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Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
h ps://doi.o g/10.1186/s12889-025-23698-w BMC Public Heal h
*Co espondence:
Bi gi Babi sch
[email p o ec ed]
Full lis o au ho in o ma ion is a ailable a he end o he a icle
Abs ac
Backg ound Al hough he COVID-19 pandemic has demons ably led o an inc ease in heal h inequi ies, only
a ew s udies ha e analyzed hei unde lying mechanisms by aking in o accoun socioeconomic s a us and
sociodemog aphic di e ences a he same ime. Simila ly, only ew s udies ha e explo ed he impac o COVID-19
con ainmen measu es on inequi ies in li ing condi ions, heal h- ela ed isks, and coping esou ces. This s udy aims
o add ess hese gaps by explo ing he complex associa ions o socioeconomic and sociodemog aphic ac o s wi h
changes in li e ci cums ances, pandemic- ela ed expe iences, sel - a ed heal h, and well-being among adul s li ing in
Ge many.
Me hods A o al o 2,123 adul s (women: 49.8%, men: 50.2%) li ing in Ge many pa icipa ed in he c oss-sec ional
online s udy ExCo:Well be ween July and Augus 2022. The su ey included ques ions on socioeconomic s a us,
sociodemog aphic ac o s, social ci cums ances, esou ces and bu dens, as well as heal h ou comes. The da a we e
analyzed using bi a ia e and mul i a iable logis ic eg ession analyses.
Resul s Ou esul s show signi ican dispa i ies in sel - a ed heal h and men al well-being based on socioeconomic
s a us. Fo sociodemog aphic di e ences, he esul s a e mixed, wi h only women consis en ly showing wo se
heal h ou comes han men. Immig a ion s a us played a limi ed ole. Al hough measu es o con ain he COVID-19
pandemic mo e commonly a ec ed he li e and wo k condi ions o mo e p i ileged pa icipan s, socioeconomically
disad an aged pa icipan s expe ienced highe bu dens and had ewe coping esou ces. Logis ic eg ession analyses
showed ha heal h inequi ies dec eased when esou ces and bu dens we e conside ed.
Conclusions By co e ing he whole pe iod o he COVID-19 pandemic, ou da a allow o an o e all assessmen o
his c i ical ime as well as a be e unde s anding o mechanisms unde lying heal h inequi ies. Ou indings sugges
ha mo e impo an han he numbe o go e nmen -induced social changes is hei quali y and hei po en ial o
AQ1
AQ2
Socioeconomic and sociodemog aphic
di e ences in he consequences o he
COVID-19 pandemic and hei impac on sel -
a ed heal h and men al well-being: esul s
om a c oss-sec ional s udy in Ge many
Bi gi Babi sch1* and C is inaCiupi u-Pla h2
Page 2 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
In oduc ion
SARS-CoV-2 a ec ed all socie ies and es ed hei esil-
ience in dealing wi h his unknown i us ha caused
o e 7 million dea hs wo ldwide [1], and mo e han
174,000 a ali ies in Ge many alone [2]. In addi ion o
la ge-scale accina ion p og ams, b oade public heal h
and social measu es (PHSM) we e implemen ed o con-
ain he COVID-19 pandemic, including cu ews, physi-
cal dis ancing, business closu es, and mask wea ing.
In Ge many, hese s a egies we e deployed alongside
nume ous economic policy measu es designed o alle i-
a e he inancial bu den o he pandemic.
Impac o he COVID-19 pandemic on sel - a ed heal h and
well-being
Apa om i s high dea h oll, he COVID-19 pandemic
also con ibu ed o signi ican educ ions in sel - a ed
heal h [3–5] and well-being [6–13]. Al hough he magni-
ude o hese associa ions a ied ac oss di e en samples
[8, 10–12, 14–17], aken oge he hey deli e a well-
ounded o e iew o he heal h impac s o he pandemic,
as sel - a ed heal h and well-being a e wo o he mos
commonly used heal h indica o s [18, 19]. Despi e hei
pa ial o e lap and la gely subjec i e na u e, hese wo
cons uc s p o ide dis inc in o ma ion abou indi idual
heal h. Albei usually elying on a single-i em assessmen ,
sel - a ed heal h is a b oad and la gely s able cons uc
e lec ing indi iduals’ pe cep ion o hei unc ioning
a he in e sec ion o physical, men al, and social heal h
[20]. In u n, well-being e e s o a s a e o posi i e men-
al heal h, in which indi iduals can each hei ull po en-
ial and e ec i ely con ibu e o hei communi y as
socially and psychologically well-adjus ed and unc ion-
ing membe s [21].
Sociodemog aphic di e ences in he impac o he COVID-
19 pandemic on sel - a ed heal h and well-being
The e ec s o he COVID-19 pandemic on sel - a ed
heal h and well-being ha e a ied no only in magni ude,
bu also ac oss di e en popula ion g oups [11, 13, 22].
Typically, women [5, 23], olde age g oups [5] and people
wi h low educa ional a ainmen [4, 5], lowe income o
inancial insecu i y [4, 24, 25] we e less likely o a e hei
heal h as good du ing he COVID-19 pandemic. Simi-
la ly, mos s udies ound an associa ion be ween poo e
well-being and emale gende [6, 8, 10, 13, 22, 26–28],
younge age [6, 8, 11, 13, 22], lowe educa ional a ain-
men [8, 10, 11, 26, 27, 29], lowe household incomes
AQ3
[13], li ing in socioeconomically disad an aged neigh-
bo hoods [6, 7] and ha ing a ch onic disease [13, 26, 27].
Explana o y ac o s in sel - a ed heal h and well-being in
he COVID-19 pandemic
O e all, bo h he di ec h ea posed by SARS-CoV-2
and PHSM consequences such as inancial insecu i y and
educed social con ac s con ibu ed o educ ions in sel -
a ed heal h [3, 17, 24] and men al well-being [7, 22, 30].
Al hough PHSM ypically had a g ea e impac on socio-
economically disad an aged popula ions [31, 32], some
s udies ound ha inc eased isks we e only associa ed
wi h some PHSM (e.g., job loss, wo sening inancial si u-
a ion) [33, 34], bu no o he s (e.g., educ ions in wo k
hou s) [33].
In con as , coping s a egies such as exe cising o
spending ime wi h amily we e posi i ely associa ed wi h
well-being [26] and indi iduals wi h a high unc ional
coping p o ile also had he highes well-being sco es
[35]. People epo ing lowe well-being used signi ican ly
mo e dis ac ion s a egies such as home en e ainmen ,
while hose wi h highe well-being dedica ed mo e ime
o sel -ca e, amily and iends [36]. O e all, he abili y o
cope wi h es ic ions in social li e was lowe in socioeco-
nomically disad an aged popula ions [34].
Heal h inequi ies be o e and du ing he COVID-19
pandemic
Nume ous s udies ha e consis en ly shown ha socio-
economic and sociodemog aphic di e ences play an
impo an ole in shaping indi iduals’ chances o li ing
in good heal h [37–40]. In Ge many, e en p io o he
pandemic, socie al ac o s such as he inc ease in income
inequali y be ween 1994 and 2014 we e associa ed wi h a
signi ican decline in sel - a ed heal h [41] and li e expec-
ancy [42]. A he same ime, indi idual cha ac e is ics
like gende [43, 44] and mig a ion [45, 46] a e s ong p e-
dic o s o heal h s a us among people li ing in Ge many.
The concep ual amewo k p oposed by he WHO
Commission on Social De e minan s o Heal h (CSDH)
clea ly dis inguishes be ween such s uc u al (e.g., poli-
cies, socioeconomic and sociodemog aphic ac o s)
and in e media y (e.g., li ing condi ions, psychosocial
ac o s) de e minan s o heal h [47]. D awing on his
amewo k, i is impo an o no e ha he COVID-
19 pandemic occu ed wi hin he con ex o p eexis -
ing social and heal h inequi ies associa ed wi h g ea e
ulne abili y and highe isk o poo e heal h ou comes
nega i ely impac ma e ial and social li elihoods in he long un. To imp o e heal h equi y, ailo ed social secu i y and
heal h p omo ion in e en ions need o be sys ema ically in eg a ed in pandemic o c isis esponse plans.
Keywo ds Socioeconomic s a us, Sociodemog aphic ac o s, Heal h inequi y, COVID-19, Sel -e icacy, Resou ces,
Bu den, Sel - a ed heal h, Men al well-being
Page 3 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
among socioeconomically disad an aged g oups, a phe-
nomenon desc ibed as a syndemic pandemic [48–54].
A highe isk o con ac ing COVID-19, a mo e se e e
cou se o disease, and highe mo ali y [2, 31, 48, 49, 55–
66] ha e been ound in socioeconomically disad an aged
g oups, a pa e n also no ed in Ge many [67, 68].
Fac o s d i ing heal h inequi y du ing COVID-19
The ac o s unde lying obse ed COVID-19 dispa i ies
a e clea ly oo ed in much o he same mechanisms ha
a e esponsible o endemic heal h inequi ies [48, 49, 54,
64, 69, 70]. As a esul o he d as ic social changes du ing
he COVID-19 pandemic, s uc u es o social dispa i y
we e likely ein o ced o exace ba ed [54]. Acco dingly,
a COVID-19-speci ic adap a ion o he CSDH [70]
included PHSM as s uc u al de e minan s and he di -
e en isks o exposu e o SARS-CoV-2 as in e media y
de e minan s o heal h.
The highe ulne abili y o socioeconomically disad-
an aged g oups o he COVID-19 pandemic can he e-
o e be unde s ood as a double bu den esul ing om (1)
a highe pandemic impac on he s uc u al and in e -
media y de e minan s o heal h [47] and (2) a poo e
heal h s a us p io o he pandemic [37–40]. Speci ically,
socioeconomically disad an aged g oups had a highe
p obabili y o expe iencing a de e io a ion in hei li ing
condi ions, mo e isks, and ewe esou ces and coping
mechanisms [48, 49, 54, 70]. Agains his backg ound,
he amoun and quali y o coping esou ces a ailable a e
likely o play a c ucial ole in he eme gence o heal h
inequi ies [71–73].
The e o e, dis inguishing be ween ex-an e and ex-pos
social and heal h inequi ies was sugges ed as a help ul
mechanism o wo king ou he inequi able s uc u es
and indi idual possibili ies ha a ec ed he handling o
d ama ic pandemic- ela ed changes o esul ed om
hese changes [74]. Using hese amewo ks can help
iden i y speci ic s a egies o adequa ely suppo socio-
economically disad an aged g oups du ing u u e public
heal h c ises and a oid an inc ease in heal h inequi ies in
he long e m.
S udy aim, esea ch ques ions, and hypo heses
While a g owing body o esea ch has in es iga ed he
ole o socioeconomic s a us and sociodemog aphic ac-
o s in shaping expe iences du ing he COVID-19 pan-
demic, de ailed analyses o he in e play be ween hese
ac o s, changes in li ing condi ions, and heal h- ela ed
esou ces emain limi ed. Exis ing s udies o en ocus on
single de e minan s o b oad indica o s, lea ing a gap in
unde s anding he complex inequi ies ha eme ged du -
ing he pandemic as illus a ed by he concep o syn-
demic pandemic [48–54]. Fu he esea ch is needed
o assess he ole o heal h- ela ed esou ces and hei
in e play wi h isk ac o s in a di e en ia ed manne ,
which is c ucial o elucida e heal h inequi ies associa ed
wi h he COVID-19 pandemic.
To add ess his esea ch gap, ou s udy p o ides
a de ailed examina ion o he complex associa ions
be ween socioeconomic and sociodemog aphic ac o s,
changes in li e ci cums ances, pandemic- ela ed expe i-
ences, and sel - a ed heal h and well-being among adul s
li ing in Ge many. The main esea ch ques ion explo ed
in his s udy is: How is he ela ionship o socioeconomic
and sociodemog aphic ac o s wi h sel - a ed heal h o
men al well-being in luenced by pandemic- ela ed bu -
dens and esou ces in Ge many?
The ollowing hypo heses we e es ed:
1) People wi h low socioeconomic s a us epo poo e
sel - a ed heal h and lowe men al well-being
compa ed o people wi h high socioeconomic s a us.
2) Olde people, women, as well as immig an s and
hei (di ec ) descendan s epo poo e sel - a ed
heal h and lowe men al well-being compa ed
o younge people, men, and people wi hou an
immig a ion his o y.
3) The social consequences and bu dens associa ed
wi h he COVID-19 pandemic a e g ea e among
people wi h low socioeconomic s a us han among
hose wi h high socioeconomic s a us.
4) Resou ces a e lowe among people wi h low
socioeconomic s a us han among hose wi h high
socioeconomic s a us.
5) Resou ces and bu dens in luence he associa ion o
socioeconomic and sociodemog aphic ac o s wi h
sel - a ed heal h and men al well-being, espec i ely.
Wi h i s ich da a on social de e minan s, changes in li -
ing condi ions, and speci ic heal h- ela ed esou ces, his
pape con ibu es o a deepe unde s anding o heal h
inequi ies in Ge many and can help iden i y oppo u-
ni ies o suppo popula ion heal h unde challenging
ci cums ances.
Me hods
S udy design
The da a o igina e om he c oss-sec ional, online
s udy “Expe iencing he COVID-19 Pandemic: Associa-
ion be ween Resou ces, Social Heal h, and Well-Being
(ExCo:Well)”. The impac o he COVID-19 pandemic
ex ended beyond di ec heal h h ea s o signi ican ly
al e daily li e due o PHSM. Recognizing his p o ound
and unequal impac ExCo:Well aimed o in es iga e 1.
how PHSM a ec ed indi iduals’ daily li e expe iences, 2.
whe he hese expe iences we e d i en by socioeconomic
and sociodemog aphic di e ences, and 3. how all hese
ac o s a ec ed sel - a ed heal h and men al well-being.
Page 4 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
This s udy builds on and expands exis ing esea ch by
p o iding a de ailed desc ip ion o changes ela ed o
PHSM, COVID-19 ela ed bu dens, and COVID-19 spe-
ci ic and gene al esou ces (e.g., gene al sel -e icacy).
Beginning in Ma ch 2020, nume ous measu es o con-
ain he COVID-19 pandemic we e enac ed in Ge many
by he go e nmen a he ede al and s a e le el, including
cu ews, physical dis ancing, he closu e o businesses,
and mask wea ing. The measu es we e dynamically
adap ed o he SARS-CoV-2 in ec ion a es and ha e
been signi ican ly scaled back since May 2022 and com-
ple ely elimina ed as o 8 Ap il 2023 [75, 76]. ExCo:Well
was conduc ed in Ge many om 22 July 2022 o 22
Augus 2022, gene a ing insigh s in o pa icipan s’ iews
and expe iences o he en i e COVID-19 pandemic and
he i s mon hs a e pandemic es ic ions we e loos-
ened. Da a we e collec ed by an ex e nal su ey company
( espondi, h ps://mingle. espondi.com) om membe s
o an online panel ha has been success ully used in
o he popula ion-based s udies du ing he COVID-pan-
demic [77].
The su ey included 49 ques ions, di ided in o he
ollowing sec ions: COVID-19 pandemic expe iences,
COVID-19 ela ed pe sonal and socie al changes,
COVID-19 ela ed (digi al) heal h li e acy, COVID-19
speci ic and gene al esou ces, sel - a ed heal h, men-
al well-being, pe sonal a i udes, COVID-19 speci ic
bu dens, socioeconomic, and sociodemog aphic ac-
o s. Whe e e possible, alida ed ins umen s we e
used in he de elopmen o he su ey; he de elopmen
o new ques ions speci ically o assess COVID-19- e-
la ed aspec s ollowed a s uc u ed quali a i e app oach
including cogni i e in e iews (see Ope a ionaliza ion
sec ion o de ails). The s udy is epo ed acco ding o
he STROBE s a emen [78].
S udy sample
All pa icipan s we e membe s o an online panel who
we e in o med abou he s udy and in i ed o pa icipa e
by an ex e nal su ey company. A o al o 4,753 people
accep ed he in i a ion and me he inclusion c i e ia, o
which 3,175 comple ed he online ques ionnai e in ull.
Quo a sampling was used o achie e ep esen a i eness
in e ms o age (18 o 74 yea s) and gende (c ossed), as
well as ede al s a e based on Eu os a 2020 da a. Mo e-
o e , a quo a o 30% was se o people wi h low educa-
ional a ainmen o ensu e su icien da a we e a ailable
o s a i ied analyses. This co esponds o he dis ibu-
ion o educa ional a ainmen among people li ing in
Ge many [79].
A sample size was calcula ed o eg ession analy-
sis, equi ing a minimum o 1,169 pa icipan s (powe
o 0.9, e ec size o 0.02, signi icance le el o α = 0.05)
[80]. Howe e , o allow o s a i ied analyses (e.g., by
immig a ion s a us o educa ional a ainmen ), i was
decided o inc ease he sample size. The inal sample size
o 2,123 was andomly selec ed by he ex e nal su ey
company, which is app op ia e in e ms o quo as (see
abo e) and da a quali y.
A e comple ion o he da a collec ion, an anonymized
da a se was p o ided o he esea ch eam by he ex e -
nal su ey company. All he da a p o ec ion equi emen s
we e gua an eed by he ex e nal company. The s udy was
app o ed by he e hics commi ee o Osnab ück Uni e -
si y (E hik-41/2022, 28.6.2022).
Ope a ionaliza ion
Sociodemog aphic and socioeconomic a iables
In his s udy, socioeconomic (educa ion, income, sub-
jec i e social s a us) and sociodemog aphic ac o s (age,
gende , immig a ion s a us) we e assessed using a ious
measu es. Age was di ided in o ou g oups in line wi h
ede al heal h epo ing p ocedu es [81]: 18–29, 30–44,
45–64, and 65–74 yea s. Gende was sel - epo ed by
pa icipan s as ‘male’ o ‘ emale’. Immig a ion s a us was
assessed acco ding o he ecommended s anda ds in
Ge many [82–84]. A dis inc ion was made be ween wo
ca ego ies: (a) immig an s and hei (di ec ) descendan s
(i.e., pa icipan s no bo n in Ge many o pa icipan s
bo n in Ge many wi h bo h pa en s bo n ou side o Ge -
many) and (b) people wi hou an immig a ion his o y
(i.e., pa icipan s and one o bo h pa en s bo n in Ge -
many) [84].
Educa ion was assessed using he CASMIN classi ica-
ion [85] and di ided in o basic, medium and highe edu-
ca ional a ainmen [86]. Subjec i e social s a us (SSS)
was measu ed using he MacA hu Scale o Subjec i e
Social S a us [87] as a sel -assessmen on a 10-s ep lad-
de . Pa icipan s’ esponses we e hen ca ego ized as low
(scale alues 1–4), medium (scale alues 5–6) and high
SSS (scale alues 7–10) [88]. Income was assessed as he
mon hly ne household income in line wi h he demo-
g aphic epo ing s anda d [89]. In addi ion, pa icipan s
we e gi en he op ion o o e ‘no esponse’. Fo he analy-
sis, income ca ego ies we e combined in o ou mon hly
ne household income g oups (< €1.000, €1.000-2.999;
€3.000-4.999; >=€5.000). An adjus men o income le el
by household size was no possible. In o ma ion on pa -
ne ship and pa en al s a us, as well as communi y size
was also eques ed.
Li ing si ua ion du ing he COVID-19 pandemic
Se e al aspec s o pa icipan s’ li ing si ua ion we e su -
eyed o assess he changes hey ha e expe ienced due
o he COVID-19 pandemic in Ge many. Pa icipan s
we e asked (a) o p o ide an o e all assessmen o how
easy i was o hem o na iga e he COVID-19 pandemic
and (b) o indica e how much hei li e ci cums ances
Page 5 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
changed du ing his ime. Bo h aspec s we e assessed
using 5-poin Like scales wi h he ollowing answe
op ions (a) 1= ‘ e y easy’, 2= ‘easy’, 3= ‘nei he easy no
di icul ’, 4= ‘di icul ’, 5= ‘ e y di icul ’, (b) 1= ‘no a all’,
2= ‘ a he weak’, 3= ‘nei he s ong no weak’, 4= ‘ a he
s ong’, 5= ‘ e y s ong’), which we e combined in o h ee
g oups o analysis (1= ‘ a he di icul o a he s ong’;
2= ‘nei he ’; 3= ‘ a he easy o a he weak’).
In addi ion, he p e alence o he mos common PHSM
in Ge many (e.g., wo king om home, ex a wo k, clo-
su e o companies o loss o employmen , wo k hou
educ ion, educ ion in o e ime and/o holiday, del-
ega ion o o he asks, and homeschooling) [75, 76] we e
assessed ( esponse ca ego ies: ‘yes’, ‘no’, ‘no applicable’).
Each ca ego y was analyzed sepa a ely. A limi a ion o
his assessmen is ha i does no p o ide in o ma ion on
he magni ude and du a ion o hese changes.
In o de o gauge how pa icipan s expe ienced he
en i e COVID-19 pandemic, hey we e asked o indica e
he ex en o which hey el h ea ened, bu dened, and
es ic ed du ing his ime. Fo his pu pose, hey we e
gi en i e esponse op ions anging om ‘ e y s ong’ o
‘no a all’. This 5-poin Like scale was educed o h ee
alues o analysis. Mo eo e , o explo e how he pa -
icipan s’ li ing si ua ion eco e ed a e he PHSM we e
scaled back, hey we e asked o es ima e how simila
hei cu en li ing si ua ion was compa ed o hei li -
ing si ua ion be o e he COVID-19 pandemic. The ex en
o which pa icipan s’ li e si ua ion had e u ned o no -
mal was assessed in wo ways: i s , using a 5-poin Lik-
e scale ( esponse ca ego ies: ‘no a all’ o ‘ e y s ong’),
and second, using a slide scale ha allowed esponden s
o selec any numbe be ween 0 and 100%.
Bu dens du ing he COVID-19 pandemic
The COVID-19 Pandemic- ela ed Bu den Scale (CBS)
was c ea ed o assess speci ic bu dens on social li e
esul ing om PHSM o con ain he COVID-19 pan-
demic in Ge many. The scale i ems we e de eloped in
2021 based on a comp ehensi e li e a u e e iew, includ-
ing bo h scien i ic and popula sou ces, and alida ed
h ough cogni i e in e iews (N = 5). The i ems cap u e
no only changes in ma e ial li ing condi ions, bu also
bu dens expe ienced in daily li e. The inal CBS included
12 i ems a ed on a 5-poin Like Scale (1= ‘comple ely
disag ee’, 2= ‘mos ly disag ee’, 3= ‘somewha ag ee’, 4=
‘mos ly ag ee’, 5= ‘comple ely ag ee’). In addi ion, he
esponse ca ego y ‘does no apply’ was o e ed. Because
o hei simila meaning, he esponse ca ego ies ‘does
no apply’ and ‘s ongly disag ee’ we e me ged in he
analysis. To es ima e he o e all bu den, he CBS sco e
was calcula ed by adding all 12 i ems ( ange 12–60). Reli-
abili y was good, wi h C onbach’s alpha = 0.869.
P incipal componen analysis (PCA) e ealed wo inde-
penden ac o s o he CBS: (1) ma e ial bu den ( ange:
6–30, C onbach’s alpha = 0.833) and (2) psychosocial bu -
den ( ange: 6–30, C onbach’s alpha = 0.851) (see Addi-
ional ile 1, Supplemen a y Table 1).
Resou ces du ing he COVID-19 pandemic
The COVID-19 Pandemic-Rela ed Resou ces and Coping
Scale (CRCS) was de eloped in 2020 based on a comp e-
hensi e li e a u e e iew o coping s a egies du ing he
pandemic, including bo h scien i ic and popula sou ces,
and alida ed h ough cogni i e in e iews (N = 5). The
inal CRCS included 12 i ems a ed on a 5-poin Like
scale (1= ‘does no apply a all’, 2= ‘applies o a low ex en ’,
3= ‘applies o a mode a e ex en ’, 4= ‘applies o a la ge
ex en ’, 5= ‘applies o a e y la ge ex en ’).
To es ima e he o e all le el o coping, he CRCS sco e
was calcula ed by adding all 12 i ems ( ange 12–60). Reli-
abili y was good, wi h C onbach’s alpha o s anda d-
ized i ems = 0.881. Fo he CRCS, a PCA was pe o med,
iden i ying wo ac o s: (1) sel - ocused coping s a egies
( ange: 7–35, C onbach’s alpha = 0.856) and (2) social
engagemen ( ange: 5–25, C onbach’s alpha = 0.756) (see
Addi ional ile 1, Supplemen a y Table 2).
Pa icipan s’ gene al sel -e icacy (GSE) was assessed
using he 10-i em scale de eloped by Je usalem &
Schwa ze [90]. The i ems measu e op imis ic expec-
a ions o compe ence, i.e., he con idence ha one can
mas e a di icul si ua ion, whe eby success is a ibu ed
o one’s own abili ies. A o al sco e was gene a ed ( ange
10 o 40), wi h highe alues indica ing highe sel -e i-
cacy. A dicho omous a iable (low s. high sel -e icacy)
was c ea ed using he alue 29 as a cu -o poin [90].
Reliabili y was excellen (C onbach’s alpha = 0.926).
Sel - a ed heal h and men al well-being
To desc ibe he heal h s a us o he sample, pa icipan s’
sel - a ed heal h [91] and he p esence o a ch onic dis-
ease (‘yes’/’no’) we e assessed. Using a 5-poin Lik-
e scale, he pa icipan s we e asked o a e hei
o e all heal h s a us om ‘ e y good’ o ‘ e y poo ’
[91]. A dicho omous a iable was c ea ed o dis inguish
be ween ‘ a he good’ ( esponse ca ego ies: ‘good’ and
‘ e y good’) and ‘ a he poo ’ ( esponse ca ego ies: ‘sa is-
ac o y’, ‘poo ’ and ‘ e y poo ’) sel - a ed heal h.
The WHO-5 ques ionnai e [92] was used o su ey
men al well-being. All i e i ems we e added o ob ain a
o al sco e ( ange 0–25). Following B ähle e al. [93], a
dicho omous a iable was c ea ed wi h a cu -o poin a
13. Reliabili y was excellen (C onbach’s alpha = 0.923).
Da a analysis
The da a we e analyzed using IBM SPSS Ve sion 29.0.
Uni a ia e and bi a ia e analyses we e ca ied ou o he

Page 6 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
desc ip i e analysis. The median was used when he da a
we e no no mally dis ibu ed, as de e mined by he Kol-
mogo o -Smi no es .
All analyses we e s a i ied by socioeconomic (educa-
ional a ainmen (CASMIN), mon hly ne household
income, and SSS) and sociodemog aphic (age, gende ,
and immig a ion s a us) a iables. Signi icance was es ed
using he Pea son chi2- es , he Mann-Whi ney-U es ,
and he K uskal-Wallis es , as app op ia e.
Fac o analyses we e conduc ed o examine he p ope -
ies o he new scales (CBS, CRCS). The eliabili y o all
scales was es ed wi h C onbach’s alpha.
Mul i a iable logis ic eg ession models we e cal-
cula ed o sel - a ed heal h (1 = a he good) and o
men al well-being (1 = high) as dependen a iables. The
independen a iables we e selec ed based on heo e i-
cal conside a ions and included block-wise: (1) socioeco-
nomic and sociodemog aphic a iables, (2) esou ces and
bu dens, and (3) p esence o a ch onic disease.
The signi icance le el was se a 0.05 o all analyses.
Resul s
S udy sample
Female and male pa icipan s we e almos equally ep-
esen ed in he sample, e lec ing he gende dis ibu-
ion o he popula ion li ing in Ge many. On a e age,
pa icipan s we e 46.3 yea s old; he la ges age g oup
was be ween 45 and 65 yea s old (40.0%). In o al, 9.4%
o he pa icipan s we e immig an s o hei (di ec )
descendan s. A basic le el o educa ion was a ained by
31.3%, a medium le el by 47.7% and a high le el by 21.0%
o he pa icipan s. Two- hi ds o he pa icipan s had a
mon hly ne household income be ween 1,000 and 4,999
eu os; 7.6% did no answe his ques ion. SSS was classi-
ied as low by 29.8% o pa icipan s and as high by 32.5%.
A o al o 61.4% li ed in a pa ne ship, 55.2% had chil-
d en and 42.4% li ed in a place wi h ewe han 20,000
inhabi an s. A SARS-CoV-2 in ec ion was epo ed by
37.4% o he pa icipan s (see Table1).
Changes in and pe cep ions o pe sonal li ing condi ions
du ing he COVID-19 pandemic
The PHSM o con ain he COVID-19 pandemic ha e
d as ically changed li ing condi ions and e ealed
nume ous pa e ns o inequi y. Conside ing he whole
pe iod o he COVID-19 pandemic, hal o he pa ici-
pan s (52.5%) epo ed expe iencing a he signi ican
li e changes. This was signi ican ly mo e common among
younge pa icipan s (60.8%) and hose wi h a low SSS
(56.6%), bu also among hose wi h highe educa ion
(55.5%).
O e all, 30.3% o esponden s wo ked om home,
19.2% epo ed addi ional wo k, 11.3% los hei jobs,
15.1% expe ienced wo k hou educ ions, 14.9% had
o educe o e ime o ake lea e, 15.4% we e gi en new
esponsibili ies, and 18.8% had o ake on homeschooling
o childca e esponsibili ies. Many o hese li e changes
we e mo e commonly epo ed by pa icipan s wi h
highe socioeconomic s a us.
The COVID-19 pandemic was pe cei ed as h ea en-
ing by 40.3% o pa icipan s, bu dening by 49.8%, and
es ic i e by 51.4%. These pe cep ions a ied mo e
ac oss sociodemog aphic g oups, bu li le ac oss socio-
economic s a a, whe e only signi ican di e ences wi h
ega d o he pe cei ed bu den o he COVID-19 pan-
demic we e no ed. Speci ically, a highe pe cen age o
olde pa icipan s pe cei ed he pandemic as a h ea ,
ye signi ican ly mo e pa icipan s in younge age g oups
el bu dened by he pandemic. Female pa icipan s a ed
wo se han male pa icipan s on all assessed measu es.
Na iga ing he COVID-19 pandemic was e ospec-
i ely a ed as being a he di icul by a hi d o he pa -
icipan s. Younge age g oups, emale pa icipan s, and
pa icipan s wi h lowe SSS we e signi ican ly mo e likely
o epo his.
Table 1 Desc ip ion o he s udy sample
Cha ac e is ics (N = 2,123) N%
Gende
Female 1,058 49.8
Male 1,065 50.2
Age g oups
18–29 yea s 406 19.1
30–44 yea s 567 26.7
45–64 yea s 849 40.0
65–74 yea s 301 14.2
Age (in yea s, median) 2,123 47.0
Age (in yea s, mean, (s d. de )) 2,123 46.3 (15.4)
Immig an s and hei (di ec ) descendan s 199 9.4
Educa ional a ainmen (CASMIN)
Basic 665 31.3
Medium 1,013 47.7
Highe 445 21.0
Mon hly ne household income
No answe 161 7.6
Up o unde 1,000 eu os 243 11.4
1,000 o 2,999 eu os 947 44.6
3,000 o 4,999 eu os 576 27.1
5,000 eu os and mo e 196 9.2
SSS
Low 633 29.8
Medium 800 37.7
High 690 32.5
Li ing in pa ne ship 1,303 61.4
Child en 1,171 55.2
Communi y size
Fewe han 20,000 inhabi an s 900 42.4
In ec ion wi h SARS-CoV-2 (sel - epo ed) 793 37.4
Page 7 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
A he ime o da a collec ion, 43.3% o he s udy pa -
icipan s epo ed ha hei cu en li ing si ua ion had
s a ed o become mo e simila o hei li ing si ua ion
be o e he COVID-19 pandemic. This is consis en wi h
pa icipan s’ o e all assessmen ha hei cu en li -
ing si ua ion co esponds o 79% (median) o hei li ing
si ua ion be o e he COVID-19 pandemic. Reco e y a es
we e signi ican ly lowe among pa icipan s who we e
younge , emale, and had lowe SSS. Fo example, 50.9%
o pa icipan s wi h high SSS s. 34.8% o pa icipan s
wi h low SSS epo ed ha hey had e u ned o hei
usual, p e-pandemic li ing si ua ion (see Table 2, see
Addi ional ile 2, Supplemen a y Table2_1 o he esul s
s a i ied o immig a ion s a us, educa ional a ainmen
(CASMIN) and mon hly ne household income).
Expe ienced bu dens du ing he COVID-19 pandemic
The majo i y o pa icipan s expe ienced bu dens ela ed
o hei pe sonal, social and ma e ial si ua ion, as mea-
su ed by he COVID-19 Pandemic- ela ed Bu den Scale
(CBS). Conside ing he en i e COVID-19 pandemic,
22.5% o he pa icipan s el ha hei li elihood was
h ea ened and 34.3% assumed ha i would ake a long
ime o e u n o hei p e ious li ing s anda d. A high
pe cen age o pa icipan s expe ienced challenges in
hei social li es and in coping wi h changed li ing con-
di ions. Younge age g oups, emale pa icipan s, immi-
g an s and hei (di ec ) descendan s, and hose wi h low
SSS pe cei ed hei li e si ua ion as mo e challenging,
wi h ew excep ions. The o e all pe cei ed bu den was
low, wi h a median CBS sco e o 24.0 ( ange 12–60). This
was also ound o bo h he Psychosocial bu den subscale
(median = 15.0, ange 6–30) and he Ma e ial bu den sub-
scale (median = 8.0, ange 6–30). Bo h ypes o bu dens
we e signi ican ly g ea e among younge age g oups and
pa icipan s wi h low SSS (see Table3, see Addi ional ile
2, Supplemen a y Table3_1 o he esul s s a i ied o
immig a ion s a us, educa ional a ainmen (CASMIN)
and mon hly ne household income).
Resou ces du ing he COVID-19 pandemic
Al hough mos pa icipan s ied o li e a no mal daily
li e, hey also used di e en coping s a egies o adap o
hei new, es ic ed li ing si ua ion, such as aking mo e
ime o elax (42.7%) o spending mo e ime in na u e
(44.6%). In addi ion, a hi d o he s udy pa icipan s
inc eased he ime hey spen wi h hei amilies and
made mo e e o s o imp o e hei heal h. The e we e
some signi ican social di e ences, showing ha olde
pa icipan s and hose wi h low SSS we e less likely o
use mos o he assessed coping s a egies. A mixed pa -
e n was no ed ega ding gende di e ences in coping
s a egies.
Almos hal o he sample had high GSE, wi h a median
o 29.0 and a mean (s anda d de ia ion) o 28.5 (5.7).
Howe e , la ge social di e ences in pa icipan s’ GSE
we e obse ed. Fo example, GSE sco es we e signi i-
can ly highe among pa icipan s wi h highe educa ional
a ainmen , highe SSS, and highe mon hly ne house-
hold income, as well as among male pa icipan s and
olde age g oups (see Table4, see Addi ional ile 2, Sup-
plemen a y Table4_1 o he esul s s a i ied o immi-
g a ion s a us, educa ional a ainmen (CASMIN) and
mon hly ne household income).
Sel - a ed heal h and men al well-being
O e all, 47.3% o he sample a ed hei heal h as e y
good o good, and 50.4% had a ch onic disease. Olde
pa icipan s and pa icipan s wi h low SSS epo ed
poo e sel - a ed heal h and we e also mo e likely o ha e
a ch onic disease. Fo example, 73.6% o pa icipan s wi h
low SSS a ed hei heal h as a he poo as opposed o
jus 31.2% o pa icipan s wi h high SSS.
Almos wo- hi ds o he sample epo ed high men al
well-being le els, bu he e we e no able di e ences by
socioeconomic s a us, wi h signi ican ly mo e pa ici-
pan s wi h lowe SSS epo ing lowe men al well-being
le els. Con a y o sel - a ed heal h, younge pa ici-
pan s (median = 14.0) a ed hei men al well-being lowe
han olde pa icipan s (median = 17.0) (see Table5, see
Addi ional ile 2 Supplemen a y Table5_1 o he esul s
s a i ied o immig a ion s a us, educa ional a ainmen
(CASMIN) and mon hly ne household income).
E ec s o socioeconomic and sociodemog aphic ac o s,
esou ces, and bu dens on sel - a ed heal h and men al
well-being
Mul i a iable logis ic eg ession analyses e ealed ha
sel - a ed heal h was in luenced by socioeconomic and
sociodemog aphic ac o s as well as esou ces and bu -
dens. Model 1 showed lowe odds o pa icipan s assess-
ing hei sel - a ed heal h s a us as ‘ a he good’ among
olde and emale pa icipan s as well as among pe sons
wi h lowe SSS. People wi h high SSS we e 4.4 imes
[3.30–5.81] mo e likely o ha e a ‘ a he good’ sel - a ed
heal h s a us han people wi h low SSS.
When esou ces and bu dens we e conside ed (model
2), GSE (1.10 [1.08–1.12]) inc eased he odds o a ‘ a he
good’ sel - a ed heal h s a us, while COVID-19- ela ed
bu dens (CBS) had a nega i e e ec (0.97 [0.96–0.98]).
In model 3, only Psychosocial Bu dens (0.97 [0.95–0.98])
educed, while Sel -Focused Coping S a egies (1.03
[1.00-1.05]) sligh ly inc eased he odds o epo ing a
‘ a he good’ sel - a ed heal h s a us. In he inal model
4, he p esence o a ch onic disease was added and
eme ged as s ong isk ac o o sel - a ed heal h (0.19,
Page 8 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
Cha ac e is ics (N = 2,123) NAge Gende SSS To al
18–29 30–44 45–64 65–74 p1M F p1L M H p1
Changes in li e h ough measu es o con ain he
COVID-19 pandemic
< 0.001 0.038 0.016
Ra he s onga (%) 1,115 60.8 57.8 48.3 43.2 50.6 54.4 56.6 52.9 48.4 52.5
Wo king om home (%) < 0.001 < 0.001 < 0.001
Yes 644 56.7 40.4 20.7 3.0 34.8 25.8 16.6 28.2 45.4 30.3
No 606 24.1 32.5 32.0 17.3 29.1 28.0 25.9 31.9 27.1 28.5
No applicable 873 19.2 27.2 47.2 79.7 36.1 46.2 57.5 39.9 27.5 41.1
Ex a wo k (%) < 0.001 < 0.001 < 0.001
Yes 408 26.1 30.3 14.7 1.7 19.2 19.3 14.1 21.0 21.9 19.2
No 945 51.2 49.6 46.3 20.9 49.3 39.7 36.2 45.6 50.9 44.5
No applicable 770 22.7 20.1 39.0 77.4 31.5 41.0 49.8 33.4 27.2 36.3
Loss o employmen (%) < 0.001 < 0.001 < 0.001
Yes 240 15.0 13.9 10.4 4.0 12.5 10.1 12.3 11.4 10.3 11.3
No 1,116 58.9 64.2 52.4 22.6 57.4 47.7 39.7 54.9 61.7 52.6
No applicable 767 26.1 21.9 37.2 73.4 30.1 42.2 48.0 33.8 28.0 36.1
Wo k hou educ ions (%) < 0.001 < 0.001 < 0.001
Yes 321 19.2 21.2 13.7 2.3 16.9 13.3 13.3 15.0 17.0 15.1
No 1,016 53.7 57.7 47.8 21.6 52.0 43.7 37.3 49.9 55.2 47.9
No applicable 786 27.1 21.2 38.5 76.1 31.1 43.0 49.4 35.1 27.8 37.0
Reduc ion o e ime and/o holiday (%) < 0.001 < 0.001 < 0.001
Yes 317 19.0 22.0 13.1 1.3 16.8 13.0 11.2 13.8 19.7 14.9
No 1,023 55.2 57.3 48.3 21.3 51.2 45.2 38.5 52.3 52.3 48.2
No applicable 783 25.9 20.6 38.6 77.4 32.0 41.8 50.2 34.0 28.0 36.9
Delega ion o o he asks (%) < 0.001 < 0.001 < 0.001
Yes 328 26.8 20.8 11.4 1.3 15.9 15.0 12.0 15.3 18.8 15.4
No 1,020 48.3 57.5 50.4 23.3 52.0 44.0 38.2 50.2 54.5 48.0
No applicable 775 24.9 21.7 38.2 75.4 32.1 40.9 49.8 34.5 26.7 36.5
Homeschooling (%) < 0.001 < 0.001 < 0.001
Yes 400 20.7 35.8 12.1 3.3 18.8 18.9 16.3 18.0 22.2 18.8
No 787 44.6 35.8 40.3 20.3 42.1 32.0 28.1 39.5 42.5 37.1
No applicable 936 34.7 28.4 47.6 76.4 39.2 49.1 55.6 42.5 35.4 44.1
Pe cei ed h ea om he COVID-19 pandemic 0.013 0.003 0.390
Ra he s onga (%) 855 40.9 39.3 38.6 45.8 36.8 43.8 42.8 38.5 40.0 40.3
Pe cei ed bu den o he COVID-19 pandemic < 0.001 < 0.001 < 0.001
Ra he s onga (%) 1,057 58.6 52.7 46.9 40.5 44.1 55.5 55.9 49.8 44.2 49.8
Pe cei ed es ic ions due o he COVID-19
pandemic
< 0.001 < 0.001 0.092
Ra he s onga (%) 1,092 59.9 58.7 47.6 37.2 47.1 55.8 55.1 50.0 49.7 51.4
Table 2 Expe iences and changes in he li e si ua ion h ough he COVID-19 pandemic s a i ied by age, gende and SSS
Page 9 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
[0.15–0.24]). The impac o socioeconomic and sociode-
mog aphic ac o s on sel - a ed heal h dec eased when
addi ional a iables we e included.
Model 1 signi ican ly con ibu ed o he p edic ion o
sel - a ed heal h and explained 25% o i s a iance, which
inc eased o 43% when addi ional a iables we e aken
in o accoun (model 4). All models had good model i
(Hosme -Lemeshow-Tes ) (see Table6).
Simila esul s we e ound in he analysis o men al
well-being (see Table 7). Model 1 showed ha he odds
o ha ing a high men al well-being le el was highe o
people wi h a highe le el o educa ion (1.45 [1.06–1.99]),
medium (1.93 [1.53–2.44]) o high SSS (4.13 [3.11–5.48]),
as well as o olde pa icipan s (1.02 [1.01–1.02]); lowe
odds we e obse ed o emale pa icipan s (0.64 [0.53–
0.78]). Resou ces inc eased and bu dens dec eased he
odds o high men al well-being (models 2 and 3), wi h he
excep ion o he Ma e ial Bu den Subscale o he CBS.
In he inal model 4, ha ing a ch onic disease was asso-
cia ed wi h 53% lowe odds o high men al well-being.
Immig a ion s a us did no eme ge as a signi ican p e-
dic o o nei he sel - a ed heal h no men al well-being
(see Tables6 and 7) in any o he models. The con ibu-
ion o social de e minan s owa d a high men al well-
being le el dec eased om model 1 o model 4, bu only
medium SSS became insigni ican .
The logis ic eg ession models we e s a is ically signi i-
can and had good model i (Hosme -Lemeshow-Tes ).
The explained a iance inc eased om 16% in model 1 o
34% in model 4 (see Table7).
Discussion
The aim o he s udy was o explo e he complex asso-
cia ions be ween socioeconomic and sociodemog aphic
ac o s, changes in li e ci cums ances, pandemic- ela ed
bu dens and esou ces, and indica o s o sel - a ed heal h
and well-being among adul s li ing in Ge many. As such,
he s udy con ibu es o a be e unde s anding o how
endemic heal h inequi ies, which ha e been documen ed
in nume ous s udies bo h in e na ionally [37, 38] and in
Ge many [39–42] con ibu ed o he ad e se impac s o
he COVID-19 pandemic, which has been cha ac e ized
as a syndemic pandemic [48–54]. The main s eng h o
ou s udy lies in u ilizing mul iple measu es o socioeco-
nomic s a us, sociodemog aphic di e ences, and li ing
condi ions du ing he COVID-19 pandemic, and le e ag-
ing hem o cha ac e ize li e expe iences and hei in lu-
ence on sel - a ed heal h and men al well-being. Ano he
s eng h o he s udy is ha i was ca ied ou a he end
o he COVID-19 pandemic, p o iding a e ospec i e
assessmen o he whole pandemic pe iod and all he
associa ed changes in pa icipan s’ social ci cums ances
and heal h.
Cha ac e is ics (N = 2,123) NAge Gende SSS To al
18–29 30–44 45–64 65–74 p1M F p1L M H p1
O e all assessmen o dealing wi h he COVID-19
pandemic
0.010 < 0.001 < 0.001
Ra he di icul b (%) 759 42.9 37.2 33.6 29.6 31.6 39.9 43.4 34.3 30.4 35.8
Change in li ing si ua ion due o he elaxa ion o
COVID-19- ela ed es ic ions
< 0.001 0.456 < 0.001
Ra he s onga (%) 919 54.9 50.4 37.7 29.9 43.3 43.3 34.8 43.5 50.9 43.3
Pe cen age o adjus men be ween cu en li ing
si ua ion and e e yday li e be o e he co ona i us
pandemic
<.0013.0202<.0013
Median 2,123 70.0 75.0 80.0 80.0 80.0 77.0 71.0 77.5 80.0 79.0
1 Pea son Chi2-Tes unless o he wise no ed; 2 Mann-Whi ney-U es ; 3 K uskal-Wallis es ; a Includes he esponse ca ego ies: ‘ a he s ong’ and ‘ e y s ong’; b Includes he esponse ca ego ies: ‘di icul ’ and ‘ e y di icul ’;
Gende : M Male, F Female, SSS: L Low, M Medium, H High
Table 2 (con inued)
Page 16 o 18Babi sch and Ciupi u-Pla h BMC Public Heal h (2025) 25:2523
no only enhance ou unde s anding o syndemic pan-
demic impac s bu also p o ide insigh s o ailo ing pub-
lic heal h in e en ions. In addi ion o ini ia i es aimed a
comba ing he sp ead and heal h consequences o SARS-
CoV-2, heal h p omo ion measu es should be an in e-
g al pa o c isis managemen . Gi en hei p ominence
as isk ac o s in ou s udy, policymake s and heal hca e
p o ide s should sys ema ically inco po a e s a egies
ha e ec i ely add ess ma ke s o socioeconomic disad-
an age o educe heal h dispa i ies du ing u u e heal h
c ises.
Abb e ia ions
CBS COVID-19 Pandemic ela ed Bu den Scale
CRCS COVID-19 Pandemic-Rela ed Resou ces and Coping Scale
F Female
GSE Gene al sel -e icacy
ID Immig an s and hei (di ec ) descendan s
M Male
NIH No immig a ion his o y
PHSM Public heal h and social measu es
SSS Subjec i e social s a us
Supplemen a y In o ma ion
The online e sion con ains supplemen a y ma e ial a ailable a h p s : / / d o i . o
g / 1 0 . 1 1 8 6 / s 1 2 8 8 9 - 0 2 5 - 2 3 6 9 8 - w.
Supplemen a y Ma e ial 1.I ems on he CBS and CRCS scales.In o ma ion
is p o ided on he i ems and componen s o he CBS and CRCS scales and
subscales.
Supplemen a y Ma e ial 2.Addi ional analyses a e p o ided ega ding
immig a ion s a us, educa ional a ainmen (CASMIN) and mon hly ne
household income.Findings a e p esen ed ega ding immig a ion s a us,
educa ional a ainmen (CASMIN) and mon hly ne household income.
Acknowledgemen s
The au ho s hank all pa icipan s o suppo ing his s udy by sha ing hei
iews.
Au ho s' con ibu ions
S udy design (BB), Da a analysis (BB, CCP), Ini ial D a (BB), W i ing, Edi ing and
P oo eading (BB, CCP).
Funding
Open Access unding enabled and o ganized by P ojek DEAL. Open Access
unding enabled and o ganized by P ojek DEAL. Open Access unding
enabled and o ganized by P ojek DEAL. This esea ch ecei ed no ex e nal
unding. The APC was pa ly unded by he publica ion und, which is inanced
by he Osnab ück Uni e si y and he Ge man Resea ch Founda ion (DFG).
Da a a ailabili y
The da a ha suppo he indings o his pape a e a ailable om he
co esponding au ho upon easonable eques .
Decla a ions
E hics app o al and consen o pa icipa e
The s udy was conduc ed in acco dance wi h he Decla a ion o Helsinki and
app o ed by he E hics Commi ee o Osnab ück Uni e si y (E hik-41/2022,
28.6.2022). All pa icipan s we e membe s o an online panel who we e
in o med abou he s udy and ga e in o med consen o pa icipa ion. The
s udy was conduc ed in acco dance wi h ele an guidelines and egula ions.
Consen o publica ion
No applicable.
Compe ing in e es s
The au ho s decla e no compe ing in e es s.
Au ho de ails
1Depa men o New Public Heal h, Ins i u e o Heal h Resea ch and
Educa ion, School o Human Sciences, Osnab ück Uni e si y, Osnab ück,
Ge many
2Depa men o Public Heal h, Bas y Uni e si y, Kenmo e, WA, USA
Recei ed: 26 Feb ua y 2024 / Accep ed: 22 June 2025
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