Intersectional inequalities in self-rated health in Germany across sex/gender, migration, education and income: a cross-sectional study

Abstract

Background: Health inequalities by sex/gender, migration, education and income persist across Europe, yet intersectionality-informed research on how these social positions jointly shape self-rated health (SRH) remains limited. Methods: We conducted a cross-sectional analysis of the German National Cohort (NAKO; n=179 861). Sex/gender, education and income were combined with three migration characteristics (any migration, Turkish and ethnic German resettler backgrounds) into three 16-strata exposure variables. We used Poisson regression with robust SEs to estimate adjusted frequencies and relative risks of poor SRH, adjusting for age, household size and study site. Departures from additivity were assessed using two-, three-, four-way and total relative excess risk due to interaction (RERI). Results: Poor SRH followed a social gradient. Adjusted frequency of poor SRH generally increased with each additional marginalised social position, from 6.3% (95% CI 5.5% to 7.2%) among high education and income migrant men to 22.6% (95% CI 21.3% to 23.8%) among low education and income migrant women. Adjusted frequencies were highest among participants with Turkish background. Joint exposure to female sex/gender, migration and low education and income was associated with risk of poor SRH beyond the sum of individual effects. Total RERIs for four-way intersections were 1.10 (95% CI 0.83 to 1.37) for any migration, 3.09 (95% CI 2.02 to 4.15) for Turkish and 1.62 (95% CI 0.84 to 2.41) for ethnic German resettler backgrounds. Conclusions: SRH in Germany exhibits pronounced intersectional inequalities. Individuals occupying multiple marginalised social positions experienced a disproportionate burden of poor SRH, highlighting the importance of intersectionality in population health monitoring.