Sociocultural factors that reduce risks of homicide in Dar es Salaam: a case control study.

OBJECTIVES: This study was performed to examine the potential contributions of sociocultural activities to reduce risks of death by homicide. METHODS: This study was designed as a case control study. Relatives of 90 adult homicide victims in Dar es Salaam Region, Tanzania, in 2005 were interviewed. As controls, 211 participants matched for sex and 5-year age group were randomly selected from the same region and interviewed regarding the same contents. RESULTS: Bivariate analysis revealed significant differences between victims and controls regarding educational status, occupation, family structure, frequent heavy drinking, hard drug use and religious attendance. Conditional logistic regression analysis indicated that the following factors were significantly related to not becoming victims of homicide: being in employment (unskilled labour: OR=0.04, skilled labour: OR=0.07, others: OR=0.04), higher educational status (OR=0.02), residence in Dar es Salaam after becoming an adult (compared with those who have resided in Dar es Salaam since birth: OR=3.95), living with another person (OR=0.07), not drinking alcohol frequently (OR=0.15) and frequent religious service attendance (OR=0.12). CONCLUSIONS: Frequent religious service attendance, living in the same place for a long time and living with another person were shown to be factors that contribute to preventing death by homicide, regardless of place of residence and neighbourhood environment. Existing non-structural community resources and social cohesive networks strengthen individual and community resilience against violence.

The impact of community-based, workshop activities in multiple local dialects on the vaccination coverage, sanitary living and the health status of multiethnic populations in Lao PDR.

Studies on effective community-based intervention in areas inhabited by multiple ethnic groups are limited. The present study was performed to evaluate the impact of workshop activities in multiple local dialects guided by lay facilitators on vaccination coverage, sanitary living and health status in a northern district of Lao PDR. In target villages, facilitators were selected and trained to assist at village meetings to discuss health issues and develop and implement action plans. Manuals and posters with graphics were distributed. Skills were taught through demonstrations by specialists. The vaccination coverage among children and women improved significantly after 1 year. Villagers started using toilets, collecting and burning garbage, and isolating animals from human dwellings, and these activities were continued in 76, 84 and 87% of villages, respectively, 5 years after the start of the activities. The frequency of villagers falling ill was reduced in 67% of the villages. After adjustment for sociocultural characteristics and ethnicity, both the continuous sanitary living index and the reduction in the frequency of villagers falling ill were associated with the higher levels of community participation in the workshop activities. The results demonstrated that the community-based workshop activities improved vaccination coverage, sanitary living and health status. Participatory group discussions in local dialects and village activities led by lay facilitators, supervision and consultation by district trainers who were well recognized by villagers, and the distribution of pictorial educational materials can be an effective and sustainable health promotion approaches among multiethnic groups in under-resourced areas.

Prevalence of and factors influencing posttraumatic stress disorder among mothers of children under five in Kabul, Afghanistan, after decades of armed conflicts.

BACKGROUND: In the period following wars and other forms of armed conflict, health and quality of life of mothers is a major concern as they have the closest contact with children. The present study was performed to examine the impact of exposure to events related to armed conflicts on post traumatic stress disorder (PTSD) among women raising children, and to identify factors that alleviate the negative consequences of exposure to traumatic events. METHODS: A structured interview survey was conducted in Kabul Province, Afghanistan, in 2006. The subjects were the mothers of children less than 5 years old randomly selected from 1400 households in Kabul Province, Afghanistan. Symptoms of PTSD were assessed according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Exposure to traumatic events related to armed conflict, experience of hardship with regard to basic needs, resources that the subjects seek for mental health support, and socioeconomic variables were evaluated. Logistic regression analysis was performed to determine the association between PTSD symptoms and predictor variables. RESULTS: The prevalence rate of PTSD among 1172 women participated in this study was 29.8%. The most prevalent symptom was arousal (74.8%), followed by re-experiencing (54.9%) and avoidance (33.7%). The prevalence rate of PTSD symptoms among subjects who reported having experienced at least one event related to armed conflict (52.7%) was significantly higher than that among those who reported no such experiences (9.6%). Experience of food shortage was independently associated with PTSD. Seeking support for mental health was related to lower prevalence of PTSD symptoms among those who reported no direct experience of events related to armed conflict. However, no such relationship was observed with PTSD symptoms among those who reported having direct experience of events related to armed conflict. CONCLUSION: Direct exposure to traumatic events was significantly associated with PTSD symptoms among women raising children. For those who had experienced armed conflict-related events, food security mitigated the occurrence of PTSD symptoms; however, support seeking behavior did not show a significant mitigating influence on PTSD. Means to alleviate the negative influence of exposure to armed conflicts on the quality of life of women should be developed from the viewpoint of quality of mental health support and avoidance of material hardship.

Bone development in children living on house-boats on a river in Vietnam.

BACKGROUND: With the rapid urbanization of Vietnam, living on boats has come to be associated with underprivileged socioeconomic status, and there are major concerns regarding the health of children living under such conditions. Bone development is a critical concern in children because the foundation for skeletal health is established early in life. We evaluated the bone properties of children living under underprivileged conditions on boats in Hue City, Vietnam, with respect to a number of household factors. METHODS: One hundred and twenty children aged 7-11 years selected randomly from households living on boats in Hue were included in this study. Tibial and radial speed of sound (SOS) were measured by non-invasive quantitative ultrasonometry. Socioeconomic profiles, health promotion proficiency, and nutritional intake of households were assessed by structured interview. The bone properties of 60 children aged 7-11 living on land were also assessed as controls. RESULTS: The Z-scores of tibial and radial SOS of boat children were -0.16 +/- 0.89 and -0.24 +/- 0.75 (mean +/- SD), respectively. Tibial SOS exhibited a significant correlation with radial SOS (r = 0.39, P < 0.01). Among the household factors examined, the educational level of fathers (P < 0.05) and the health promotion proficiency (P < 0.05) of households exhibited positive associations with the tibial bone properties of the children. The tibial and radial SOS of boat children were lower than those of children living on land (P = 0.001 and P = 0.086, respectively). CONCLUSION: The results of the present study revealed the underdevelopment of bone properties in children living on houseboats, which was correlated with their living conditions.

Factors associated with the health and nutritional status of children under 5 years of age in Afghanistan: family behaviour related to women and past experience of war-related hardships.

BACKGROUND: The present study was performed to assess, beyond socio-economic factors, independent associations between the health and nutritional status of children under 5 years old and (1) family behavioural factors related to women with regard to child care and (2) war-related experience by the household of hardships in Afghanistan. METHODS: The subjects were all children born during the previous 5 years from 1400 households in Kabul Province, Afghanistan and were selected by multistage sampling in March 2006. Height and weight measurements of the children and culturally sensitive interviews with their mothers were conducted by household visits. Child mortality, morbidity and nutritional status were evaluated. Four areas were assessed as variables for family behavioural factors related to women: education of mothers, child marriage of the mothers, maternal autonomy in obtaining healthcare for children and preference for a female physician. Hardships experienced by the family were examined by determining their satisfaction of basic material needs and by any experience of being forced to leave a preferred residence. RESULTS: A total of 2474 children from 1327 households completed the examinations and interviews; among them, 101 children were deceased by the time of the interview visits. Diarrhoea (32.5%) and acute respiratory infection (41.0%) were common child health problems and both emaciation (12.4%) and linear growth retardation (39.9%) were prevalent. Regardless of the influence of economic, demographic, family behavioural or hardships experience factors, a lack of maternal autonomy (79.1%) was associated with the occurrence of acute respiratory infection (odds-ratio = 1.72; 95% confidence interval = 1.23, 2.40), and linear growth retardation of children (odds-ratio = 1.38; 95% confidence interval = 1.01, 1.90); a lack of education of the mother (71.7%) and child marriage of the mothers (18.3%) were associated with diarrhoea (odds-ratio = 1.84; 95% confidence interval = 1.40, 2.41; odds-ratio = 1.46; 95% confidence interval = 1.08, 1.96, respectively); a shortage of basic material needs (59.1%) was associated with diarrhoea (odds-ratio = 1.35; 95% confidence interval = 1.08, 1.68); and migration inside the country (52.9%) was associated with underweight children (odds-ratio = 2.48; 95% confidence interval = 1.13, 5.44). CONCLUSION: A lack of education of the mothers, child marriage, lack of maternal autonomy, shortage of basic material needs and internal displacement showed independent and significant negative associations with child health and nutritional variables in this country that has experienced a long period of conflict.

Effectiveness of a capacity-building program for community leaders in a healthy living environment: a randomized community-based intervention in rural Vietnam.

This randomized controlled study was performed to evaluate the effectiveness of an educational program entitled 'Capacity building for community leaders in a healthy living environment,' and to assess the usefulness of a participatory style of education and the applicability of an intersectoral approach in the educational process. An intervention group and a control group (consisting of 150 and 154 community leaders, respectively) were both evaluated, after the intervention group took part in a 5-day participatory-style educational program. Healthy living environment promotion competency (HPC) was evaluated by an instrument consisted of four competency areas: identifying the steps required for a healthy living environment; understanding the principles to reduce potential health risks; providing public health management to improve the living environment; and applying the principles of health communication skills. Scores between the intervention and control groups were examined to identify changes between the baseline and post-intervention periods. A qualitative evaluation of the educational program by participants and facilitators was conducted to assess the appropriateness of the intervention. The results indicated significant increases in the total HPC score and scores of individual HPC competency areas in the intervention group. Thus, the effectiveness of a capacity building program for community leaders in a healthy living environment was demonstrated. Qualitative evaluation revealed that the participatory-style and intersectoral collaboration approach facilitated the educational process. Community leaders, who are representatives of various sectors and mass organizations within the community, can be important implementers in the promotion of a healthy living environment.

Family structure and health, how companionship acts as a buffer against ill health.

BACKGROUND: Health and well-being are the result of synergistic interactions among a variety of determinants. Family structure and composition are social determinants that may also affect health behaviours and outcomes. This study was performed to examine the associations between family structure and health and to determine the protective effects of support mechanisms to improve quality of health outcome. METHODS: Six hundred people, selected by multistage sampling to obtain a representative population of men and women aged 20-60 living in communities in Japan, were included in this study. Data regarding subjective views of one's own health, family structure, lifestyle and social support were collected through structured face-to-face interviews on home visits. Systolic and diastolic blood pressures, height and weight were measured by trained examiners. The associations between family structure and health after controlling for demographics, lifestyle and social support were examined using logistic and linear regression analyses. RESULTS: Subjects living alone were significantly more likely to be in ill health, as determined using the General Health Questionnaire, in comparison to those in extended families (OR = 3.14). Subjects living alone or as couples were significantly more likely to suffer from severe hypertension in comparison to those living in extended families (OR = 8.25, OR = 4.90). These associations remained after controlling for the influence of lifestyle. Subjects living only with spouse or in nuclear family had higher probabilities of mental ill health in the absence than in the presence of people showing concern for their well-being. CONCLUSION: The results of this study infers that a support mechanism consisting of companionship and the presence of family or other people concerned for one's well being acts as a buffer against deleterious influence of living in small family that will lead to improved quality of health outcome.

Impact of conflict on infant immunisation coverage in Afghanistan: a countrywide study 2000-2003.

BACKGROUND: Infant immunisation is an effective public health intervention to reduce the morbidity and mortality of vaccine preventable diseases. However, some developing countries fail to achieve desirable vaccination coverage; Afghanistan is one such country. The present study was performed to evaluate the progress and variation in infant immunisation coverage by district and region in Afghanistan and to assess the impact of conflict and resource availability on immunisation coverage. RESULTS: This study analysed reports of infant immunisation from 331 districts across 7 regions of Afghanistan between 2000 and 2003. Geographic information system (GIS) analysis was used to visualise the distribution of immunisation coverage in districts and to identify geographic inequalities in the process of improvement of infant immunisation coverage. The number of districts reporting immunisation coverage increased substantially during the four years of the study. Progress in Bacillus Calmette-Guerin (BCG) immunisation coverage was observed in all 7 regions, although satisfactory coverage of 80% remained unequally distributed. Progress in the third dose of Diphtheria-Pertussis-Tetanus (DPT3) immunisation differed among regions, in addition to the unequal distribution of immunisation coverage in 2000. The results of multivariate logistic regression analysis indicated a significant negative association between lack of security in the region and achievement of 80% coverage of immunisation regardless of available resources for immunisation, while resource availability showed no relation to immunisation coverage. CONCLUSION: Although progress was observed in all 7 regions, geographic inequalities in these improvements remain a cause for concern. The results of the present study indicated that security within a country is an important factor for affecting the delivery of immunisation services.

Improvements in health by consultations using mobile videophones among participants in a community health promotion programme.

We conducted a health promotion programme using mobile videophones and examined changes in the participants' health conditions, health practices and their subjective sense of health. The subjects were volunteers (mean age, 59 years) recruited from a community-based health promotion group. A focus group interview was conducted to evaluate the quality of the programme. All subjects expressed concerns about lifestyle-related diseases. The subjects participated in group activities at least twice a month under the supervision of public health professionals. Six of them participated in mobile care in addition to group activities (mobile care group) and the other eight subjects (control group) participated in the regular group activities. Three consecutive health examinations were carried out at intervals of 12 weeks. There were significant reductions in low-density lipoprotein cholesterol (P = 0.01) and health locus of control internal score (P = 0.05) in the mobile care group. The subjects who used mobile phones were highly accepting of the use of the device for further health consultations. There is potential for wider application of mobile videophones in health promotion programmes for people who have concerns about lifestyle-related diseases and are seeking healthier lifestyles.

Calculation of prefectural disability-adjusted life expectancy (DALE) using long-term care prevalence and its socioeconomic correlates in Japan.

OBJECTIVES: The objectives of this study were: (1) to determine the disability weight, "utility", for calculation of disability-adjusted life expectancy (DALE) using the prevalence of long-term care; (2) to calculate prefectural DALE; and (3) to clarify the relation between DALE and area socioeconomic conditions in Japan. METHODS: Disability utility by care level (support and levels I-V) of long-term care insurance was determined by a survey of 236 professionals with four standard utility measures: EuroQol-5D, time trade-off, standard gamble, and visual analogue scale. DALE at age 65 (DALE65) and age-adjusted weighted disability prevalence (WDP) of 47 prefectures were calculated using the determined utilities, prevalence of long-term care, and life tables. The relationships of DALE and WDP to mortality from major causes and socioeconomic indicators were examined by correlation analysis. RESULTS: The determined utilities were: support, 0.78; level I, 0.68; level II, 0.64; level III, 0.44; level IV, 0.34; and level V, 0.21. The prefectural DALE65 ranged from 17.11 to 15.29 years for men and from 20.21 to 18.42 years for women. Strong correlations were found between DALE65 and mortality for both sexes. Male DALE65 was correlated with no socioeconomic indicators, while female DALE65 was correlated with some indicators. WDP was positively associated with indicators representing socioeconomic disadvantage, such as unemployment rate and percentage of elderly single households. CONCLUSIONS: The socioeconomic correlates of DALE and WDP suggested that favorable socioeconomic policies, in addition to a decrease in mortality from major causes, will contribute to significant extension of the independence period in the elderly. The method proposed here encourages the practical use of health expectancy in health policy, especially at local and regional levels.

Socioeconomic pattern of smoking in Japan: income inequality and gender and age differences.

PURPOSE: To elucidate the influence of individual socioeconomic status on smoking in Japanese adults. METHODS: Using a nationally representative sample (20,206 men and 21,093 women aged 18 to 54 years), the relation between smoking and socioeconomic characteristics was analyzed by sex and age group (18 to 24, 25 to 39, and over 40 years). RESULTS: The smoking prevalence was 57.0% for men and 16.6% for women. Living in an urban area was a negative factor for smoking in men, while a positive factor in women. Being married was positively associated with smoking in the younger population, but negatively associated in the older population. A relation between lower income and smoking was found in all groups, except in men aged 18 to 24 years. The income-related difference was most pronounced in the population aged 25 to 39 years: OR of smoking for the highest income quintile compared with the lowest was 0.60 (95% CI, 0.51-0.71) for men and 0.29 (95% CI, 0.23-0.35) for women. CONCLUSIONS: Socioeconomic status, especially income, substantially predicted smoking in the Japanese population, while the impact differed according to sex and age groups. Effective anti-smoking strategies require consideration of the gender and age differences in the socioeconomic pattern of smoking.

Cause-specific mortality differences across socioeconomic position of municipalities in Japan, 1973-1977 and 1993-1998: increased importance of injury and suicide in inequality for ages under 75.

BACKGROUND: Socioeconomic inequality in health has been a major concern in public health. This study examined socioeconomic inequality in regional mortality and the impact on inequality by cause of deaths in 1973-1977 and 1993-1998 using municipal statistics in Japan. METHODS: The municipalities across the country (N = 3244 in 1973-1977 and 3334 in 1993-1998) were classified into quintiles according to the index of socioeconomic position (SEP) obtained by principal component analysis of municipal indicators related to income and education. Mortality gradient by SEP for selected major causes of death in the population aged 0-74 years was examined using standardized mortality ratio by quintile and rate ratio of mortality across quintiles. As a measure of cause-specific impact on inequality, the number of excess deaths from each cause in the lower four SEP quintiles compared with the highest quintile was calculated. RESULTS: Mortality gradient by SEP and excess deaths in the lower SEP quintiles due to injury and suicide markedly increased from 1973-1977 to 1993-1998 for both males and females. In contrast, stroke, especially cerebral haemorrhage, showed a decrease in mortality gradient and excess deaths. For females in 1993-1998, a negative gradient of mortality by SEP was found, and cancer contributed the higher all-cause mortality in the higher SEP quintile. CONCLUSIONS: The relative importance of socioeconomic inequality in regional mortality of stroke decreased, while that of injury and suicide increased. The prevention of injury and suicide, in addition to stroke, in socioeconomically disadvantaged regions, and cancer in urban areas with higher SEP should be given priority.

Variation of health status among people living on boats in Hue, Vietnam.

OBJECTIVES: To examine patterns of disease and injury in people living on boats in Hue City, Vietnam, and their relations to socioeconomic conditions, sanitary practices, disease prevention proficiency, and people's preference to continued living on boats. METHODS: The subjects were 3737 people aged 5 years and over living on boats in Hue City, Vietnam. Diseases and injuries were diagnosed according to ICD-10. The associations between disease/injury and socioeconomic conditions, sanitary practices, disease prevention proficiency, and preference to continued living on boats were analysed by logistic regression. MAIN RESULTS: The prevalence rates of certain infectious and parasitic diseases, diseases of the respiratory system, diseases of the skin and subcutaneous tissue, diseases of the digestive system, and injuries were 85.3%, 78.0%, 51.2%, 15.4%, and 13.2%, respectively. Various associations were seen between diseases/injuries and socioeconomic conditions. Patterns of disease were strongly influenced by sanitary practices. Better disease prevention proficiency was significantly related to lower prevalence of the first three categories of diseases/injuries regardless of sex, age, or socioeconomic status (p < 0.05, p < 0.001, p < 0.001, respectively). Diseases were more prevalent among people who preferred not to continue living on boats. CONCLUSIONS: This large scale comprehensive field study illustrated major diseases and injuries among people living on boats. Variations in health status showed a web-like relation of socioeconomic conditions, sanitary practices, disease prevention proficiency, and preference to continued living on boats. Measures to develop disease prevention proficiency reduce the risk of disease and injury.

Variations in societal characteristics of spatial disease clusters: examples of colon, lung and breast cancer in Japan.

BACKGROUND: Spatial analyses and ecological studies are essential for epidemiology and public health. The present study combining these two methods was performed to identify spatial clusters of selected types of cancer in Japan and to determine their societal characteristics focusing on homogeneity among clusters. RESULTS: Spatial clusters of high mortality rates of male colon and lung cancer and of female breast cancer were identified by the spatial scan statistic using Japanese municipal data (N = 3360) from 1993 to 1998 and also municipalities were divided into four societal clusters based on socioeconomic indicators and population density (urban-rich, suburban, rural-poor, and clutter). Five, seven, and four mortality clusters were identified for lung, colon and breast cancer, respectively. For colon and breast cancer, most municipalities of all except one cluster were included in a single societal cluster (urban-rich). The municipalities associated with mortality clusters for lung cancer belonged to various societal clusters. CONCLUSION: Increased mortality rates of colon and breast cancer can be explained by homogenous societal characteristics related to urbanisation, although there were exceptional areas with higher mortality rates. The regional variation in lung cancer mortality rate appeared to be due to heterogeneous factors. These findings and the analysis performed in the present study will contribute to both nationwide and region-specific cancer prevention strategies.

Accumulation of health risk behaviours is associated with lower socioeconomic status and women's urban residence: a multilevel analysis in Japan.

BACKGROUND: Little is known about the socioeconomic differences in health-related behaviours in Japan. The present study was performed to elucidate the effects of individual and regional socioeconomic factors on selected health risk behaviours among Japanese adults, with a particular focus on regional variations. METHODS: In a nationally representative sample aged 25 to 59 years old (20,030 men and 21,076 women), the relationships between six risk behaviours (i.e., current smoking, excessive alcohol consumption, poor dietary habits, physical inactivity, stress and non-attendance of health check-ups), individual characteristics (i.e., age, marital status, occupation and household income) and regional (N = 60) indicators (per capita income and unemployment rate) were examined by multilevel analysis. RESULTS: Divorce, employment in women, lower occupational class and lower household income were generally associated with a higher likelihood of risk behaviour. The degrees of regional variation in risk behaviour and the influence of regional indicators were greater in women than in men: higher per capita income was significantly associated with current smoking, excessive alcohol consumption, stress and non-attendance of health check-ups in women. CONCLUSION: Individual lower socioeconomic status was a substantial predictor of risk behaviour in both sexes, while a marked regional influence was observed only in women. The accumulation of risk behaviours in individuals with lower socioeconomic status and in women in areas with higher income, reflecting an urban context, may contribute to their higher mortality rates.

Municipal health expectancy in Japan: decreased healthy longevity of older people in socioeconomically disadvantaged areas.

BACKGROUND: Little is known about small-area variation in healthy longevity of older people and its socioeconomic correlates. This study aimed to estimate health expectancy at 65 years (HE65) at the municipal level in Japan, and to examine its relation to area socio-demographic conditions. METHODS: HE65 of municipalities (N = 3361) across Japan was estimated by a linear regression formula with life expectancy at 65 years and the prevalence of those certificated as needing nursing care. The relation between HE65 and area socio-demographic indicators was examined using correlation coefficients. RESULTS: The estimated HE65 (years) ranged from 13.13 to 17.39 for men and from 14.84 to 20.53 for women. HE65 was significantly positively correlated with the proportion of elderly and per capita income, and negatively correlated with the percentage of households of a single elderly person, divorce rate, and unemployment rate. These relations were stronger in large municipalities (with a population of more than 100,000) than in small and medium-size municipalities. CONCLUSION: A decrease in healthy longevity of older people was associated with a higher percentage of households of a single elderly person and divorce rate, and lower socioeconomic conditions. This study suggests that older people in urban areas are susceptible to socio-demographic factors, and a social support network for older people living in socioeconomically disadvantaged conditions should be encouraged.

Improvement in maternal health literacy among pregnant women who did not complete compulsory education: policy implications for community care services.

This paper examined factors that influence the improvement in maternal health literacy among pregnant women in Paraguay, including those who did not complete compulsory education but participated in a community-based antenatal care program. Structured interviews were conducted to evaluate the pregnant women's maternal health literacy during their first, second, and third visits to the program in the Caazapa Region. The associations between individual maternal health knowledge scores and its gains, healthcare personnel capabilities, available health facility equipment, community social network, and living environment were analyzed by multiple regression analysis. The mean maternal health knowledge score from 124 women who completed three-consecutive assessments increased between the first and third interviews. Higher capabilities of healthcare personnel and better living environment were significantly related to gains in the maternal health knowledge score (p<0.01). Wider application of a community-based antenatal care program to meet the needs of those who are functionally illiterate in the standard language of the country, training for community healthcare personnel to improve capabilities, and resources for social network in the community would contribute to the improvement in maternal health literacy.

Municipal socioeconomic status and mortality in Japan: sex and age differences, and trends in 1973-1998.

The purpose of this study was to examine the sex and age differences and the time trends in the association between municipal socioeconomic status (SES) and all-cause mortality across Japan from 1973 to 1998. Sex-specific mortality of municipalities (N=3319 in 1995) by age groups (total, under 75-year, and over 75-year populations) was linked to municipal SES indicators related to income, education, unemployment and living space, and two SES composite indices formulated by principle component analysis (Index 1 related to lower income and education, and Index 2 related to unemployment and overcrowding). The relation was assessed using mortality gradients by SES quintiles and Bayesian hierarchical Poisson regression. The results showed that a lower SES was related to higher mortality for all SES indicators and composite indices. The mortality gradient was steeper for the under 75-year population than the total and over 75-year populations, and the relation between mortality and income- and education-related indicators/index was stronger for males than for females. The time trend showed an increase in the relation for Index 2, while a decrease for Index 1. This study demonstrated that lower municipal SES had an adverse influence on population health, and the influence was marked for males and premature death. Although a substantial health disadvantage still remained in lower SES areas, the impact of SES factors on geographical health variation changed over time; the association with mortality has weakened for income and education, while it has strengthened for unemployment and living space.

Increased excess deaths in urban areas: quantification of geographical variation in mortality in Japan, 1973-1998.

To quantify the magnitude of geographical health inequality by sex and age group, and to observe the change in regional distribution of health disadvantage, this study estimated excess deaths attributable to the mortality variation among municipalities across Japan from 1973 through 1998. The municipalities (N = 3340 in 1995) were divided into quintiles according to standardized mortality ratio (SMR). Using the mortality of the lowest SMR quintile as the standard, the number of excess deaths (ED) and its ratio to observed deaths (EDR) were estimated by sex, age group (total population and under 65-year population) and regional block in 1973-1977, 1978-1982, 1983-1987, 1988-1992 and 1993-1998. Total annual ED in 1993-1998 was estimated as 47,124 for males and 46,562 for females, representing EDR of 9.9 and 11.6%, respectively. The under 65-year population had a higher EDR than the total population. Rural regions showed a marked decrease in EDR in contrast to the increase in urban regions over time. The present study suggests that the reduction of a large number of deaths, especially premature deaths, is expected by elimination of geographical health inequality, and that health policies for urban residents are prioritized.

A combination of an extrapolation method and a benchmark method to develop quantitative health targets for Japan.

The aim of the present study was to propose a methodology to formulate quantitative health targets which combined an extrapolation method and a benchmark method, and to estimate the targets for mortality rates (Mb) for selected causes of death by the year 2010 in Japan. Using the extrapolation method, based on the nationwide Mt from 1988 to 1997, the Mt in 2010 was predicted using a regression model. Using the benchmark method, the paired-mean of the age-adjusted mortality rates (Mts) of the top five prefectures among 47 prefectures was calculated as the benchmark. Combining the predicted mortality and the benchmark mortality, year 2010 targets were determined. As a results year 2010 targets as percentages compared with Mt in 1997 for cancer at all sites, stomach cancer, lung cancer, colo-rectal cancer, liver cancer and stroke were estimated to be 93, 52, 94, 102, 53 and 52% for males, and 84, 43, 86, 82, 60, and 45%, for females, respectively. The methodology presented in this article could be used as a standard procedure to formulate realistic quantified health targets, which can be adopted to develop health policies in nations, regions and communities.