 25

Methods 26

Study design and study population 27

This study was based on cross-sectional data from the baseline assessment of two 28

cohort studies in East Germany: the Cardiovascular Disease, Living and Ageing in 29

Halle Study (CARLA) in Saxony-Anhalt (2002-2006)17 and the Study of Health in 30

Pomerania (SHIP) (1997-2002)18. We combined the cohorts for two reasons: firstly, 31

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these cohorts are the only once that assessed psychosocial stressors related to 1

reunification, secondly, to increase the sample size. Both studies drew random 2

samples from mandatory lists. Data collection included a standardised, computer-3

assisted interview, questionnaires and a physical examination by trained study 4

nurses. Written informed consent was obtained upon enrolment. Both studies were 5

approved by the local ethical committees of the associated medical schools. The 6

response proportion was 64% for CARLA and 69% for SHIP. The CARLA study 7

population comprised 1.779 participants aged 45 to 83 at baseline (812 women). The 8

number of subjects participating in the SHIP study was 4.308 aged 20 to 79 at 9

baseline (2.193 women). For this study, we excluded participants who had a 10

diagnosis of myocardial infarction (MI) and/or stroke that predated 1990 (N=123), had 11

not resided in the former GDR (N=120), were unoccupied before 1990 (N=1.701), 12

who were <=16yrs in 1990 (N=94), or those for whom data were missing on the 13

components of the Reunification Stress Index (RSI) (N=148). In total the study size 14

comprised N=3.901. 15

Reunification Stress Index 16

We operationalised the psychosocial stressors related to reunification through the 17

RSI. The index was computed based on the answers obtained by the following three 18

questions: “Has your occupational situation changed since reunification (since 19

1990)?”, “Has your financial situation changed since reunification (since 1990)?”, and 20

“Has your personal situation (e.g. your personal contacts with friends or relatives) 21

changed since reunification (since 1990)?” The possible answers differed between 22

the studies: CARLA: 1=greatly improved, 2=improved, 3=no change, 4=deteriorated, 23

5=greatly deteriorated, SHIP: 1=improved, 2=no change, 3=deteriorated. The 24

indicators were added into a total sum. We computed the mean of the indicators for 25

each participant. RSI was calculated and standardised to a scale from 0 to 10 to 26

make it comparable between the studies with the following formula: RSI=(mean-27

1)*10/range of the mean (mean: mean of the items of any particpants;1: minimum 28

value of the mean; 10: chosen maximum value of the RSI; range of the mean was in 29

CARLA=4 and in SHIP=2). Values less than 5 indicate an improvement in 30

psychosocial factors after reunification, a value of 5 indicates no changes in 31

psychosocial factors after reunification, and values higher than 5 indicate a 32

deterioration in psychosocial factors after reunification. The RSI was externally 33

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validated by an independently conducted interview of 19 participants of the CARLA 1

cohort. Furthermore, we also analysed the questions of the RSI separately in order to 2

estimate the proper effect of each psychosocial stressor (occupational, financial, and 3

personal) on the outcomes. 4

Cardiovascular diseases and cardiovascular risk factors 5

Prevalent MI and stroke were defined as self-reported physician’s diagnoses. 6

Coronary heart disease (CHD) was defined as the presence of MI, and/or self-7

reported coronary artery bypass surgery, and/or self-reported percutaneous coronary 8

intervention. CVD was defined as CHD and/or self-reported physician-diagnosed 9

stroke, and/or carotid surgery. Hypertension was defined as mean systolic blood 10

pressure greater or equal to 140 mmHg, and/or mean diastolic blood pressure 11

greater or equal to 90 mmHg, and/or use of antihypertensive medication according to 12

the Anatomical Therapeutic Chemical Classification System. For high-risk drinking in 13

men, we used a cut-off of >30 mg alcohol/day and in women a cut-off of >20 mg 14

alcohol/day.19 Body mass index (BMI) was calculated as kg/m2. The definition of 15

diabetes mellitus was based on self-reported physician’s diagnosis (yes/no). Smoking 16

behaviour was grouped as yes (current smoker and ex-smoker) or no (never 17

smoker). Laboratory analyses of non-fasting venous blood samples included serum 18

total cholesterol in mg/dL. In CARLA, the Centre for Epidemiological Studies 19

Depression scale (CES-D) was used to assess depressive disorders.20 This 20-item 20

scale asks respondents to evaluate how often (“rarely or never” to “most or all of the 21

time”) in the last week they had experienced a symptom. We used a cut-off of ≥ 23 22

points to define depressive disorders. 21 The presence of psychiatric disorders in the 23

SHIP cohort was assessed using the Composite International Diagnostic-Screener 24

(CID-S), a 12-item self-reported questionnaire which covers psychiatric diagnoses 25

according to DSM-IV.22 The CID-S also covers depressive disorders. The screening 26

questions for depressive disorders included the following two items: “Feelings of 27

sadness or depressed mood for a period of at least two weeks” and “Lack of interest, 28

tiredness, or loss of energy for a period of at least two weeks”. Participants who 29

answered positively to both questions were classified as having depressive disorders. 30

Educational level was composed of school and vocational education and categorised 31

into three levels: low (no or intermediate secondary school leaving certificate without 32

a completed vocational qualification), moderate (intermediate secondary school 33

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leaving certificate and vocational training), and high (upper secondary school leaving 1

certificate degree and/or a completed university degree). Details of definitions of the 2

variables are given in the respective design papers.17,18 3

Statistical analyses 4

For MI and stroke, time-to-event data were available. The beginning of the time count 5

was 1990. To examine the association between the RSI and the events MI and 6

stroke, we estimated hazard ratios (HR) and corresponding 95% confidence intervals 7

by running proportional hazard regressions. Persons without an event were 8

censored. The association of RSI with dichotomous outcomes CVD, CHD and 9

cardiovascular risk factors (hypertension, diabetes, smoking, and depressive 10

disorders) was examined by running log-binomial regression models to estimate 11

relative risks (RR) and corresponding 95% confidence intervals. In case of non-12

convergence of the models, we used Poisson regression with robust variance. For 13

the associations between the RSI and continuous metric outcomes (BMI, cholesterol, 14

and alcohol) linear regression models were applied to obtain the regression 15

coefficient beta (β) and corresponding 95% confidence intervals. To estimate the 16

association between any single psychosocial stressor (occupational, financial, and 17

personal) and cardiovascular diseases and/or cardiovascular risk factors, we used 18

the same regression models as described above. The reference group was 19

composed of those participants who experienced an improvement after reunification. 20

We checked the model assumptions by visual inspection of residual plots. Model 21

assumptions were fulfilled. We identified minimally sufficient adjustment sets (MSAS) 22

to estimate the total effect by using causal diagrams that represent the relationships 23

between exposure, outcome, and other covariables.23 Causal diagrams resulted in a 24

MSAS which contains sex, age, study and education. We tested interaction effects 25

for study*RSI, education*RSI, and age*RSI. However, no significant interaction 26

effects were found. We stratified all analyses by sex. All analyses were done with 27

SAS, version 9.3. (SAS Institute, Cary, NC, USA) 28

Results 29

51.9% of the 3.901 study participants were male. The CARLA participants were 30

older, had more cardiovascular risk factors and cardiovascular diseases than the 31

SHIP participants, except for smoking, alcohol consumption, depressive disorders, 32

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and education. In total, men had more cardiovascular diseases and cardiovascular 1

risk factors then women, except for BMI, education, and depressive disorders. The 2

mean value of the RSI was 4.8 (SD=2.4) for men and 4.9 (2.4) for women. The 3

majority of the participants had an RSI less than 5 (men 46.2%, women 42.9%). 4

34.6% of the men and 36.1% of the women underwent a deterioration in 5

psychosocial stressors after reunification. The RSI was highest in the age-group of 6

45-<55 years for both men and women (5.3 (2.4); 5.4 (2.3)). The change in 7


stressor. We observed a deterioration in the occupational situation after reunification 9

in 37.0% (men) and 38.3% (women). An improvement was reported in 31.9% of the 10

male and 28.5% of the female participants. The majority reported an improvement in 11

their financial situation (men: 55.7; women: 49.4) and no changes in the personal 12

situation after reunification (men: 65.6; women: 71.6). 13

14

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Table 1: Characteristics of the study participants, stratified by sex and study 1

CARLA SHIP TOTAL

Men

(n=703)

Women

(n=565)

Men

(n=1298)

Women

(n=1335)

Men

(n=2001)

Women

(n=1900)

Age

Mean (SD)

24 - <45 (n)

45 - <55 (n))

55 - <65 (n)

65 - <75 (n)

>=75 (n)

61.3 (8.5)

-

205

248

204

46

59.0 (7.0)

-

197

237

130

1

46.9 (12.3)

591

301

301

94

11

43.6 (11.1)

667

366

262

35

5

51.9 (13.0)

591

506

549

298

57

48.8 (12.1)

667

563

499

165

6 Ag

e g

rou

p

CV

D

MI; n (%) 42 (6.0) 7 (1.2) 30 (2.3) 5 (0.4) 72 (3.6) 12 (0.6)

Stroke; n (%) 20 (2.8) 9 (1.6) 10 (0.7) 8 (0.6) 30 (1.5) 17 (0.9)

CHD; n (%) 54 (7.7) 13 (2.3) 33 (2.5) 5 (0.4) 87 (4.3) 18 (1.0)

CVD; n (%)

69 (9.8) 22 (3.9) 41 (3.1) 13 (1.0) 110 (5.4) 35 (1.8)

Card

iova

sc

ula

r ri

sk

fac

tors

Hypertension; n (%) 534 (76.9) 377 (66.7) 784 (60.7) 455 (34.2) 1318 (66.1) 832 (43.8)

Smoker; n (%) 512 (72.8) 205 (36.3) 1011 (77.8) 739 (55.4) 1523 (76.1) 944 (49.7)

Diabetes; n (%) 83 (11.8) 62 (11.0) 80 (6.2) 57 (4.3) 163 (8.1) 119 (6.3)

High-risk drinking1; n (%) 157 (22.3) 27(4.8) 355 (27.3) 98 (7.3) 512 (25.6) 125 (6.6)

Depressive disorders; n

(%)

33 (4.9) 57 (10.3) 101 (7.8) 227 (17.1) 134 (6.8) 284 (15.1)

BMI; mean (SD) 28.2 (4.1) 28.5 (5.6) 27.8 (3.9) 26.7 (5.3) 27.9 (4.0) 27.2 (5.5)

Cholesterol; mean (SD) 208.7 (40.6) 220.6 (42.9) 227.9 (46.9) 220.2 (46.7) 220.3 (45.6) 221.2 (45.7)

Education

low; n (%)

middle; n (%)

high; n (%)

22 (3.1)

427 (60.7)

254 (36.1)

49 (8.7)

387 (68.5)

129 (22.8)

77 (5.9)

908 (70.0)

313 (24.1)

100 (7.5)

1012 (74.9)

254 (17.9)

99 (5.0)

1335 (66.8)

567 (28.3)

149 (7.9)

1382 (72.4)

369 (19.4)

Ex

po

su

re

RSI; mean (SD) 4.8 (1.6) 5.0 (1.5) 4.8 (2.7) 4.9 (2.7) 4.8 (2.4) 4.9 (2.4)

<5, n (%) =5; n (%) >5; n (%)

331 (47.1) 139 (19.8) 233 (33.1)

235 (41.6) 128 (22.7) 202 (35.8)

593 (45.7) 246 (19.0) 459 (35.4)

580 (43.5) 271 (20.3) 484 (36.3)

924 (46.2) 385 (19.2) 692 (34.6)

815 (42.9) 399 (21.0) 686 (36.1)

RSI by age group

24 - < 45; mean (SD) 45 - < 55; mean (SD) 55 - < 65; mean (SD) 65 - < 75; mean (SD) > 75; mean (SD)

- 5.3 (1.8) 4.9 (1.6) 4.4 (1.4) 4.8 (1.2)

- 5.4 (1.6) 4.8 (1.5) 4.9 (1.2) 3.3 (-)

4.5 (2.7) 5.3 (2.7) 5.2 (2.6) 3.8 (2.5) 2.4 (2.0)

4.6 (2.7) 5.4 (2.6) 5.1 (2.8) 3.7 (2.4) 2.6 (2.3)

4.5 (2.7) 5.3 (2.4) 5.1 (2.2) 4.2 (1.8) 4.3 (1.6)

4.6 (2.7) 5.4 (2.3) 5.0 (2.2) 4.6 (1.6) 2.8 (2.0)

Occupational situation

Improvement; n (%) No change; n (%) Deterioration; n (%)

211 (30.0) 264 (37.5) 228 (32.4)

143 (25.3) 230 (40.7) 192 (33.9)

411 (31.7) 375 (28.9) 512 (39.5)

398 (29.8) 402 (30.1) 535 (40.1)

622 (31.1) 639 (31.9) 740 (37.0)

541 (28.5) 632 (33.3) 727 (38.3)

Financial situation


394 (56.1) 183 (26.0) 126 (17.9)

273 (48.3) 163 (28.9) 129 (22.8)

720 (55.5) 336 (25.9) 242 (18.6)

666 (49.9) 341 (25.5) 328 (24.6)

1114 (55.7) 519 (25.9) 368 (18.4)

939 (49.4) 504 (26.5) 457 (24.1)

Personal situation


46 (6.5) 488 (69.4) 169 (24.0)

23 (4.1) 422 (74.7) 120 (21.2)

131 (10.1) 825 (63.6) 342 (26.4)

139 (10.4) 938 (70.3) 258 (19.3)

177 (8.9) 1313 (65.6) 511 (25.5)

162 (8.5) 1360 (71.6) 378 (19.9)

SD=standard deviation, BMI=body mass index, MI=myocardial infarction, CHD=coronary heart disease, CVD=cardiovascular 2

disease, cholesterol in mg/dL, alcohol in g/day; 1 High-risk drinking: >30 g alcohol per day for men, > 20 g alcohol per day for 3

women 4

5

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RSI and cardiovascular diseases and cardiovascular risk factors 1

In men, no association was found between the RSI and cardiovascular diseases. In 2

women, a positive association was found between the RSI and MI (HR=1.22 95% 3

CI=0.92-1.63), stroke (HR=1.17, 95% CI=0.93-1.47), and CVD (RR=1.15, 95% 4

CI=1.00-1.33). The RSI was associated with all cardiovascular risk factors for both 5

men and women (except high-risk drinking), e.g. per unit increase in RSI, the risk of 6

diabetes in women increased by 10% (RR 1.10, 95% CI=1.01-1.20). The strongest 7

association was seen in men between the RSI and depressive disorders (RR=1.15, 8

95% CI=1.07-1.24). However, the associations between the RSI and cardiovascular 9

risk factors were stronger in women than in men. 10

Table 2: Associations of RSI with cardiovascular diseases and cardiovascular risk 11

factors in men and women 12

Adjusted by education, study, age 13

BMI=body mass index, MI=myocardial infarction, CHD=coronary heart disease, CVD=cardiovascular disease, cholesterol in 14

mg/dL, alcohol in g/day, High-risk drinking: >30 g alcohol per day for men, > 20 g alcohol per day for women 15

16

Psychosocial stressors and CVD 17

We observed a strong association of CVD in women who reported a deterioration or 18

no change in their occupational situation after reunification compared with women 19

who reported an occupational improvement (RR=4.04, CI 95%=1.21-13.43 20

respectively 3.76, CI 95%=1.03-13.72) (Table 3). We found no associations between 21

other cardiovascular diseases and occupational, financial, and personal changes. 22

Men Women

crude adjusted crude adjusted

Card

iov

ascu

lar

dis

ea

se

s

HR (CI 95%) HR (CI 95%) HR (CI 95%) HR (CI 95%) MI 0.98 (0.88-1.08) 1.01 (0.90-1.13) 1.21 (0.92-1.57) 1.22 (0.92-1.63) Stroke 0.90 (0.76-1.06) 0.94 (0.78-1.15) 1.17 (0.94-1.46) 1.17 (0.93-1.47)

RR (CI 95%) RR (CI 95%) RR (CI 95%) RR (CI 95%) CVD 0.94 (0.88-1.01) 0.96 (0.87-1.06) 1.10 (1.00-1.22) 1.15 (1.00-1.33) CHD 0.95 (0.88-1.04) 0.97 (0.87-1.09) 1.07 (0.93-1.24) 1.13 (0.89-1.43)

RR (CI 95%) RR (CI 95%) RR (CI 95%) RR (CI 95%)

Card

iova

scu

lar

risk f

acto

rs

Hypertension 1.02 (1.002-1.03) 1.02 (1.002-1.03) 1.04 (1.02-1.06) 1.04 (1.02-1.06) Smoking 1.02 (1.01-1.02) 1.01 (1.004-1.02) 1.03 (1.01-1.05) 1.03 (1.01-1.04) Diabetes 1.03 (0.98-1.10) 1.05 (0.98-1.13) 1.07 (1.01-1.13) 1.10 (1.01-1.20) High-risk drinking 0.98 (0.95-1.02) 0.99 (0.95-1.02) 0.97 (0.90-1.05) 0.99 (0.92-1.06) Depressive disorders

1.15 (1.06-1.24) 1.15 (1.07-1.24) 1.07 (1.01-1.12) 1.07 (1.02-1.11)

β (CI 95%) β (CI 95%) β (CI 95%) β (CI 95%) BMI 0.17 (0.09-0.24) 0.16 (0.08-0.24) 0.32 (0.22-0.42) 0.25 (0.16-0.55) Cholesterol 1.44 (0.60-2.28) 1.47 (0.64-2.43) 1.70 (0.85-2.55) 1.40 (0.59-2.20)

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Table 3: Associations of the changes in occupational, financial, and personal 1

situation after reunification with CVD in men and women 2

Men Women




Improvement 1 1 1 1

No change 0.97 (0.63-1.49) 0.71 (0.46-1.08) 4.56 (1.33-15.54) 3.76 (1.03-13.72)

Deterioration 0.68 (0.43-1.08) 0.79 (0.50-1.26) 3.96 (1.16-13.55) 4.04 (1.21-13.43)

Financial situation

Improvement 1 1 1 1

No change 0.99 (0.65-1.50) 0.91 (0.60-1.36) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.69 (0.40-1.20) 0.90 (0.52-1.58) 2.10 (0.25-1.81) 2.63 (0.29-2.37)

Personal situation

Improvement 1 1 1 1

No change 0.67 (0.38-1.17) 0.77 (0.45-1.31) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.64 (0.34-1.20) 0.87 (0.48-1.59) 2.10 (0.25-1.81) 2.63 (0.29-2.37)

Adjusted by education, study, age, “Improvement”= Reference group 3

4

Occupational situation and cardiovascular risk factors 5

Deterioration in the occupational situation was considerably associated with 6

cardiovascular risk factors for both men and women. The strongest associations were 7

observed for diabetes in women, for depressive disorders in men, and for cholesterol 8

for both men and women. The relative risk for diabetes in women who reported an 9

occupational deterioration after reunification compared with women who had an 10

occupational improvement after reunification was 1.66 (CI 95% 1.05-2.63). For an 11

occupational deterioration associated with depressive disorders in men, the 12

corresponding relative risk was 1.85 (CI 95% 1.24-2.77). In men who underwent 13

occupational deterioration after reunification, total cholesterol increased by about 14

7.65 mg/dL (CI 95% 2.70-12.61) compared to men who had an occupational 15

improvement after reunification. No relevant association was observed for high-risk 16

drinking. 17

18

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Table 4 Associations of the changes of the occupational, financial and personal situation after the reunification with cardiovascular risk

factors in men and women

Men Women Men Women Men Women

Occupational situation Financial situation Personal situation

crude adjusted crude adjusted crude adjusted crude adjusted crude adjusted crude adjusted

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

Hyper-

tension

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.10

(1.02-1.18)

1.08

(1.06-1.16)

1.12

(0.99-1.27)

1.08

(0.97-1.20)

1.04

(0.93-1.18)

1.06

(0.94-1.19)

1.12

(0.91-1.36)

1.02

(0.85-1.21)

Deterioration 1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.07

(0.99-1.16)

1.11

(1.02-1.20)

1.16

(1.01-1.29)

1.19

(1.06-1.34)

1.02

(0.89-1.16)

1.06

(0.94-1.21)

1.12

(0.91-1.40)

1.08

(0.87-1.33)

Smoking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.09

(1.03-1.15)

1.05

(0.99-1.12)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.98

(0.90-1.07)

0.98

(0.90-1.07)

0.92

(0.79-1.08)

1.01

(0.86-1.17)

Deterioration 1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.15

(1.08-1.22)

1.11

(1.04-1.18)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.89-1.07)

0.96

(0.88-1.06)

0.98

(0.82-1.17)

1.02

(0.86-1.21)

Diabetes

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.09

(0.77-1.56)

1.06

(0.75-1.51)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.85

(0.51-1.42)

0.90

(0.55-1.48)

0.76

(0.43-1.33)

0.82

(0.47-1.45)

Deterioration 1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.29

(0.89-1.88)

1.45

(1.01-2.11)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.56-1.67)

1.12

(0.65-1.94)

0.75

(0.39-1.45)

0.81

(0.32-1.16)

High-risk

drinking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.84-1.21)

1.06

(0.88-1.28)

0.90

(0.85-1.40)

0.95

(0.61-1.48)

1.05

(0.88-1.25)

1.06

(0.89-1.27)

0.65

0.42-1.02

0.72

(0.45-1.13)

0.84

(0.66-10.7)

0.84

0.66-1.07

0.66

0.39-1.12

0.69

(0.41-1.18)

Deterioration 0.96

(0.80-1.15)

0.97

(0.81-1.17)

1.05

(0.69-1.59

1.17

0.76-1.81

1.08

(0.88-131)

1.04

(0.85-1.27)

0.83

(0.55-1.27)

0.90

(0.59-1.38)

0.83

(0.63-7.08

0.79

0.60-1.03

0.74

0.40-1.36

0.79

(0.43-1.46)

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Improvement 1 1 1 1 1 1 1 1 1 1 1 1

Depressive

disorders

No change 0.69

(0.42-1.15)

0.73

(0.44-1.21)

0.89

(0.66-1.19)

0.97

(0.72-1.29)

0.84

(0.54-1.30)

0.89

(0.56-1.42)

1.02

(0.77-1.32)

1.02

(0.78-1.35)

0.67

(0.37-1.18)

0.71

(0.40-1.25)

0.93

(0.62-1.41)

1.02

(0.67-1.56)

Deterioration

1.77

(1.20-2.61)

1.85

(1.24-2.77)

1.19

(0.92-1.55)

1.23

(0.94-1.60)

1.85

(1.27-2.68)

1.83

(1.24-2.89)

1.29

(1.01-1.67)

1.32

(1.02-1.70)

1.52

(0.85-2.72)

1.51

(0.85-2.56)

1.65

(1.07-2.54)

1.67

(1.08-2.59)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

BMI

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 0.51

(0.0-0.92)

0.30

(-0.10-0.71)

0.43

(-0.17-0.71)

-0.03

(-0.61-0.53)

0.28

(-0.11-0.68)

0.18

(-0.21-0.58)

0.87

(0.32-1.43)

0.61

(0.09-1.14)

0.20

(-0.41-0.82)

0.24

(-0.36-0.86)

0.63

(-0.24-1.51)

0.39

(-0.43-1.22)

Deterioration 1.18

(0.74-1.62)

1.02

(0.58-1.45)

1.63

(1.02-2.24)

1.17

(0.58-1.76)

0.73

(0.25-1.20)

0.75

(0.28-1.23)

1.55

(0.93-2.16)

1.34

(0.74-1.94)

0.31

(-0.40-1.03)

0.50

(-0.20-1.21)

1.00

(-0.03-2.05)

0.81

(-0.17-1.80)

Cholesterol

mg/dL

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 3.34

(-1.43-8.11)

3.65

(-1.05-8.3)

0.44

(-0.70-964)

1.82

(-3.08-6.74)

5.60

(1.00-10.20)

5.24

(0.68-9.79)

2.52

(-2.40-7.45)

1.81

(-2.88-6.51)

2.69

(-4.36-9.75)

5.62

(-1.26-12.52)

2.09

(-5.37-9.57)

2.34

(-4.63-9.31)

Deterioration 8.96

(3.94-13.99)

7.65

(2.70-12.61)

11.25

(6.21-16.2)

7.83

(3.06-12.60)

8.62

(3.18-14.05)

8.93

(3.52-14.35)

7.19

(2.11-12.26)

6.88

(2.02-11.74)

5.24

(-2.9-13.46)

7.74

(-0.44-15.93)

1.32

(-6.98-9.64)

1.18

(-6.89-9.26)

Adjusted by education, study, age; “Improvement“= reference group

BMI=body mass index; High-risk drinking: >30 g alcohol per day for men, > 20 g alcohol per day for women

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14

Financial situation and cardiovascular risk factors 1

Deterioration in the financial situation was considerably associated with 2

cardiovascular risk factors in both men and women, particularly in women. The 3

strongest associations were observed for smoking in women (RR=1.24, CI 4

95%=1.12-1.38), for diabetes in both men and women (RR=1.45, CI 95%=1.01-2.11; 5

RR=1.98, CI 95%=1.30-2.99, respectively), for depressive disorders in men 6

(RR=1.83, CI 95%=1.24-2.89), and for total cholesterol in men (β=8.93 mg/dL, CI 7

95%=3.52-14.35). No relevant association was observed for high-risk drinking (Table 8

4). 9

Personal situation and cardiovascular risk factors 10

We observed no association between changes in personal situation and 11

cardiovascular risk factors, except in women for depressive disorders. The relative 12

risk for depressive disorders in women who had a deterioration in personal situation 13

after reunification was 1.67 (CI 95% 1.08-2.59) (Table 4). 14

Discussion 15

To our knowledge, this study is the first to analyse psychosocial stressors that 16

changed through a transition with direct reference to cardiovascular outcomes on an 17

individual basis. We observed an increase in CVD morbidity in women with a higher 18

RSI. Furthermore, we found that the RSI was weakly but consistently associated with 19

cardiovascular risk factors in both men and women. Deterioration in the occupational 20

and financial situation after reunification was considerably associated with diabetes, 21

depressive disorders, cholesterol, and smoking. In general, the associations were 22

stronger in women than in men, with the exception of depressive disorders. 23

Reunification was a critical life event that no one was able to escape. The rapid 24

transition from communism or socialism to capitalism has been called “shock 25

therapy”.7 This led, at the level of the labour market, to a precarious employment 26

relationship and mass unemployment.24 Within a few years, millions of people lost 27

their jobs due to the rapid de-industrialisation in most of the transition countries. 28

Between 1989 and 1991, more than 2.5 million people in the former GDR became 29

unemployed. Fifty percent of East Germans changed their place of work during 30

1990/1991, and more than 60% of industrial workers became unemployed.25 Many 31

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studies have shown a negative impact of unemployment on health.26 The 1

unemployment rate in East Germany rose rapidly after reunification. Although 2

unemployment affected both men and women, this increased dramatically for 3

women. The rate of unemployment in 1994 in East Germany was 22% in women and 4

11% in men.25 This could also explain the stronger associations of stressors with 5

CVD and cardiovascular risk factors for women in this study. Additionally, in a 6

prospective study on the changes in perceived stress as a result of the 2008 7

economic crisis in Iceland, it was shown that the perceived stress of women after the 8

economic crisis was significantly higher than before the crisis, especially for women 9

who were unemployed. These changes were much stronger for women than for 10

men.27 This is in line with our findings. During the economic crisis in Iceland the use 11

of cardiac emergency rooms increased in women. This was explained by a state of 12

uncertainty and anxiety about the future.28 13

Our study showed a strong association between the RSI and occupational changes 14

and depressive disorders for men. In Romania and Hungary, depression and 15

affective disorders increased sharply after the collapse of the communist regime, 16

especially in men.29,30 Kopp and colleagues explained this with the loss of social 17

rank30. Men are less able to compensate for this than women.31 Cockerham assumed 18

that unhealthy lifestyles are the principal social determinant of increased mortality in 19

Russia and selected Eastern European countries. Our data suggest rather that the 20

deterioration in psychosocial factors after reunification was associated with an 21

unhealthier lifestyle like smoking habits.13 The MONICA survey in East German study 22

sites found a slight increase in smoking for women between 1988 and 1992. This 23

goes in line with our findings. 24

We found an association between personal change and depressive disorders for 25

women. The MONICA survey in East Germany found an increased number of 26

women who felt “very isolated” after reunification, particularly in unemployed 27

women.16 Unemployment and the changes in the labour market may explain the 28

decrease in social support. The working environment played a central role in the 29

GDR. The workplace ensured social care (e.g. child care, medical care, recreational 30

facility, and sporting and cultural activities). With the loss of their workplace or with a 31

change in structural labour market conditions, a lot of people lost their social 32

contacts. It could be that social isolation explains the increase in depressive 33

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disorders in women who experienced deterioration in their personal situation after 1

reunification. 2

There are some factors that limit our study. First, this analysis faces the usual 3

restrictions of a cross-sectional design: to determine the causality, a longitudinal 4

design would be required. Additionally, we cannot exclude that outcomes like 5

depressive disorders or hypertension already persisted before reunification. 6

Therefore, the direction of causality cannot be established for most of the outcomes. 7

However, the exposure RSI refers to a fixed event in the past (German reunification) 8

so we can assume a chronological order of exposure and disease outcomes MI and 9

stroke. Second, the basic surveys were undertaken from 1998 to 2006, i.e. 8 to 16 10

years after reunification. However, we argue that after this time delay answering 11

questions concerning personal impact of reunification will give a more steady 12

reflection of the personal state. Third, we assume that we lost potential participants 13

because of illness or death due to factors associated to reunification. Furthermore, it 14

is well-known that healthy women and men were more likely to migrate after 15

reunification to the western part of Germany. We thus cannot exclude a selection 16

bias, which could change our results in both directions. Fourth, some questionnaires 17

are different between the studies, e.g. for depressive disorders. 18

In summary, our findings show that psychosocial stressors have changed through 19

reunification and have favoured cardiovascular risk and cardiovascular diseases 20

factors. An explanation for these findings could be that women were more often 21

affected by unemployment after reunification. Our findings support the established 22

hypothesis that psychosocial stressors favour cardiovascular risk factors and CVD 23

after social change. Morbidity and mortality follow-up examination of both cohorts 24

could enhance the results. 25

26

Contributors 27

SB: conducted the statistical analyses and drafted the report. AK: helped designing 28

major parts of the study and helped drafting the manuscript. OK: participated in the 29

statistical analyses and helped drafting the manuscript. KHG, CK, SN, KW, MRPM, 30

COS, HV: helped designing the study, and drafting the manuscript. JH: conceived of 31

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the study, designed major parts of the study and helped drafting the manuscript. The 1

paper was revised by all authors. 2

Competing interests 3

All authors report no conflict of interest. 4

Funding 5

This work was funded by a grant from the Deutsche Forschungsgemeinschaft [SFB 6

598–02 No. Ha 2419/2-1], by a grant of the Martin-Luther-University Halle-7

Wittenberg, by the Ministry of Education and Cultural Affairs of Saxony-Anhalt, by the 8

Federal Ministry of Education and Research [No. 01ZZ9603, 01ZZ0103, 01ZZ0701], 9

and the Ministry of Cultural Affairs and the Social Ministry of the Federal State of 10

Mecklenburg-West Pomerania. 11

References 12

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22. Wittchen HU, Höfler M, Gander F et al. Screening for mental disorders: 15

performance of the Composite International Diagnostic – Screener (CID–S). 16

International Journal of Methods in Psychiatric Research. 1999;8:59-70. 17

23. Greenland S, Pearl J, Robins JM. Causal diagrams for epidemiologic 18

research. Epidemiology. 1999;10:37-48. 19

24. Stuckler D, Basu S, Suhrcke M et al.The health implications of financial crisis: 20

a review of the evidence. Ulster Med J. 2009;78:142-5. 21

25. Rosenzweig B. Deutschland Ost-Deutschland West, Opfer, Verliererinnen, 22

ungleiche Schwestern? Der Bürger im Staat. 2000;4:225-30. 23

26. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: a 24

systematic review and meta-analysis of unemployment and all-cause mortality. Soc 25

Sci Med. 2011;72:840-54. 26

27. Hauksdottir A, McClure C, Jonsson SH et al. Increased stress among women 27

following an economic collapse--a prospective cohort study. Am J Epidemiol. 28

2013;177:979-88. 29

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28. Guethjonsdottir GR, Kristjansson M, Olafsson O et al. Immediate surge in 1

female visits to the cardiac emergency department following the economic collapse in 2

Iceland: an observational study. Emerg Med J. 2012;29:694-8. 3

29. Ionescu I. Depression in post-communist Romania. Lancet. 2005;365:645-6. 4

30. Kopp MS, Skrabski A, Szekely A et al. Chronic stress and social changes: 5

socioeconomic determination of chronic stress. Ann N Y Acad Sci. 2007; 1113:325- 6

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STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies

Item

No

Recommendation

Page (p)and

line Number

(l)

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in

the title or the abstract

p 2, l 6

(b) Provide in the abstract an informative and balanced

summary of what was done and what was found

p 2, l 2-25

Introduction

Background/rationale 2 Explain the scientific background and rationale for the

investigation being reported

p 4, l 2-16

Objectives 3 State specific objectives, including any prespecified hypotheses p 4, l 17-25

Methods

Study design 4 Present key elements of study design early in the paper p 4, l 28-31

Setting 5 Describe the setting, locations, and relevant dates, including

periods of recruitment, exposure, follow-up, and data collection

p 4, l 28-31

p 5, l 1-5, 10-

31

Participants 6 (a) Give the eligibility criteria, and the sources and methods of

selection of participants

p 5, l 5-12

Variables 7 Clearly define all outcomes, exposures, predictors, potential

confounders, and effect modifiers. Give diagnostic criteria, if

applicable

p 5, l 14-32

p 6, l 1-32

Data sources/

measurement

8* For each variable of interest, give sources of data and details of

methods of assessment (measurement). Describe comparability

of assessment methods if there is more than one group

p 5, l 14-32

p 6, l 1-32

p 7, l 1,2

Bias 9 Describe any efforts to address potential sources of bias p 7, l 21-24

Study size 10 Explain how the study size was arrived at p 5, l 5-12

Quantitative variables 11 Explain how quantitative variables were handled in the

analyses. If applicable, describe which groupings were chosen

and why

p 5, l13-32

p 6, l 11-13

Statistical methods 12 (a) Describe all statistical methods, including those used to

control for confounding

p 7, l 3-27

(b) Describe any methods used to examine subgroups and

interactions

p 7, l 24/25

(c) Explain how missing data were addressed p 5, l 11/12

(d) If applicable, describe analytical methods taking account of

sampling strategy

(e) Describe any sensitivity analyses

Results

Participants 13* (a) Report numbers of individuals at each stage of study—eg

numbers potentially eligible, examined for eligibility,

confirmed eligible, included in the study, completing follow-

up, and analysed

p 5, l 5-12

p 7, l 29

(b) Give reasons for non-participation at each stage p 5, l 5-12

(c) Consider use of a flow diagram

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, Table 1

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clinical, social) and information on exposures and potential

confounders

(b) Indicate number of participants with missing data for each

variable of interest

Table 1

p 5, l 11/12

Outcome data 15* Report numbers of outcome events or summary measures Table 1

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-

adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and

why they were included

Table 2-4

(b) Report category boundaries when continuous variables were

categorized

Table 1

(c) If relevant, consider translating estimates of relative risk

into absolute risk for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and

interactions, and sensitivity analyses

(p 7, l 24/25)

Discussion

Key results 18 Summarise key results with reference to study objectives p 14, l 18-23

Limitations 19 Discuss limitations of the study, taking into account sources of

potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

p 16, l 3-18

Interpretation 20 Give a cautious overall interpretation of results considering

objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

p 14, l 24-31,

p 15, l 1-33,

p 16, l 1-5

Generalisability 21 Discuss the generalisability (external validity) of the study

results

p 16, l 19-22

Other information

Funding 22 Give the source of funding and the role of the funders for the

present study and, if applicable, for the original study on which

the present article is based

p 17, l 4-9

*Give information separately for exposed and unexposed groups.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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Democratic Republic

Journal: BMJ Open

Manuscript ID bmjopen-2015-008703.R1


Date Submitted by the Author: 24-Jul-2015








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4






10




14




(Saale), Germany 18


Germany 20




24

25



28

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Abstract 1

Objectives: 2

The aim of this study was to examine the relationship between changes in 3




cardiovascular diseases. 7




Setting: Two populations in the eastern part of Germany. 11

Participants: CARLA study: 1.779 participants aged 45 to 83 at baseline (812 12

women), SHIP study: 4.308 aged 20 to 79 at baseline (2.193 women). 13










1.20) and depressive disorders in men (RR=1.15, 95% CI =1.07-2.77). The change in 23



occupational deterioration after reunification (RR=4.04, 95% CI =1.21-13.43). 26

Conclusion: Psychosocial stressors changed during reunification and have favoured 27

cardiovascular risk factors and CVD. The associations were stronger in women than 28

in men. An explanation for these findings could be that women were more often 29

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affected by unemployment after reunification. Morbidity and mortality follow-up of 1

both cohorts could enhance the results. 2

3




basis. 7





selection bias. 12




hypertension already persisted before reunification. However, the exposure 16

RSI refers to a fixed event in the past (German reunification) so we can 17

assume a chronological order of exposure and disease outcomes MI and 18

stroke. 19

20

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Introduction 1









after the social change.10-13 10


isolation, depression, critical life events) can contribute to the development of CVD.14 12

The political, social, and economic changes in the German Democratic Republic 13







psychosocial stressors, health behaviour, and the resulting impacts on health.6,11 The 20

aim of this study was to examine the relationship between changes in psychosocial 21


hypothesised that higher levels of psychosocial stress related to this critical life event, 23

i.e. reunification, were associated with an increase in cardiovascular risk factors and 24

CVD. 25

Methods 26






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not resided in the former GDR (N=120), were unoccupied before 1990 (N=1.701; 12

mostly retired persons), who were <=16yrs in 1990 (N=94), or those for whom data 13

were missing on the components of the Reunification Stress Index (RSI) (N=148). In 14

total the study size comprised N=3.901. 15







changed since reunification (since 1990)?” We asked in a way that all study persons 22

attribute their answers to the unique event and consequences of reunification: “Now 23

we ask questions concerning reunification”. The possible answers differed between 24










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6




cohort. We validated the self-constructed RSI with an own qualitative study 4

interviewing 18 subjects from the CARLA population blindly randomly selected 5

stratified by RSI score values. The results will be published in a separate paper. 6

Furthermore, we also analysed the questions of the RSI separately in order to 7



























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Results 1

















18

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CARLA SHIP TOTAL

Men

(n=703)

Women

(n=565)

Men

(n=1298)

Women

(n=1335)

Men

(n=2001)

Women

(n=1900)

Age

Mean (SD)

24 - <45 (n)

45 - <55 (n))

55 - <65 (n)

65 - <75 (n)

>=75 (n)

61.3 (8.5)

-

205

248

204

46

59.0 (7.0)

-

197

237

130

1

46.9 (12.3)

591

301

301

94

11

43.6 (11.1)

667

366

262

35

5

51.9 (13.0)

591

506

549

298

57

48.8 (12.1)

667

563

499

165

6 Ag

e g

rou

p

CV

D

MI; n (%) 42 (6.0) 7 (1.2) 30 (2.3) 5 (0.4) 72 (3.6) 12 (0.6)

Stroke; n (%) 20 (2.8) 9 (1.6) 10 (0.7) 8 (0.6) 30 (1.5) 17 (0.9)

CHD; n (%) 54 (7.7) 13 (2.3) 33 (2.5) 5 (0.4) 87 (4.3) 18 (1.0)

CVD*; n (%)

69 (9.8) 22 (3.9) 41 (3.1) 13 (1.0) 110 (5.4) 35 (1.8)

Card

iova

sc

ula

r ri

sk

fac

tors

Hypertension; n (%) 534 (76.9) 377 (66.7) 784 (60.7) 455 (34.2) 1318 (66.1) 832 (43.8)

Smoker; n (%) 512 (72.8) 205 (36.3) 1011 (77.8) 739 (55.4) 1523 (76.1) 944 (49.7)

Diabetes; n (%) 83 (11.8) 62 (11.0) 80 (6.2) 57 (4.3) 163 (8.1) 119 (6.3)



(%)

33 (4.9) 57 (10.3) 101 (7.8) 227 (17.1) 134 (6.8) 284 (15.1)

BMI; mean (SD) 28.2 (4.1) 28.5 (5.6) 27.8 (3.9) 26.7 (5.3) 27.9 (4.0) 27.2 (5.5)


Education

low; n (%)

middle; n (%)

high; n (%)

22 (3.1)

427 (60.7)

254 (36.1)

49 (8.7)

387 (68.5)

129 (22.8)

77 (5.9)

908 (70.0)

313 (24.1)

100 (7.5)

1012 (74.9)

254 (17.9)

99 (5.0)

1335 (66.8)

567 (28.3)

149 (7.9)

1382 (72.4)

369 (19.4)

Ex

po

su

re

RSI; mean (SD) 4.8 (1.6) 5.0 (1.5) 4.8 (2.7) 4.9 (2.7) 4.8 (2.4) 4.9 (2.4)

<5, n (%) =5; n (%) >5; n (%)

331 (47.1) 139 (19.8) 233 (33.1)

235 (41.6) 128 (22.7) 202 (35.8)

593 (45.7) 246 (19.0) 459 (35.4)

580 (43.5) 271 (20.3) 484 (36.3)

924 (46.2) 385 (19.2) 692 (34.6)

815 (42.9) 399 (21.0) 686 (36.1)

RSI by age group


- 5.3 (1.8) 4.9 (1.6) 4.4 (1.4) 4.8 (1.2)

- 5.4 (1.6) 4.8 (1.5) 4.9 (1.2) 3.3 (-)

4.5 (2.7) 5.3 (2.7) 5.2 (2.6) 3.8 (2.5) 2.4 (2.0)

4.6 (2.7) 5.4 (2.6) 5.1 (2.8) 3.7 (2.4) 2.6 (2.3)

4.5 (2.7) 5.3 (2.4) 5.1 (2.2) 4.2 (1.8) 4.3 (1.6)

4.6 (2.7) 5.4 (2.3) 5.0 (2.2) 4.6 (1.6) 2.8 (2.0)



211 (30.0) 264 (37.5) 228 (32.4)

143 (25.3) 230 (40.7) 192 (33.9)

411 (31.7) 375 (28.9) 512 (39.5)

398 (29.8) 402 (30.1) 535 (40.1)

622 (31.1) 639 (31.9) 740 (37.0)

541 (28.5) 632 (33.3) 727 (38.3)

Financial situation


394 (56.1) 183 (26.0) 126 (17.9)

273 (48.3) 163 (28.9) 129 (22.8)

720 (55.5) 336 (25.9) 242 (18.6)

666 (49.9) 341 (25.5) 328 (24.6)

1114 (55.7) 519 (25.9) 368 (18.4)

939 (49.4) 504 (26.5) 457 (24.1)

Personal situation


46 (6.5) 488 (69.4) 169 (24.0)

23 (4.1) 422 (74.7) 120 (21.2)

131 (10.1) 825 (63.6) 342 (26.4)

139 (10.4) 938 (70.3) 258 (19.3)

177 (8.9) 1313 (65.6) 511 (25.5)

162 (8.5) 1360 (71.6) 378 (19.9)



women 4

* Multiple responses possible 5

6

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16







Men Women


Card

iov

ascu

lar

dis

ea

se

s




Card

iova

scu

lar

risk f

acto

rs


1.15 (1.06-1.24) 1.15 (1.07-1.24) 1.07 (1.01-1.12) 1.07 (1.02-1.11)


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Men Women




Improvement 1 1 1 1

No change 0.97 (0.63-1.49) 0.71 (0.46-1.08) 4.56 (1.33-15.54) 3.76 (1.03-13.72)

Deterioration 0.68 (0.43-1.08) 0.79 (0.50-1.26) 3.96 (1.16-13.55) 4.04 (1.21-13.43)

Financial situation

Improvement 1 1 1 1

No change 0.99 (0.65-1.50) 0.91 (0.60-1.36) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.69 (0.40-1.20) 0.90 (0.52-1.58) 2.10 (0.25-1.81) 2.63 (0.29-2.37)

Personal situation

Improvement 1 1 1 1

No change 0.67 (0.38-1.17) 0.77 (0.45-1.31) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.64 (0.34-1.20) 0.87 (0.48-1.59) 2.10 (0.25-1.81) 2.63 (0.29-2.37)


4













drinking. 17

18

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RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

Hyper-

tension

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.10

(1.02-1.18)

1.08

(1.06-1.16)

1.12

(0.99-1.27)

1.08

(0.97-1.20)

1.04

(0.93-1.18)

1.06

(0.94-1.19)

1.12

(0.91-1.36)

1.02

(0.85-1.21)

Deterioration 1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.07

(0.99-1.16)

1.11

(1.02-1.20)

1.16

(1.01-1.29)

1.19

(1.06-1.34)

1.02

(0.89-1.16)

1.06

(0.94-1.21)

1.12

(0.91-1.40)

1.08

(0.87-1.33)

Smoking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.09

(1.03-1.15)

1.05

(0.99-1.12)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.98

(0.90-1.07)

0.98

(0.90-1.07)

0.92

(0.79-1.08)

1.01

(0.86-1.17)

Deterioration 1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.15

(1.08-1.22)

1.11

(1.04-1.18)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.89-1.07)

0.96

(0.88-1.06)

0.98

(0.82-1.17)

1.02

(0.86-1.21)

Diabetes

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.09

(0.77-1.56)

1.06

(0.75-1.51)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.85

(0.51-1.42)

0.90

(0.55-1.48)

0.76

(0.43-1.33)

0.82

(0.47-1.45)

Deterioration 1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.29

(0.89-1.88)

1.45

(1.01-2.11)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.56-1.67)

1.12

(0.65-1.94)

0.75

(0.39-1.45)

0.81

(0.32-1.16)

High-risk

drinking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.84-1.21)

1.06

(0.88-1.28)

0.90

(0.85-1.40)

0.95

(0.61-1.48)

1.05

(0.88-1.25)

1.06

(0.89-1.27)

0.65

0.42-1.02

0.72

(0.45-1.13)

0.84

(0.66-10.7)

0.84

0.66-1.07

0.66

0.39-1.12

0.69

(0.41-1.18)

Deterioration 0.96

(0.80-1.15)

0.97

(0.81-1.17)

1.05

(0.69-1.59

1.17

0.76-1.81

1.08

(0.88-131)

1.04

(0.85-1.27)

0.83

(0.55-1.27)

0.90

(0.59-1.38)

0.83

(0.63-7.08

0.79

0.60-1.03

0.74

0.40-1.36

0.79

(0.43-1.46)

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Improvement 1 1 1 1 1 1 1 1 1 1 1 1

Depressive

disorders

No change 0.69

(0.42-1.15)

0.73

(0.44-1.21)

0.89

(0.66-1.19)

0.97

(0.72-1.29)

0.84

(0.54-1.30)

0.89

(0.56-1.42)

1.02

(0.77-1.32)

1.02

(0.78-1.35)

0.67

(0.37-1.18)

0.71

(0.40-1.25)

0.93

(0.62-1.41)

1.02

(0.67-1.56)

Deterioration

1.77

(1.20-2.61)

1.85

(1.24-2.77)

1.19

(0.92-1.55)

1.23

(0.94-1.60)

1.85

(1.27-2.68)

1.83

(1.24-2.89)

1.29

(1.01-1.67)

1.32

(1.02-1.70)

1.52

(0.85-2.72)

1.51

(0.85-2.56)

1.65

(1.07-2.54)

1.67

(1.08-2.59)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

BMI

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 0.51

(0.0-0.92)

0.30

(-0.10-0.71)

0.43

(-0.17-0.71)

-0.03

(-0.61-0.53)

0.28

(-0.11-0.68)

0.18

(-0.21-0.58)

0.87

(0.32-1.43)

0.61

(0.09-1.14)

0.20

(-0.41-0.82)

0.24

(-0.36-0.86)

0.63

(-0.24-1.51)

0.39

(-0.43-1.22)

Deterioration 1.18

(0.74-1.62)

1.02

(0.58-1.45)

1.63

(1.02-2.24)

1.17

(0.58-1.76)

0.73

(0.25-1.20)

0.75

(0.28-1.23)

1.55

(0.93-2.16)

1.34

(0.74-1.94)

0.31

(-0.40-1.03)

0.50

(-0.20-1.21)

1.00

(-0.03-2.05)

0.81

(-0.17-1.80)

Cholesterol

mg/dL

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 3.34

(-1.43-8.11)

3.65

(-1.05-8.3)

0.44

(-0.70-964)

1.82

(-3.08-6.74)

5.60

(1.00-10.20)

5.24

(0.68-9.79)

2.52

(-2.40-7.45)

1.81

(-2.88-6.51)

2.69

(-4.36-9.75)

5.62

(-1.26-12.52)

2.09

(-5.37-9.57)

2.34

(-4.63-9.31)

Deterioration 8.96

(3.94-13.99)

7.65

(2.70-12.61)

11.25

(6.21-16.2)

7.83

(3.06-12.60)

8.62

(3.18-14.05)

8.93

(3.52-14.35)

7.19

(2.11-12.26)

6.88

(2.02-11.74)

5.24

(-2.9-13.46)

7.74

(-0.44-15.93)

1.32

(-6.98-9.64)

1.18

(-6.89-9.26)



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14









4). 9






Discussion 15



individual basis. We analysed the consequences of the reunification for psychosocial 18

stressors. Reunification was a fixed event in the past which entailed changes of 19

these factors. We observed an increase in CVD morbidity in women with a higher 20

RSI. Furthermore, we found that the RSI was weakly but consistently associated with 21











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rank30. Men are less able to compensate for this than women.31 Cockerham assumed 20














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reunification. 4








years after reunification. However, we argue that after this time delay answering 12

questions concerning personal impact of reunification will give a more steady 13

reflection of the personal state. Third, we assume that we lost potential participants 14

because of illness or death due to factors associated to reunification. Furthermore, it 15

is well-known that healthy women and men were more likely to migrate after 16

reunification to the western part of Germany. We thus cannot exclude a selection 17

bias, which could change our results in both directions. Fourth, some questionnaires 18

are different between the studies, e.g. for depressive disorders. But in analyses 19

stratified by study effects were similar. However, we are prudent with the 20

interpretation of the effects, because a depressive disorder exists for a long period; 21

therefore it is possible that depressed persons answer in a negative way followed by 22

the depressive disorder. 23

In summary, our findings show that psychosocial stressors have changed through 24

reunification and have favoured cardiovascular risk and cardiovascular diseases 25

factors. An explanation for these findings could be that women were more often 26





31

Contributors 32

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Funding 9







Data sharing statement 16

No additional data are available. 17

References 18

1. Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, Tolonen H et al. Contribution of 19

trends in survival and coronar y-event rates to changes in coronary heart disease 20

mortality: 10-year results from 37 WHO MONICA Project populations. Lancet. 21

1999;353:1547-57. 22

2. Bobak M, Marmot M. East-West mortality divide and its potential explanations: 23

proposed research agenda. BMJ (Clinical Research Ed). 1996;312:421-5. 24




West Germany and Poland. II: short-term trends during transition and in the 1990s. J 28

Epidemiol Community Health. 2000;54:899-906. 29

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6. Landsbergis P, Klumbiene J. Coronary heart disease mortality in Russia and 3

eastern Europe. Am J Public Health. 2003;93:1793. 4



8. Kuulasmaa K, Tunstall-Pedoe H, Dobson A et al. Estimation of contribution of 7

changes in classic risk factors to trends in coronary-event rates across the WHO 8

MONICA Project populations. Lancet. 2000;355:675-87. 9

9. Leon DA, Chenet L, Shkolnikov VM et al. Huge variation in Russian mortality 10

rates 1984–94: artefact, alcohol, or what? Lancet. 1997;350:383-8. 11


psychosocial risk factors explain the European East-West gap in health status? Eur J 13

Public Health. 2001;11:65-73. 14


JAMA: 1998;279:790-1. 16




13. Cockerham WC. The Social Determinants of the Decline of Life Expectancy in 20

Russia and Eastern Europe: A Lifestyle Explanation. Journal of Health and Social 21

Behavior. 1997;38:117-30. 22


factors with risk of acute myocardial infarction in 11119 cases and 13648 controls 24

from 52 countries (the INTERHEART study): case-control study. Lancet. 25

2004;364:953-62. 26


Abschlussforschungsbericht an das Bundesministerium für Bildung, Wissenschaft, 28

Forschung und Technologie. 1997. 29

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17. Greiser KH, Kluttig A, Schumann B et al. Cardiovascular disease, risk factors 3

and heart rate variability in the elderly general population: design and objectives of 4

the CARdiovascular disease, Living and Ageing in Halle (CARLA) Study. BMC 5

Cardiovasc Disord. 2005;5:33. 6


health examination survey in an east German region: objectives and design. Soz 8

Praventivmed. 2001;46:186-94. 9

19. Bühringer G, Augustin R, Bergmann E et al.(Hrsg) (2000) Alkoholkonsum und 10

alkoholbezogene Störungen in Deutschland. Schriftenreihe des Bundesministeriums 11

für Gesundheit. Bd128, Nomos Baden-Baden 12

20. Radloff LS, The CES-D Scale: A Self-Report Depression Scale for Research in 13

the General Population. Applied Psychological Measurement, 1977. 1: 385-401. 14

21. Milette K, Hudson M, Baron M, Thombs BD, Group CSR. Comparison of the 15

PHQ-9 and CES-D depression scales in systemic sclerosis: internal consistency 16

reliability, convergent validity and clinical correlates. Rheumatology. 2010;49(4):789-17

96. 18


performance of the Composite International Diagnostic – Screener (CID–S). 20

International Journal of Methods in Psychiatric Research. 1999;8:59-70. 21



24. Stuckler D, Basu S, Suhrcke M et al.The health implications of financial crisis: 24

a review of the evidence. Ulster Med J. 2009;78:142-5. 25



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systematic review and meta-analysis of unemployment and all-cause mortality. Soc 2

Sci Med. 2011;72:840-54. 3

27. Hauksdottir A, McClure C, Jonsson SH et al. Increased stress among women 4

following an economic collapse--a prospective cohort study. Am J Epidemiol. 5

2013;177:979-88. 6


female visits to the cardiac emergency department following the economic collapse in 8

Iceland: an observational study. Emerg Med J. 2012;29:694-8. 9

29. Ionescu I. Depression in post-communist Romania. Lancet. 2005;365:645-6. 10


socioeconomic determination of chronic stress. Ann N Y Acad Sci. 2007; 1113:325-12

338. 13

31. Rethelyi JM, Kopp MS. Hierarchy disruption: Women and men. Behav Brain Sci 14

2004; 27:305-307. 15

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No

Recommendation

Page (p)and

line Number

(l)



p 2, l 6



p 2, l 2-25

Introduction



p 4, l 2-16


Methods




p 4, l 28-31

p 5, l 1-5, 10-

31



p 5, l 5-12



applicable

p 5, l 14-32

p 6, l 1-32

Data sources/

measurement




p 5, l 14-32

p 6, l 1-32

p 7, l 1,2





and why

p 5, l13-32

p 6, l 11-13



p 7, l 3-27


interactions

p 7, l 24/25



sampling strategy


Results




up, and analysed

p 5, l 5-12

p 7, l 29




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confounders



Table 1

p 5, l 11/12






Table 2-4


categorized

Table 1





(p 7, l 24/25)

Discussion





p 16, l 3-18




p 14, l 24-31,

p 15, l 1-33,

p 16, l 1-5


results

p 16, l 19-22

Other information




p 17, l 4-9







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Democratic Republic

Journal: BMJ Open



Date Submitted by the Author: 31-Aug-2015








BMJ Open on N



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4






10




14




(Saale), Germany 18


Germany 20




24

25



28

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Abstract 1

Objectives: 2

Aim of this study was to examine the relationship between changes in psychosocial 3


hypothesised that higher levels of psychosocial stress related to German 5


cardiovascular diseases (CVD). 7




Setting: Two populations in East Germany. 11

Participants: CARLA-study: 1.779 participants aged 45 to 83 at baseline (812 12

women), SHIP-study: 4.308 aged 20 to 79 at baseline (2.193 women). 13










1.20) and depressive disorders in men (RR=1.15, 95% CI=1.07-2.77). The change in 23



occupational deterioration after reunification (RR=4.04, 95% CI=1.21-13.43). 26

Conclusion: Deterioration of psychosocial stressors (occupational, financial, and 27

personal) related to German reunification was associated with cardiovascular risk 28

factors and CVD. The associations were stronger in women than in men. An 29

explanation for these findings could be that women were more often affected by 30

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unemployment after reunification. Morbidity and mortality follow-up of both cohorts 1


3




basis. 7





selection bias. 12



• Because of the time lag between the event of reunification 1989/90 and the 15

interview, where the Reunification Stress Index questionnaire was applied, 16

recall bias may have influenced the results. However, we evaluated validity 17

and reliability of the Reunification Stress Index and found no indication for 18

recall bias. 19





stroke. 24

25

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Introduction 1









after the social change.10-13 Assumed determinants of psychosocial stressors in this 10

context are: occupational stressors e.g. unemployment5,11, mass-privatization7, job 11

strain12, financial stressors5,11,14,15, and personal stressors e.g. social isolation12,15 12

critical life events12. 13


isolation, depression, critical life events) can contribute to the development of CVD.16-15

23 The political, social, and economic changes in the German Democratic Republic 16







psychosocial stressors, health behaviour, and the resulting impacts on health.6,11 23

However, specific psychosocial stressors have not been identified.13 We analysed 24

changes of occupational, financial, and personal situation after the reunification as 25

determinates of psychosocial stressors. Therefore, the aim of this study was to 26

examine the relationship between individually perceived changes in psychosocial 27


hypothesised that higher levels of individually perceived psychosocial stress related 29

to this critical life event, i.e. reunification, were associated with an increase in 30

cardiovascular risk factors and CVD. 31

Methods 32

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Results 6

















23

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CARLA SHIP TOTAL

Men

(n=703)

Women

(n=565)

Men

(n=1298)

Women

(n=1335)

Men

(n=2001)

Women

(n=1900)

Age

Mean (SD)

24 - <45 (n)

45 - <55 (n))

55 - <65 (n)

65 - <75 (n)

>=75 (n)

61.3 (8.5)

-

205

248

204

46

59.0 (7.0)

-

197

237

130

1

46.9 (12.3)

591

301

301

94

11

43.6 (11.1)

667

366

262

35

5

51.9 (13.0)

591

506

549

298

57

48.8 (12.1)

667

563

499

165

6 Ag

e g

rou

p

CV

D

MI; n (%) 42 (6.0) 7 (1.2) 30 (2.3) 5 (0.4) 72 (3.6) 12 (0.6)

Stroke; n (%) 20 (2.8) 9 (1.6) 10 (0.7) 8 (0.6) 30 (1.5) 17 (0.9)

CHD; n (%) 54 (7.7) 13 (2.3) 33 (2.5) 5 (0.4) 87 (4.3) 18 (1.0)

CVD*; n (%)

69 (9.8) 22 (3.9) 41 (3.1) 13 (1.0) 110 (5.4) 35 (1.8)

Card

iova

sc

ula

r ri

sk

fac

tors

Hypertension; n (%) 534 (76.9) 377 (66.7) 784 (60.7) 455 (34.2) 1318 (66.1) 832 (43.8)

Smoker; n (%) 512 (72.8) 205 (36.3) 1011 (77.8) 739 (55.4) 1523 (76.1) 944 (49.7)

Diabetes; n (%) 83 (11.8) 62 (11.0) 80 (6.2) 57 (4.3) 163 (8.1) 119 (6.3)



(%)

33 (4.9) 57 (10.3) 101 (7.8) 227 (17.1) 134 (6.8) 284 (15.1)

BMI; mean (SD) 28.2 (4.1) 28.5 (5.6) 27.8 (3.9) 26.7 (5.3) 27.9 (4.0) 27.2 (5.5)


Education

low; n (%)

middle; n (%)

high; n (%)

22 (3.1)

427 (60.7)

254 (36.1)

49 (8.7)

387 (68.5)

129 (22.8)

77 (5.9)

908 (70.0)

313 (24.1)

100 (7.5)

1012 (74.9)

254 (17.9)

99 (5.0)

1335 (66.8)

567 (28.3)

149 (7.9)

1382 (72.4)

369 (19.4)

Ex

po

su

re

RSI; mean (SD) 4.8 (1.6) 5.0 (1.5) 4.8 (2.7) 4.9 (2.7) 4.8 (2.4) 4.9 (2.4)

<5, n (%) =5; n (%) >5; n (%)

331 (47.1) 139 (19.8) 233 (33.1)

235 (41.6) 128 (22.7) 202 (35.8)

593 (45.7) 246 (19.0) 459 (35.4)

580 (43.5) 271 (20.3) 484 (36.3)

924 (46.2) 385 (19.2) 692 (34.6)

815 (42.9) 399 (21.0) 686 (36.1)

RSI by age group


- 5.3 (1.8) 4.9 (1.6) 4.4 (1.4) 4.8 (1.2)

- 5.4 (1.6) 4.8 (1.5) 4.9 (1.2) 3.3 (-)

4.5 (2.7) 5.3 (2.7) 5.2 (2.6) 3.8 (2.5) 2.4 (2.0)

4.6 (2.7) 5.4 (2.6) 5.1 (2.8) 3.7 (2.4) 2.6 (2.3)

4.5 (2.7) 5.3 (2.4) 5.1 (2.2) 4.2 (1.8) 4.3 (1.6)

4.6 (2.7) 5.4 (2.3) 5.0 (2.2) 4.6 (1.6) 2.8 (2.0)



211 (30.0) 264 (37.5) 228 (32.4)

143 (25.3) 230 (40.7) 192 (33.9)

411 (31.7) 375 (28.9) 512 (39.5)

398 (29.8) 402 (30.1) 535 (40.1)

622 (31.1) 639 (31.9) 740 (37.0)

541 (28.5) 632 (33.3) 727 (38.3)

Financial situation


394 (56.1) 183 (26.0) 126 (17.9)

273 (48.3) 163 (28.9) 129 (22.8)

720 (55.5) 336 (25.9) 242 (18.6)

666 (49.9) 341 (25.5) 328 (24.6)

1114 (55.7) 519 (25.9) 368 (18.4)

939 (49.4) 504 (26.5) 457 (24.1)

Personal situation


46 (6.5) 488 (69.4) 169 (24.0)

23 (4.1) 422 (74.7) 120 (21.2)

131 (10.1) 825 (63.6) 342 (26.4)

139 (10.4) 938 (70.3) 258 (19.3)

177 (8.9) 1313 (65.6) 511 (25.5)

162 (8.5) 1360 (71.6) 378 (19.9)



women 4


6

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Men Women


Card

iov

ascu

lar

dis

ea

se

s




Card

iova

scu

lar

risk f

acto

rs


1.15 (1.06-1.24) 1.15 (1.07-1.24) 1.07 (1.01-1.12) 1.07 (1.02-1.11)


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Men Women




Improvement 1 1 1 1

No change 0.97 (0.63-1.49) 0.71 (0.46-1.08) 4.56 (1.33-15.54) 3.76 (1.03-13.72)

Deterioration 0.68 (0.43-1.08) 0.79 (0.50-1.26) 3.96 (1.16-13.55) 4.04 (1.21-13.43)

Financial situation

Improvement 1 1 1 1

No change 0.99 (0.65-1.50) 0.91 (0.60-1.36) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.69 (0.40-1.20) 0.90 (0.52-1.58) 2.10 (0.25-1.81) 2.63 (0.29-2.37)

Personal situation

Improvement 1 1 1 1

No change 0.67 (0.38-1.17) 0.77 (0.45-1.31) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.64 (0.34-1.20) 0.87 (0.48-1.59) 2.10 (0.25-1.81) 2.63 (0.29-2.37)


4













drinking. 17

18

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RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

Hyper-

tension

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.10

(1.02-1.18)

1.08

(1.06-1.16)

1.12

(0.99-1.27)

1.08

(0.97-1.20)

1.04

(0.93-1.18)

1.06

(0.94-1.19)

1.12

(0.91-1.36)

1.02

(0.85-1.21)

Deterioration 1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.07

(0.99-1.16)

1.11

(1.02-1.20)

1.16

(1.01-1.29)

1.19

(1.06-1.34)

1.02

(0.89-1.16)

1.06

(0.94-1.21)

1.12

(0.91-1.40)

1.08

(0.87-1.33)

Smoking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.09

(1.03-1.15)

1.05

(0.99-1.12)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.98

(0.90-1.07)

0.98

(0.90-1.07)

0.92

(0.79-1.08)

1.01

(0.86-1.17)

Deterioration 1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.15

(1.08-1.22)

1.11

(1.04-1.18)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.89-1.07)

0.96

(0.88-1.06)

0.98

(0.82-1.17)

1.02

(0.86-1.21)

Diabetes

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.09

(0.77-1.56)

1.06

(0.75-1.51)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.85

(0.51-1.42)

0.90

(0.55-1.48)

0.76

(0.43-1.33)

0.82

(0.47-1.45)

Deterioration 1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.29

(0.89-1.88)

1.45

(1.01-2.11)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.56-1.67)

1.12

(0.65-1.94)

0.75

(0.39-1.45)

0.81

(0.32-1.16)

High-risk

drinking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.84-1.21)

1.06

(0.88-1.28)

0.90

(0.85-1.40)

0.95

(0.61-1.48)

1.05

(0.88-1.25)

1.06

(0.89-1.27)

0.65

0.42-1.02

0.72

(0.45-1.13)

0.84

(0.66-10.7)

0.84

0.66-1.07

0.66

0.39-1.12

0.69

(0.41-1.18)

Deterioration 0.96

(0.80-1.15)

0.97

(0.81-1.17)

1.05

(0.69-1.59

1.17

0.76-1.81

1.08

(0.88-131)

1.04

(0.85-1.27)

0.83

(0.55-1.27)

0.90

(0.59-1.38)

0.83

(0.63-7.08

0.79

0.60-1.03

0.74

0.40-1.36

0.79

(0.43-1.46)

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Improvement 1 1 1 1 1 1 1 1 1 1 1 1

Depressive

disorders

No change 0.69

(0.42-1.15)

0.73

(0.44-1.21)

0.89

(0.66-1.19)

0.97

(0.72-1.29)

0.84

(0.54-1.30)

0.89

(0.56-1.42)

1.02

(0.77-1.32)

1.02

(0.78-1.35)

0.67

(0.37-1.18)

0.71

(0.40-1.25)

0.93

(0.62-1.41)

1.02

(0.67-1.56)

Deterioration

1.77

(1.20-2.61)

1.85

(1.24-2.77)

1.19

(0.92-1.55)

1.23

(0.94-1.60)

1.85

(1.27-2.68)

1.83

(1.24-2.89)

1.29

(1.01-1.67)

1.32

(1.02-1.70)

1.52

(0.85-2.72)

1.51

(0.85-2.56)

1.65

(1.07-2.54)

1.67

(1.08-2.59)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

BMI

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 0.51

(0.0-0.92)

0.30

(-0.10-0.71)

0.43

(-0.17-0.71)

-0.03

(-0.61-0.53)

0.28

(-0.11-0.68)

0.18

(-0.21-0.58)

0.87

(0.32-1.43)

0.61

(0.09-1.14)

0.20

(-0.41-0.82)

0.24

(-0.36-0.86)

0.63

(-0.24-1.51)

0.39

(-0.43-1.22)

Deterioration 1.18

(0.74-1.62)

1.02

(0.58-1.45)

1.63

(1.02-2.24)

1.17

(0.58-1.76)

0.73

(0.25-1.20)

0.75

(0.28-1.23)

1.55

(0.93-2.16)

1.34

(0.74-1.94)

0.31

(-0.40-1.03)

0.50

(-0.20-1.21)

1.00

(-0.03-2.05)

0.81

(-0.17-1.80)

Cholesterol

mg/dL

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 3.34

(-1.43-8.11)

3.65

(-1.05-8.3)

0.44

(-0.70-964)

1.82

(-3.08-6.74)

5.60

(1.00-10.20)

5.24

(0.68-9.79)

2.52

(-2.40-7.45)

1.81

(-2.88-6.51)

2.69

(-4.36-9.75)

5.62

(-1.26-12.52)

2.09

(-5.37-9.57)

2.34

(-4.63-9.31)

Deterioration 8.96

(3.94-13.99)

7.65

(2.70-12.61)

11.25

(6.21-16.2)

7.83

(3.06-12.60)

8.62

(3.18-14.05)

8.93

(3.52-14.35)

7.19

(2.11-12.26)

6.88

(2.02-11.74)

5.24

(-2.9-13.46)

7.74

(-0.44-15.93)

1.32

(-6.98-9.64)

1.18

(-6.89-9.26)



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4). 9






Discussion 15



individual basis. We analysed the consequences of the reunification for changes in 18

psychosocial stressors (occupational, financial, and personal). Reunification was a 19

fixed event in the past which entailed changes of these factors. We investigated if 20

different reflections of German reunification on the psychosocial level may be 21

associated with different levels of risk factors or frequencies of occurrence of 22

disease. We observed an increase in CVD morbidity in women with a higher RSI. 23

Furthermore, we found that the RSI was weakly but consistently associated with 24








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rank.39 Men are less able to compensate for this than women.40 Cockerham assumed 23











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reunification. 7








years after reunification. Because of this time lag recall bias may have influenced the 15

results. However, we evaluated validity and reliability of the Reunification Stress 16

Index and found no severe indication for recall bias. We argue that after this time 17

delay answering questions concerning personal impact of reunification will give a 18

more steady reflection of the personal state. Furthermore, participants were not told 19

the specific study hypotheses and therefore would not have been aware of the 20

potential link between reunification related stress and CVD. Consequently, if there is 21

a kind of recall error regarding reunification related stressors, participants with and 22

without relevant outcomes should be equally affected. This kind of nondifferential 23

misclassification would result in an underestimation of effects. Third, we assume that 24

we lost potential participants because of illness or death due to factors associated to 25

reunification. Furthermore, it is well-known that healthy women and men were more 26

likely to migrate after reunification to the western part of Germany. We thus cannot 27

exclude a selection bias, which could change our results in both directions. Fourth, 28

some questionnaires are different between the studies, e.g. for depressive disorders. 29

But in analyses stratified by study effects were similar. However, we are prudent with 30

the interpretation of the effects, because a depressive disorder exists for a long 31

period; therefore it is possible that depressed persons answer in a negative way 32

followed by the depressive disorder. Fifth, potentially we cover not all psychosocial 33

stressors due to a transition. However, we decided to analyse psychosocial stressors 34

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in terms of occupation, financial, and personal stressors, because in view of the 1

appropriate literature these factors seem to be the most relevant. 2

In summary, our findings show that a deterioration of psychosocial stressors in terms 3

of occupational, financial, and personal stressors related to German reunification was 4

associated with cardiovascular risk factors and CVD. An explanation for these 5

findings could be that women were more often affected by unemployment after 6

reunification. Our findings support the established hypothesis that psychosocial 7

stressors favour cardiovascular risk factors and CVD after social change. Morbidity 8

and mortality follow-up examination of both cohorts could enhance the results. 9

10

Contributors 11









Funding 20









References 29

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1. Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, Tolonen H et al. Contribution 1

of trends in survival and coronar y-event rates to changes in coronary heart 2

disease mortality: 10-year results from 37 WHO MONICA Project 3

populations. Lancet. 1999;353:1547-57. 4

2. Bobak M, Marmot M. East-West mortality divide and its potential 5

explanations: proposed research agenda. BMJ (Clinical Research Ed). 6

1996;312:421-5. 7




West Germany and Poland. II: short-term trends during transition and in the 11

1990s. J Epidemiol Community Health. 2000;54:899-906. 12



6. Landsbergis P, Klumbiene J. Coronary heart disease mortality in Russia 15

and eastern Europe. Am J Public Health. 2003;93:1793. 16



8. Kuulasmaa K, Tunstall-Pedoe H, Dobson A et al. Estimation of contribution 19

of changes in classic risk factors to trends in coronary-event rates across 20

the WHO MONICA Project populations. Lancet. 2000;355:675-87. 21

9. Leon DA, Chenet L, Shkolnikov VM et al. Huge variation in Russian 22

mortality rates 1984–94: artefact, alcohol, or what? Lancet. 1997;350:383-23

8. 24


psychosocial risk factors explain the European East-West gap in health 26

status? Eur J Public Health. 2001;11:65-73. 27


JAMA: 1998;279:790-1. 29




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13. Cockerham WC. The Social Determinants of the Decline of Life 1

Expectancy in Russia and Eastern Europe: A Lifestyle Explanation. Journal 2

of Health and Social Behavior. 1997;38:117-30. 3

14. Kopp M, Skrabski A, Szanto Z, Siegrist J. Psychosocial determinants of 4

premature cardiovascular mortality differences within Hungary. J Epidemiol 5

Community Health 2006;60(9):782-8. 6

15. Kozieł S, Lopuszańska M, Szklarska A, Lipowicz A. The negative health 7

consequences of unemployment: the case of Poland. Econ Hum Biol 8

2010;8(2):255-60. 9


factors with risk of acute myocardial infarction in 11119 cases and 13648 11

controls from 52 countries (the INTERHEART study): case-control study. 12

Lancet. 2004;364:953-62. 13

17. Eller NH, Netterstrom B, Gyntelberg F, et al. Work-related psychosocial 14

factors and the development of ischemic heart disease: a systematic 15

review. Cardiol Rev 2009;17(2):83-97. 16

18. Kivimaki M, Nyberg ST, Batty GD, et al. Job strain as a risk factor for 17

coronary heart disease: a collaborative meta-analysis of individual 18

participant data. Lancet 2012;380(9852):1491-7. 19

19. Zellweger MJ, Osterwalder RH, Langewitz W, Pfisterer ME. Coronary 20

artery disease and depression. Eur Heart J 2004;25(1):3-9. 21

20. Knox SS, Uvnas-Moberg K. Social isolation and cardiovascular disease: an 22

atherosclerotic pathway? Psychoneuroendocrinology 1998;23(8):877-90. 23

21. Theorell T. Critical life changes. A review of research. Psychother 24

Psychosom 1992;57(3):108-17. 25

22. Dittmann K, Rittner K, Weber I, Siegrist J. [Premature myocardial infarct 26

and social stress]. MMW Munch Med Wochenschr 1981;123(48):1841-2. 27

23. Justice B. Critical life events and the onset of illness. Compr Ther 28

1994;20(4):232-8. 29


Abschlussforschungsbericht an das Bundesministerium für Bildung, 31

Wissenschaft, Forschung und Technologie. 1997. 32



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26. Greiser KH, Kluttig A, Schumann B et al. Cardiovascular disease, risk 1

factors and heart rate variability in the elderly general population: design 2

and objectives of the CARdiovascular disease, Living and Ageing in Halle 3

(CARLA) Study. BMC Cardiovasc Disord. 2005;5:33. 4


health examination survey in an east German region: objectives and 6

design. Soz Praventivmed. 2001;46:186-94. 7

28. Bühringer G, Augustin R, Bergmann E et al.(Hrsg) (2000) Alkoholkonsum 8

und alkoholbezogene Störungen in Deutschland. Schriftenreihe des 9

Bundesministeriums für Gesundheit. Bd128, Nomos Baden-Baden 10

29. Radloff LS, The CES-D Scale: A Self-Report Depression Scale for 11

Research in the General Population. Applied Psychological Measurement, 12

1977. 1: 385-401. 13

30. Milette K, Hudson M, Baron M, Thombs BD, Group CSR. Comparison of 14

the PHQ-9 and CES-D depression scales in systemic sclerosis: internal 15

consistency reliability, convergent validity and clinical correlates. 16

Rheumatology. 2010;49(4):789-96. 17


performance of the Composite International Diagnostic – Screener (CID–19

S). International Journal of Methods in Psychiatric Research. 1999;8:59-70. 20



33. Stuckler D, Basu S, Suhrcke M et al.The health implications of financial 23

crisis: a review of the evidence. Ulster Med J. 2009;78:142-5. 24




systematic review and meta-analysis of unemployment and all-cause 28

mortality. Soc Sci Med. 2011;72:840-54. 29

36. Hauksdottir A, McClure C, Jonsson SH et al. Increased stress among 30

women following an economic collapse--a prospective cohort study. Am J 31

Epidemiol. 2013;177:979-88. 32

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female visits to the cardiac emergency department following the economic 2

collapse in Iceland: an observational study. Emerg Med J. 2012;29:694-8. 3

38. Ionescu I. Depression in post-communist Romania. Lancet. 2005;365:645-4

6. 5


socioeconomic determination of chronic stress. Ann N Y Acad Sci. 2007; 7

1113:325-338. 8

40. Rethelyi JM, Kopp MS. Hierarchy disruption: Women and men. Behav 9

Brain Sci 2004; 27:305-307. 10

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line Number

(l)



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p 4, l 2-16


Methods




p 4, l 28-31

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31



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p 5, l 14-32

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Changes of individual perception in psychosocial stressors related to German reunification in 1989/1990 and

cardiovascular risk factors and cardiovascular diseases in a population-based study in East Germany

Journal: BMJ Open



Date Submitted by the Author: 21-Oct-2015








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1

Changes of individual perception in psychosocial stressors related to German 1

reunification in 1989/1990 and cardiovascular risk factors and cardiovascular 2

diseases in a population-based study in East Germany 3

4






10




14




(Saale), Germany 18


Germany 20




24



27

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2

Abstract 1

Objectives: 2

Aim was to examine the relationship between individually perceived changes in 3




cardiovascular diseases (CVD). 7




Setting: Two populations in East-Germany. 11

Participants: CARLA-study: 1.779 participants aged 45 to 83 at baseline (812 12

women), SHIP-study: 4.308 aged 20 to 79 at baseline (2.193 women). 13


reunification were operationalised by the Reunification-Stress-Index (RSI; scale from 15

0 to 10). This index was composed of questions that were related to individually 16

perceived changes in psychosocial stressors (occupational, financial, and personal) 17

after reunification. To examine the associations between the RSI and each stressor 18

separately with cardiovascular risk factors and CVD, regression models were used. 19




1.20) and depressive disorders in men (RR=1.15, 95% CI=1.07-2.77). The change in 23



occupational deterioration after reunification (RR=4.04, 95% CI=1.21-13.43). 26

Conclusion: Individually perceived deterioration of psychosocial stressors 27

(occupational, financial, and personal) related to German reunification was 28

associated with cardiovascular risk factors and CVD. The associations were stronger 29

in women than in men. An explanation for these findings could be that women were 30

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more often affected by unemployment after reunification. Morbidity and mortality 1

follow-up of both cohorts could enhance the results. 2

3


• This study is the first to analyse individually perceived psychosocial stressors 5

that changed through a transition with direct reference to cardiovascular 6

outcomes on an individual basis. 7





selection bias. 12



• Because of the time lag between the event of reunification 1989/90 and the 15

interview, where the Reunification Stress Index questionnaire was applied, 16

recall bias may have influenced the results. However, we evaluated validity 17

and reliability of the Reunification Stress Index and found no indication for 18

recall bias. 19





stroke. 24

25

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4

Introduction 1









after the social change.10-13 Assumed determinants of psychosocial stressors in this 10

context are: occupational stressors e.g. unemployment5,11, mass-privatization7, job 11

strain12, financial stressors5,11,14,15, and personal stressors e.g. social isolation12,15 12

critical life events12. 13


isolation, depression, critical life events) can contribute to the development of CVD.16-15

23 The political, social, and economic changes in the German Democratic Republic 16







psychosocial stressors, health behaviour, and the resulting impacts on health.6,11 23

However, specific psychosocial stressors have not been identified.13 We analysed 24

individually perceived changes of occupational, financial, and personal situation after 25

the reunification as determinates of psychosocial stressors. Therefore, the aim of this 26

study was to examine the relationship between individually perceived changes in 27


effects. We hypothesised that higher levels of individually perceived psychosocial 29

stress related to this critical life event, i.e. reunification, were associated with an 30

increase in cardiovascular risk factors and CVD. 31

32

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Methods 1
































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Results 8

The characteristics of the study participants are shown in table 1. 51.9% of the 3.901 9

study participants were male. The CARLA participants were older, had more 10

cardiovascular risk factors and cardiovascular diseases than the SHIP participants, 11

except for smoking, alcohol consumption, depressive disorders, and education. In 12

total, men had more cardiovascular diseases and cardiovascular risk factors then 13

women, except for BMI, education, and depressive disorders. The mean value of the 14

RSI was 4.8 (SD=2.4) for men and 4.9 (2.4) for women. The majority of the 15

participants had an RSI less than 5 (men 46.2%, women 42.9%). 34.6% of the men 16

and 36.1% of the women underwent a deterioration in psychosocial stressors after 17

reunification. The RSI was highest in the age-group of 45-<55 years for both men 18

and women (5.3 (2.4); 5.4 (2.3)). The change in occupational situation related to 19

reunification was the major contributing psychosocial stressor. We observed a 20

deterioration in the occupational situation after reunification in 37.0% (men) and 21

38.3% (women). An improvement was reported in 31.9% of the male and 28.5% of 22

the female participants. The majority reported an improvement in their financial 23

situation (men: 55.7; women: 49.4) and no changes in the personal situation after 24

reunification (men: 65.6; women: 71.6). 25

26

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CARLA SHIP TOTAL

Men

(n=703)

Women

(n=565)

Men

(n=1298)

Women

(n=1335)

Men

(n=2001)

Women

(n=1900)

Age

Mean (SD)

24 - <45 (n)

45 - <55 (n))

55 - <65 (n)

65 - <75 (n)

>=75 (n)

61.3 (8.5)

-

205

248

204

46

59.0 (7.0)

-

197

237

130

1

46.9 (12.3)

591

301

301

94

11

43.6 (11.1)

667

366

262

35

5

51.9 (13.0)

591

506

549

298

57

48.8 (12.1)

667

563

499

165

6 Ag

e g

rou

p

CV

D

MI; n (%) 42 (6.0) 7 (1.2) 30 (2.3) 5 (0.4) 72 (3.6) 12 (0.6)

Stroke; n (%) 20 (2.8) 9 (1.6) 10 (0.7) 8 (0.6) 30 (1.5) 17 (0.9)

CHD; n (%) 54 (7.7) 13 (2.3) 33 (2.5) 5 (0.4) 87 (4.3) 18 (1.0)

CVD*; n (%)

69 (9.8) 22 (3.9) 41 (3.1) 13 (1.0) 110 (5.4) 35 (1.8)

Card

iova

sc

ula

r ri

sk

fac

tors

Hypertension; n (%) 534 (76.9) 377 (66.7) 784 (60.7) 455 (34.2) 1318 (66.1) 832 (43.8)

Smoker; n (%) 512 (72.8) 205 (36.3) 1011 (77.8) 739 (55.4) 1523 (76.1) 944 (49.7)

Diabetes; n (%) 83 (11.8) 62 (11.0) 80 (6.2) 57 (4.3) 163 (8.1) 119 (6.3)



(%)

33 (4.9) 57 (10.3) 101 (7.8) 227 (17.1) 134 (6.8) 284 (15.1)

BMI; mean (SD) 28.2 (4.1) 28.5 (5.6) 27.8 (3.9) 26.7 (5.3) 27.9 (4.0) 27.2 (5.5)


Education

low; n (%)

middle; n (%)

high; n (%)

22 (3.1)

427 (60.7)

254 (36.1)

49 (8.7)

387 (68.5)

129 (22.8)

77 (5.9)

908 (70.0)

313 (24.1)

100 (7.5)

1012 (74.9)

254 (17.9)

99 (5.0)

1335 (66.8)

567 (28.3)

149 (7.9)

1382 (72.4)

369 (19.4)

Ex

po

su

re

RSI; mean (SD) 4.8 (1.6) 5.0 (1.5) 4.8 (2.7) 4.9 (2.7) 4.8 (2.4) 4.9 (2.4)

<5, n (%) =5; n (%) >5; n (%)

331 (47.1) 139 (19.8) 233 (33.1)

235 (41.6) 128 (22.7) 202 (35.8)

593 (45.7) 246 (19.0) 459 (35.4)

580 (43.5) 271 (20.3) 484 (36.3)

924 (46.2) 385 (19.2) 692 (34.6)

815 (42.9) 399 (21.0) 686 (36.1)

RSI by age group


- 5.3 (1.8) 4.9 (1.6) 4.4 (1.4) 4.8 (1.2)

- 5.4 (1.6) 4.8 (1.5) 4.9 (1.2) 3.3 (-)

4.5 (2.7) 5.3 (2.7) 5.2 (2.6) 3.8 (2.5) 2.4 (2.0)

4.6 (2.7) 5.4 (2.6) 5.1 (2.8) 3.7 (2.4) 2.6 (2.3)

4.5 (2.7) 5.3 (2.4) 5.1 (2.2) 4.2 (1.8) 4.3 (1.6)

4.6 (2.7) 5.4 (2.3) 5.0 (2.2) 4.6 (1.6) 2.8 (2.0)



211 (30.0) 264 (37.5) 228 (32.4)

143 (25.3) 230 (40.7) 192 (33.9)

411 (31.7) 375 (28.9) 512 (39.5)

398 (29.8) 402 (30.1) 535 (40.1)

622 (31.1) 639 (31.9) 740 (37.0)

541 (28.5) 632 (33.3) 727 (38.3)

Financial situation


394 (56.1) 183 (26.0) 126 (17.9)

273 (48.3) 163 (28.9) 129 (22.8)

720 (55.5) 336 (25.9) 242 (18.6)

666 (49.9) 341 (25.5) 328 (24.6)

1114 (55.7) 519 (25.9) 368 (18.4)

939 (49.4) 504 (26.5) 457 (24.1)

Personal situation


46 (6.5) 488 (69.4) 169 (24.0)

23 (4.1) 422 (74.7) 120 (21.2)

131 (10.1) 825 (63.6) 342 (26.4)

139 (10.4) 938 (70.3) 258 (19.3)

177 (8.9) 1313 (65.6) 511 (25.5)

162 (8.5) 1360 (71.6) 378 (19.9)



women 4


6

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risk factors were stronger in women than in men (Table 2). 10






16







Men Women


Card

iov

ascu

lar

dis

ea

se

s




Card

iova

scu

lar

risk f

acto

rs


1.15 (1.06-1.24) 1.15 (1.07-1.24) 1.07 (1.01-1.12) 1.07 (1.02-1.11)


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Men Women




Improvement 1 1 1 1

No change 0.97 (0.63-1.49) 0.71 (0.46-1.08) 4.56 (1.33-15.54) 3.76 (1.03-13.72)

Deterioration 0.68 (0.43-1.08) 0.79 (0.50-1.26) 3.96 (1.16-13.55) 4.04 (1.21-13.43)

Financial situation

Improvement 1 1 1 1

No change 0.99 (0.65-1.50) 0.91 (0.60-1.36) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.69 (0.40-1.20) 0.90 (0.52-1.58) 2.10 (0.25-1.81) 2.63 (0.29-2.37)

Personal situation

Improvement 1 1 1 1

No change 0.67 (0.38-1.17) 0.77 (0.45-1.31) 3.45 (0.47-2.51) 3.10 (0.45-2.14)

Deterioration 0.64 (0.34-1.20) 0.87 (0.48-1.59) 2.10 (0.25-1.81) 2.63 (0.29-2.37)


4













drinking. 17

18

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RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

RR

(CI 95%)

Hyper-

tension

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.06

(0.98-1.15)

0.99

(0.92-1.07)

1.10

(1.02-1.18)

1.08

(1.06-1.16)

1.12

(0.99-1.27)

1.08

(0.97-1.20)

1.04

(0.93-1.18)

1.06

(0.94-1.19)

1.12

(0.91-1.36)

1.02

(0.85-1.21)

Deterioration 1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.08

(1.003-1.17)

1.06

(0.98-1.14)

1.07

(0.99-1.16)

1.11

(1.02-1.20)

1.16

(1.01-1.29)

1.19

(1.06-1.34)

1.02

(0.89-1.16)

1.06

(0.94-1.21)

1.12

(0.91-1.40)

1.08

(0.87-1.33)

Smoking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.01

(0.94-1.08)

0.99

(0.93-1.06)

1.09

(1.03-1.15)

1.05

(0.99-1.12)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.98

(0.90-1.07)

0.98

(0.90-1.07)

0.92

(0.79-1.08)

1.01

(0.86-1.17)

Deterioration 1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.11

(1.05-1.18)

1.09

(1.03-1.16)

1.15

(1.08-1.22)

1.11

(1.04-1.18)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.89-1.07)

0.96

(0.88-1.06)

0.98

(0.82-1.17)

1.02

(0.86-1.21)

Diabetes

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.23

(0.84-1.80)

1.02

(0.70-1.49)

1.09

(0.77-1.56)

1.06

(0.75-1.51)

1.12

(1.00-1.24)

1.11

(1.01-1.24)

0.85

(0.51-1.42)

0.90

(0.55-1.48)

0.76

(0.43-1.33)

0.82

(0.47-1.45)

Deterioration 1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.20

(0.83-1.74)

1.20

(0.83-1.73)

1.29

(0.89-1.88)

1.45

(1.01-2.11)

1.27

(1.14-1.41)

1.24

(1.12-1.38)

0.97

(0.56-1.67)

1.12

(0.65-1.94)

0.75

(0.39-1.45)

0.81

(0.32-1.16)

High-risk

drinking

Improvement 1 1 1 1 1 1 1 1 1 1 1 1

No change 1.01

(0.84-1.21)

1.06

(0.88-1.28)

0.90

(0.85-1.40)

0.95

(0.61-1.48)

1.05

(0.88-1.25)

1.06

(0.89-1.27)

0.65

0.42-1.02

0.72

(0.45-1.13)

0.84

(0.66-10.7)

0.84

0.66-1.07

0.66

0.39-1.12

0.69

(0.41-1.18)

Deterioration 0.96

(0.80-1.15)

0.97

(0.81-1.17)

1.05

(0.69-1.59

1.17

0.76-1.81

1.08

(0.88-131)

1.04

(0.85-1.27)

0.83

(0.55-1.27)

0.90

(0.59-1.38)

0.83

(0.63-7.08

0.79

0.60-1.03

0.74

0.40-1.36

0.79

(0.43-1.46)

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Improvement 1 1 1 1 1 1 1 1 1 1 1 1

Depressive

disorders

No change 0.69

(0.42-1.15)

0.73

(0.44-1.21)

0.89

(0.66-1.19)

0.97

(0.72-1.29)

0.84

(0.54-1.30)

0.89

(0.56-1.42)

1.02

(0.77-1.32)

1.02

(0.78-1.35)

0.67

(0.37-1.18)

0.71

(0.40-1.25)

0.93

(0.62-1.41)

1.02

(0.67-1.56)

Deterioration

1.77

(1.20-2.61)

1.85

(1.24-2.77)

1.19

(0.92-1.55)

1.23

(0.94-1.60)

1.85

(1.27-2.68)

1.83

(1.24-2.89)

1.29

(1.01-1.67)

1.32

(1.02-1.70)

1.52

(0.85-2.72)

1.51

(0.85-2.56)

1.65

(1.07-2.54)

1.67

(1.08-2.59)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

β

(CI 95%)

BMI

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 0.51

(0.0-0.92)

0.30

(-0.10-0.71)

0.43

(-0.17-0.71)

-0.03

(-0.61-0.53)

0.28

(-0.11-0.68)

0.18

(-0.21-0.58)

0.87

(0.32-1.43)

0.61

(0.09-1.14)

0.20

(-0.41-0.82)

0.24

(-0.36-0.86)

0.63

(-0.24-1.51)

0.39

(-0.43-1.22)

Deterioration 1.18

(0.74-1.62)

1.02

(0.58-1.45)

1.63

(1.02-2.24)

1.17

(0.58-1.76)

0.73

(0.25-1.20)

0.75

(0.28-1.23)

1.55

(0.93-2.16)

1.34

(0.74-1.94)

0.31

(-0.40-1.03)

0.50

(-0.20-1.21)

1.00

(-0.03-2.05)

0.81

(-0.17-1.80)

Cholesterol

mg/dL

Improvement 0 0 0 0 0 0 0 0 0 0 0 0

No change 3.34

(-1.43-8.11)

3.65

(-1.05-8.3)

0.44

(-0.70-964)

1.82

(-3.08-6.74)

5.60

(1.00-10.20)

5.24

(0.68-9.79)

2.52

(-2.40-7.45)

1.81

(-2.88-6.51)

2.69

(-4.36-9.75)

5.62

(-1.26-12.52)

2.09

(-5.37-9.57)

2.34

(-4.63-9.31)

Deterioration 8.96

(3.94-13.99)

7.65

(2.70-12.61)

11.25

(6.21-16.2)

7.83

(3.06-12.60)

8.62

(3.18-14.05)

8.93

(3.52-14.35)

7.19

(2.11-12.26)

6.88

(2.02-11.74)

5.24

(-2.9-13.46)

7.74

(-0.44-15.93)

1.32

(-6.98-9.64)

1.18

(-6.89-9.26)



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4). 9






Discussion 15


changed individually through a transition with direct reference to cardiovascular 17

outcomes on an individual basis. We analysed the consequences of the reunification 18

for changes in psychosocial stressors (occupational, financial, and personal). 19

Reunification was a fixed event in the past which entailed changes of these factors. 20

We investigated if different reflections of German reunification on the psychosocial 21

level may be associated with different levels of risk factors or frequencies of 22

occurrence of disease. We observed an increase in CVD morbidity in women with a 23

higher RSI. Furthermore, we found that the RSI was weakly but consistently 24

associated with cardiovascular risk factors in both men and women. Deterioration in 25

the occupational and financial situation after reunification was considerably 26

associated with diabetes, depressive disorders, cholesterol, and smoking. In general, 27

the associations were stronger in women than in men, with the exception of 28

depressive disorders. 29



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rank.39 Men are less able to compensate for this than women.40 Cockerham assumed 24










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reunification. 8








years after reunification. Because of this time lag recall bias may have influenced the 16

results. However, we evaluated validity and reliability of the Reunification Stress 17

Index and found no severe indication for recall bias. We argue that after this time 18

delay answering questions concerning personal impact of reunification will give a 19

more steady reflection of the personal state. Furthermore, participants were not told 20

the specific study hypotheses and therefore would not have been aware of the 21

potential link between reunification related stress and CVD. Consequently, if there is 22

a kind of recall error regarding reunification related stressors, participants with and 23

without relevant outcomes should be equally affected. This kind of nondifferential 24

misclassification would result in an underestimation of effects. Third, we assume that 25

we lost potential participants because of illness or death due to factors associated to 26

reunification. Furthermore, it is well-known that healthy women and men were more 27

likely to migrate after reunification to the western part of Germany. We thus cannot 28

exclude a selection bias, which could change our results in both directions. Fourth, 29

some questionnaires are different between the studies, e.g. for depressive disorders. 30

But in analyses stratified by study effects were similar. However, we are prudent with 31

the interpretation of the effects, because a depressive disorder exists for a long 32

period; therefore it is possible that depressed persons answer in a negative way 33

followed by the depressive disorder. Fifth, potentially we cover not all psychosocial 34

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stressors due to a transition. However, we decided to analyse psychosocial stressors 1

in terms of occupation, financial, and personal stressors, because in view of the 2

appropriate literature these factors seem to be the most relevant. 3

In summary, our findings show that a individually perceived deterioration of 4

psychosocial stressors in terms of occupational, financial, and personal stressors 5

related to German reunification was associated with cardiovascular risk factors and 6

CVD. An explanation for these findings could be that women were more often 7





12

Contributors 13









Funding 22








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References 2

1. Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, Tolonen H et al. Contribution 3

of trends in survival and coronar y-event rates to changes in coronary heart 4

disease mortality: 10-year results from 37 WHO MONICA Project 5

populations. Lancet. 1999;353:1547-57. 6

2. Bobak M, Marmot M. East-West mortality divide and its potential 7

explanations: proposed research agenda. BMJ (Clinical Research Ed). 8

1996;312:421-5. 9




West Germany and Poland. II: short-term trends during transition and in the 13

1990s. J Epidemiol Community Health. 2000;54:899-906. 14



6. Landsbergis P, Klumbiene J. Coronary heart disease mortality in Russia 17

and eastern Europe. Am J Public Health. 2003;93:1793. 18



8. Kuulasmaa K, Tunstall-Pedoe H, Dobson A et al. Estimation of contribution 21

of changes in classic risk factors to trends in coronary-event rates across 22

the WHO MONICA Project populations. Lancet. 2000;355:675-87. 23

9. Leon DA, Chenet L, Shkolnikov VM et al. Huge variation in Russian 24

mortality rates 1984–94: artefact, alcohol, or what? Lancet. 1997;350:383-25

8. 26


psychosocial risk factors explain the European East-West gap in health 28

status? Eur J Public Health. 2001;11:65-73. 29


JAMA: 1998;279:790-1. 31

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coronary heart disease: a collaborative meta-analysis of individual 21

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Item

No

Recommendation

Page (p)and

line Number

(l)



p 2, l 6



p 2, l 2-25

Introduction



p 4, l 2-16


Methods




p 4, l 28-31

p 5, l 1-5, 10-

31



p 5, l 5-12



applicable

p 5, l 14-32

p 6, l 1-32

Data sources/

measurement




p 5, l 14-32

p 6, l 1-32

p 7, l 1,2





and why

p 5, l13-32

p 6, l 11-13



p 7, l 3-27


interactions

p 7, l 24/25



sampling strategy


Results




up, and analysed

p 5, l 5-12

p 7, l 29




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confounders



Table 1

p 5, l 11/12






Table 2-4


categorized

Table 1





(p 7, l 24/25)

Discussion





p 16, l 3-18




p 14, l 24-31,

p 15, l 1-33,

p 16, l 1-5


results

p 16, l 19-22

Other information




p 17, l 4-9







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