gms | German Medical Science

GMS Psycho-Social-Medicine

Corporate journal of German scientific societies in psychosocial medicine

ISSN 1860-5214

Health care utilization in Germany: The NWIn research network

Editorial Special issue: Health care utilization in Germany: The NWIn research network

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  • corresponding author Christian Janßen - Munich University of Applied Sciences, Department of Applied Social Sciences, Munich, Germany
  • author Enno Swart - Otto-von-Guericke University of Magdeburg, Institute of Social Medicine and Health Economics, Magdeburg, Germany
  • author Thomas von Lengerke - Hannover Medical School, Medical Psychology Unit, Hannover, Germany
  • NWIn Research Network

GMS Psychosoc Med 2012;9:Doc12

doi: 10.3205/psm000090, urn:nbn:de:0183-psm0000906

Published: October 25, 2012

© 2012 Janßen et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Recent national and international socio-epidemiological research has consistently demonstrated a significant social gradient in health-related quality of life, morbidity and mortality, favoring the higher and disadvantaging the lower social status groups. This holds true both for Germany and Europe in general as well as for other industrialized countries such as USA or Canada. For instance, in Germany differences in life expectancy between top and lowest income groups range up to 10 years. Against this background, a crucial scientific and political question is whether the health care system in- or decreases this gap. First research findings in Germany indicate that the gap might be influenced more by differences in utilization than in supply.

In 2002, the working group “Health Care Research” was founded within the German Association of Medical Sociology (Deutsche Gesellschaft für Medizinische Soziologie, DGMS), consisting of about 30 scientists. In the following years, several workshops at national and international conferences were held by members of this group. In 2007, a first book resulted from this collaboration, which was published by Juventa and presented medical sociological health care research in its full scope [1]. Subsequently, the special importance of utilization of health care triggered a proposal to the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) for funding a scientific network on “Health care utilization in Germany”. After its approval (grant no.: JA-1849, 1-1), the network started off under the designation of NWIn Research Network (NWIn: “Netzwerk Inanspruchnahme”, i.e. “Utilization Network”) in January 2010 for a three years funding period. In 2013, a book publication provisionally entitled “Health care utilization in Germany: theory, methodology, and outcomes” is scheduled to be published by Springer Science + Business Media. As one of its key features, all chapters of this edited book will relate to one and the same theoretical approach, namely one (if not the) internationally leading framework for utilization research: the Behavioral Model of Health Care Utilization (BM) by US medical sociologist and health services researcher Ronald M. Andersen [2], [3].

Prior to this book publication, we are happy to present for the NWIn Research Network this special issue of GMS Psycho-Social-Medicine (P-S-M). In the first of six contributions, Birgit Babitsch, Daniela Gohl and Thomas von Lengerke via a systematic review assess the explicit use of Andersen’s BM in studies conducted in Europe or Anglo-American countries and published between January 1998 and March 2011 [4]. Although associations of higher utilization were found with older age, being a woman, higher income and poorer health, there were several inconsistencies across studies, among others that the operationalizations of the model revealed that only a small common set of variables was used, and that there were huge variations in the way these variables were categorized, especially in regard to predisposing and enabling factors. The next contribution of Enno Swart deals with large scale population surveys [5]. Comparing data from the East-West Survey (OW1991), the 1998 Federal National Health Survey (BGS1998), the 2003 Telephone Health Survey (TEL2003), the 2009 German Health Update (GEDA2009), the 26 waves of the Socio-Economic-Panel (SOEP) and the 16 waves of the Bertelsmann Healthcare Monitor, he claims that the results of the questions on the use of outpatient care services are not easily comparable due to differences in target groups, reference period, types of physicians contacted and response categories. Next, Silke B. Wolfenstetter, Petra Menn, Rolf Holle, Andreas Mielck, Christa Meisinger and Thomas von Lengerke analyze the relationships between changes in body weight and outpatient medical care utilization using data from MONICA/KORA cohorts in the region of Augsburg. Their analysis shows that, compared to maintained normal weight, maintained overweight, weight gain or loss over seven up to ten years are associated with higher outpatient physician utilization in adults, especially given baseline obesity [6]. The next contribution of Bernhard Borgetto and Holm Thieme deals with the utilization of physical therapy and self-help groups in Germany in patients with rheumatic diseases [7]. Their main result is that evidence exists for wide variations in the utilization of physical therapy services due to individual and context factors but also to an underuse of such services among patients with rheumatic diseases in Germany. In another systematic review, Christian Janßen, Stefanie Sauter and Christoph Kowalski investigate the impact of social factors on the use of prevention and health promotion services in Germany [8]. Their review shows that there is already significant and relevant evidence in the published literature for the relationship between lower social status and lower use of such services, but that there are also a few “blind spots” such as a lack of studies dealing with tertiary prevention, especially with regard to men, but also to health promotion with regard to both gender groups. Finally, Daniel Lüdecke, Eva Mnich and Christopher Kofahl deal with the caregivers of elderly dependents [9]. Their analysis of data of the EUROFAMCARE study clearly indicates that use of support services aimed directly at the caregivers is very low. Among socio-demographic characteristics, gender and education have the greatest impact on service use.

All in all, these papers should provide interested readers both with an in-depth insight into how health care utilization is scrutinized within NWIn, and with stimulating results on the BM, utilization research methodology, and selected empirical questions. Following-up on this, the upcoming 2013 book publication will to our knowledge be the first endeavour to analyse the social determinants of health care utilization in Germany via systematic use of theoretical approaches, research methods and empirical results of medical sociology. Besides using the BM as the recurrent theme throughout the book, the empirical contributions will be based either on analysis of primary respectively secondary data or results of systematic literature reviews using equivalent literature search strategies. While the book will analyse the situation in Germany, it will deliberately be published in English in order to stimulate communication with international research communities. Thus, we hope that it will provide a blueprint for health care utilization analyses in other countries.


NWIn Research Network

Members of the NWIn Research Network are (in alphabetical order): Birgit Babitsch, Bernhard Borgetto, Cornelia Bormann, Carolin Donath, Kerstin Hofreuther-Gätgens, Tristan Gloede, Rolf Holle, Daniela Gohl, Elmar Gräßel, Hannes Grau, Christian Janßen, Jens Klein, Christopher Kofahl, Olaf von dem Knesebeck, Mirjam Körner, Christoph Kowalski, Simone Kunz, Thomas von Lengerke, Daniel Lüdecke, Birte Maschke, Andreas Mielck, Christa Meisinger, Petra Menn, Eva Mnich, Larissa Schwarzkopf, Achim Siegel, Ulrich Stößel, Enno Swart, Holm Thieme, Gudrun Ulbrecht, Silke B. Wolfenstetter.

“Health care utilization in Germany – theoretical approaches, methods and empirical results in Medical Sociology” (NWIn) is funded by the Deutsche Forschungsgemeinschaft (German Research Foundation, grant no.: JA 1849/1-1).

Competing interests

The authors declare that they have no competing interests.


Janßen C, Borgetto B, Heller G, eds. Medizinsoziologische Versorgungsforschung: Theoretische Ansätze, Methoden, Instrumente und empirische Befunde [Medical Sociology and Health Care Research: theoretical approaches, methods, instruments and empirical results]. Weinheim: Juventa; 2007.
Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995 Mar;36(1):1-10.
Andersen RM, Davidson PL. Improving access to care in America: individual and contextual indicators. In: Andersen RM, Rice TH, Kominski EF, eds. Changing the U.S. health care system: key issues in health services, policy, and management. San Francisco, CA: Jossey-Bass; 2001. p. 3-30.
Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. GMS Psychosoc Med. 2012;9:Doc11. DOI: 10.3205/psm000089 External link
Swart E. The prevalence of medical services. How comparable are the results of large-scale population surveys use in Germany? GMS Psychosoc Med. 2012;9:Doc10. DOI: 10.3205/psm000088 External link
Wolfenstetter SB, Menn P, Holle R, Mielck A, Meisinger C, von Lengerke T. Body weight changes and outpatient medical care utilisation: Results of the MONICA/KORA cohorts S3/F3 and S4/F4. GMS Psychosoc Med. 2012;9:Doc09. DOI: 10.3205/psm000087 External link
Thieme H, Borgetto B. Utilisation of rheumatology care services in Germany: the case of physical therapy and self-help groups. GMS Psychosoc Med. 2012;9:Doc08. DOI: 10.3205/psm000086 External link
Janßen C, Sauter S, Kowalski C. The influence of social determinants on the use of prevention and health promotion services: Results of a systematic literature review. GMS Psychosoc Med. 2012;9:Doc07. DOI: 10.3205/psm000085 External link
Lüdecke D, Mnich E, Kofahl C. The impact of sociodemographic factors on the utilisation of support services for family caregivers of elderly dependents – results from the German sample of the EUROFAMCARE study. GMS Psychosoc Med. 2012;9:Doc06. DOI: 10.3205/psm000084 External link