"What Did You Do in the War, Daddy?": Paternal Military Conscription During WWII, Economic Hardship and Family Violence in Childhood, and Health in Late Life in Japan.

Childhood adversity is a risk factor for poor health in late life and includes economic hardship and family violence, whose prevalence is high among offspring of military conscripted father. We assessed the association between paternal military conscription (PMC) and paternal war death (PWD) during Second World War and self-rated health (SRH) among older adults in Japan. Data were obtained from a population-based cohort of functionally independent people aged 65 years or older from 39 municipalities across Japan in 2016. Information on PMC and SRH was obtained through a self-report questionnaire. A total of 20,286 participants were analyzed with multivariate logistic regression to investigate the association between PMC, PWD, and poor health. Causal mediation analysis was performed to see whether childhood economic hardship and family violence mediated the association. Among participants, 19.7% reported PMC (including 3.3% PWD). In the age- and sex-adjusted model, older people with PMC showed higher risk of poor health (odds ratio [OR]: 1.16, 95% confidence interval [CI] [1.06, 1.28]), while those with PWD were not associated (OR: 0.96, 95% CI [0.77, 1.20]). Causal mediation showed a mediation effect of childhood family violence exposure on the association between PMC and poor health (proportion mediated: 6.9%). Economic hardship did not mediate the association. PMC, but not PWD, increased the risk of poor health in older age, which was partially explained by the exposure to family violence in childhood. There appears to be a transgenerational health impact of war which continues to affect the health of offspring as they age.

Stepwise Tobacco Price Increase and Smoking Behavioral Changes in Japan: The Japan "Society and New Tobacco" Internet Survey 2017-2021 Longitudinal Study.

INTRODUCTION: Tobacco price increase is an effective measure to reduce tobacco smoking. In Japan, the price of combustible cigarettes increased in 2018 and 2020, and that of heated tobacco products increased every year from 2018 to 2020 by tobacco excise taxation. Also, the general consumption tax increase in 2019 slightly raised the retail prices of tobacco products. We investigated the impact of this stepwise tobacco price increase on combustible cigarette smoking status among Japanese adults. AIMS AND METHODS: Five waves of annual longitudinal data (2017-2021) from The Japan "Society and New Tobacco" Internet Survey (JASTIS) (31 930 observations of 11 896 individuals) were analyzed. Multivariable logistic regression with a generalized estimating equation was fitted, adjusting for the prefecture of residence, age, sex, socioeconomic status, health status, alcohol drinking, former smoker's duration of smoking cessation, and the current smoker's number of cigarettes smoked per day. RESULTS: The 2018 price increase was associated with a reduction in relapse (adjusted odds ratio [aOR] 0.54, 95% confidence interval [CI] 0.42-0.68) and an increment in cessation (aOR 1.20, 95% CI 1.02-1.42). The price increase in 2019 was not associated with relapse (aOR 0.84, 95% CI 0.63-1.10) or cessation (aOR 0.95, 95% CI 0.80-1.13). The 2020 price increase was associated with a reduction in relapse (aOR 0.59, 95% CI 0.42-0.81) and an increment in cessation (aOR 1.45, 95% CI-1.21, 1.73). CONCLUSION: The price increase caused by tobacco excise taxation was associated with a reduction in combustible cigarette smoking. IMPLICATIONS: Japan introduced a policy of stepwise increase in tobacco excise taxation in 2018. We analyzed five-wave longitudinal data to investigate the impact of the policy. Tobacco price increases in 2018 and 2020 were associated with a reduction in combustible cigarette smoking. Tobacco price increases in 2019 by general consumption tax were not associated with a change in combustible cigarette smoking.

Role of Libraries in Human Flourishing: Adolescents' Motivational Orientation for Occupation.

INTRODUCTION: Adolescence is crucial for human flourishing and strongly influences having meaning in life. We investigated the association between local public library density as a shared resource and motivational orientation toward their occupation in Japanese adolescents. METHODS: A longitudinal study was conducted using data from a nationwide birth cohort survey in Japan (n = 12,184). At age 7, their caregivers answered questionnaires on children including the number of books read. Library density (low, moderate, or high) in each municipality was obtained from national statistics. At age 15, the adolescents indicated whether they had decided on an occupation and selected motivational orientations from among intrinsic (own ability and interest), extrinsic (high earnings, social class, or job stability), and altruistic (social contribution) orientations. Multilevel linear probability models were fitted, adjusting for confounders, including household socioeconomic status and city size. RESULTS: Intrinsic, extrinsic, and altruistic motivations for desired occupation were reported by 40.7%, 31.9% and 41.8% of participants, respectively. Living in a municipality with a high library density at age 7 was associated with having intrinsic motivation at age 15 than low density by 3.1 percentage points (95% confidence interval (CI): 0.35, 5.85). The association was more prominent for those with lower income (P for interaction = 0.026). Neither extrinsic nor altruistic motivations were associated with library density (coefficient: -0.13; 95% CI: -2.81, 2.56; coefficient: 0.08; 95% CI: -2.72, 2.88 percentage points, respectively). CONCLUSIONS: Developing libraries in communities could encourage intrinsic motivation in adolescents, specifically for those in low-income households.

Forecasting future dental health expenditures: Development of a framework using data from 32 OECD countries.

OBJECTIVE: To (1) develop a framework for forecasting future dental expenditures, using currently available information, and (2) identify relevant research and data gaps such that dental expenditure predictions can continuously be improved in the future. METHODS: Our analyses focused on 32 OECD countries. Dependent on the number of predictors, we employed dynamic univariate and multivariate modelling approaches with various model specifications. For univariate modelling, an auto-regressive (AR) dynamic model was employed to incorporate historical trends in dental expenditures. Multivariate modelling took account of historical trends, as well as of relationships between dental expenditures, dental morbidity, economic growth in terms of gross domestic product and demographic changes. RESULTS: Estimates of dental expenditures varied substantially across different model specifications. Models relying on dental morbidity as one of the predictors performed worst regardless of their specification. Using the best-fitted model specification, that is the univariate second-order autoregression [AR(2)], the forecasted dental expenditures across 32 OECD countries amounted to US$316bn (95% forecasted interval, FI: 258-387) in 2020, US$434bn (95%FI: 354-532) in 2030 and US$594bn (95%FI: 485-728) in 2040. Per capita spending in 2040 was forecasted to be highest in Germany (US$889, 95%FI: 726-1090) and lowest in Mexico (US$52, 95%FI: 42-64). CONCLUSIONS: The present study demonstrates the feasibility and challenges in predicting dental expenditures and can serve as a basis for improvement towards more sustainable and resilient health policy and resource planning. Within the limitations of available data sources, our findings suggest that dental expenditures in OECD countries could increase substantially over the next two decades and vary considerably across countries. For more accurate estimation and a better understanding of determinants of dental expenditures, more comprehensive data on dental spending and dental morbidity are urgently needed.

[Factors related to the passive attitude of caregivers on dental care visit when elementary and junior high school children are diagnosed with dental caries].

Objectives　Early diagnosis and treatment are particularly important for children who have dental caries. It has been reported that some children are not taken to a dental clinic even though they are diagnosed with dental caries at school dental check-ups. The purpose of this study is to investigate factors related to the passive attitude of caregivers regarding dental care visits when elementary and junior high school children are diagnosed with dental caries.Methods　A cross-sectional study was conducted utilizing data from the 2016 Adachi Child Health Impact of Living Difficulty (A-CHILD) study. A questionnaire was administered to 1,994 parents of 4th and 6th grade students in elementary school, and 8th grade students in junior high school. Out of the 1,994 parents, 1,652 (83%) responded. Caregivers were asked whether they take their child to the dental clinic immediately if their child is diagnosed with dental caries. Those who answered "cannot take immediately" were defined as caregivers with a passive attitude towards dental care visits. Their reasoning was further probed by the questionnaire. The validity of the answer (i.e., taking their child to the dental clinic) was assessed with the child's untreated dental caries obtained from the results from the school dental health checkup. The number of children excluded in the analysis due to a lack of information on dental caries and/or the attitude of the parents was 1,613. A logistic regression analysis was performed to investigate the association between passive attitude on dental care visit and demographic factors (e.g., child's sex, grade, number of siblings, and household members), lifestyle (e.g., time home for caregiver, grandparent co-residence, skipping breakfast, snacking habits, sugar-sweetened beverage intake, frequency of teeth brushing, and parent-child relationship), and socioeconomic status (e.g., annual household income, educational attainment of caregiver, employment status of caregiver).Results　In total, 269 (16.7%) caregivers reported a passive attitude for the dental care visit of their child. The most frequent reason was "I don't have time to take my child to the dental clinic" (172 people, 55.8%). The passive attitude by the caregivers was associated with untreated decay for the child (P<0.001). The passive attitude of the caregiver on the dental care visit was associated with lower maternal educational attainment, skipping breakfast for the child, and lower frequency of brushing teeth. In elementary school children, the passive attitude of the caregiver on the dental care visit was also significantly associated with maternal employment, later time of getting home by the mother and a lack of interaction with children by the caregiver.Conclusion　The passive attitude of the caregiver as pertaining to the dental care visit of the child was associated with maternal socioeconomic background. Health promotion activities considering maternal socioeconomic background is needed.

Income and education are associated with transitions in health status among community-dwelling older people in Japan: the JAGES cohort study.

BACKGROUND: Health inequalities are an emerging issue in ageing societies, but inequalities in pre-frailty, which is suffered by almost half of older people, are mostly unknown. OBJECTIVE: This study aimed to determine the association between the socio-economic status (SES) and changes across pre-frailty, frailty, disability and all-cause mortality. METHODS: We conducted a prospective cohort study across 23 Japanese municipalities between 2010 and 2013. Functionally independent community-dwelling older adults aged ≥65 years (n = 65 952) in 2010 were eligible for the study. The baseline survey was conducted from 2010 to 2012, and the self-reporting questionnaires were mailed to 126 438 community-dwelling older adults [64.8% (81 980/126 438) response rate]. The follow-up survey was conducted in 2013. Overall, 65 952 individuals were followed up [80.4% (65 952/81 980) follow-up rate]. The health status was classified into five groups: robust; pre-frailty; frailty; disability and death. We conducted three multinomial logistic regression models stratified by the initial disability status. Educational attainment and equivalized household income were separately added to the models as exposures after adjusting for covariates. RESULTS: Participants with the lowest educational level were less likely to recover from pre-frailty to robust compared with those with the highest level [odds ratio (OR) (95% confidence interval (CI)) = 0.84 (0.76-0.93)]. The participants with the lowest income level were also less likely to recover from pre-frailty to robust compared with those with the highest level [OR (95% CI) = 0.80 (0.69-0.91)]. CONCLUSIONS: Older individuals with a lower SES were less likely to recover from a pre-frailty status.

Does the Type of Temporary Housing Make a Difference in Social Participation and Health for Evacuees of the Great East Japan Earthquake and Tsunami? A Cross-Sectional Study.

BACKGROUND: Although the majority of survivors of the huge Great East Japan Earthquake and Tsunami evacuated to two types of temporary housings, prefabricated housing and rented housing, health effects of these different environments were unclear. We examined whether prevalent social participation in prefabricated housing brought larger health benefits than in rented housing using the largest health survey data of the disaster survivors. METHODS: This cross-sectional study used a 2012 survey by the Miyagi Prefectural Government, in which almost all of evacuees were targeted (response rate: 61.6%). Self-rated health (SRH) and psychological distress measured via K6 score were the dependent variables, and social participation was the independent variable. Odds ratios of the social participation on health variables were estimated using logistic regression models. To assess the contribution of social participation, the population attributable fraction (PAF) was estimated. RESULTS: The participants lived in prefabricated and rented housing numbered 19,726 and 28,270, respectively. Participants in prefabricated housing had poorer SRH and K6 than those in rented housing. The proportions of participants engaging in social participation of prefabricated and rented housing were 38.2% and 15.4%, respectively. The absence of social participation was significantly associated with poor SRH and K6 among participants in both housing types. The PAFs of social participation with good SRH were 39.5% in prefabricated housing and 14.4% in rented housing. For K6, the PAFs were 47.1% and 19.5% in prefabricated and rented housing, respectively. CONCLUSION: Compared to the residents in rented housing, residents in prefabricated housing had more frequent opportunities for social participation, which was associated with larger health benefits.

The Causal Effect of Education on Tooth Loss: Evidence From United Kingdom Schooling Reforms.

Associations between education and oral health have frequently been reported, but until now there has been no causal evidence. Exploiting exogenous variation in the duration of schooling due to 1947 and 1972 reforms in mandatory schooling in the United Kingdom, we examined the causal relationship between education and tooth loss in older age. We conducted a cross-sectional study using data from waves 3 (2006-2007), 5 (2010-2011), and 7 (2014-2015) of the English Longitudinal Study of Ageing. We used a 2-stage least squares instrumental variable approach and included 5,667 respondents (average age = 67.8 years; 44.4% were men) in the analyses, of whom 819 (14.5%) had no teeth. The schooling reforms increased the duration of education by an average of 0.624 years (95% confidence interval: 0.412, 0.835). For respondents born within ±6 years of the pivotal cohorts, a 1-year increment of education causally reduced the probability of edentulism by 9.1 (95% confidence interval: 1.5, 16.8) percentage points. The effects were stronger for the 1947 reform than for the 1972 reform. Results were robust to broadening of the cohort bandwidth and functional form of the cohort trend. The findings suggest that investment in education produces improved oral health later in life.

Copayment Exemption Policy and Healthcare Utilization after the Great East Japan Earthquake.

Healthcare utilization after natural disasters remains understudied. In general, people in Japan pay 10%-30% of total amount of costs, according to their health insurance plan. A policy exempting survivors from copayments was introduced after the Great East Japan Earthquake in March 2011, which had a magnitude of 9.0 on the Richter scale and followed by devastating tsunamis. Among the disaster-affected areas, Miyagi prefecture experienced the largest number of deaths and the greatest extent of damage. However, the exemption was suspended in Miyagi prefecture from April, 2013, because of the huge governmental financial burden due to the immensity of damage from the disaster. Subsequently, in April 2014, the exemption was re-introduced, with smaller coverage. We, therefore, evaluated the influence of this policy change on monthly healthcare utilization in Miyagi prefecture between April 2008 and June 2015. We also evaluated the association between the proportion of people exempted from copayment in each municipality and the difference in healthcare utilization before and after the suspension using multivariable linear regression. Healthcare utilization in Miyagi increased immediately after the institution of the exemption policy and it peaked after one year. In March 2013, just before the suspension, a rapid increment in healthcare utilization was observed, suggesting that the copayment may be a barrier for people in the disaster-affected area to access to healthcare. The exemption policy did help the survivors to use healthcare utilization in Miyagi. After devastating natural disasters, policymakers should guarantee that all survivors can utilize healthcare services on demand.

Long-term Impact of Childhood Disadvantage on Late-Life Functional Decline Among Older Japanese: Results From the JAGES Prospective Cohort Study.

Background: Increasing evidence suggests an impact of childhood disadvantage on late-life functional impairment in Western countries. However, the processes by which childhood disadvantage affects functional capacity are influenced by several factors unique to particular societies. We examined the impact of childhood disadvantage on functional decline among older Japanese, using a large-scale prospective cohort study. Methods: Data came from surveys conducted in 2010 and 2013 as part of the Japan Gerontological Evaluation Study (JAGES), a nationwide cohort study targeting community-dwelling people aged 65 years and over. Childhood disadvantage included subjective childhood socioeconomic status (SES), body height, and educational level. The sample was stratified by age at baseline (65-69, 70-74, 75-79, and ≥ 80 years). Results: A total of 11,601 respondents were analyzed. In the 65-69-year group, lower childhood SES was associated with functional decline but this association was mediated by adult SES. In contrast, childhood SES was independently associated with functional decline in the older cohort. In the 75-79-year group, lower childhood SES was associated with functional decline. However, in the ≥ 80-year group, people with higher childhood SES were more likely to experience functional decline. Shorter height was associated with functional decline in the 70-74-year group. Higher education was related to functional decline in all age groups except the ≥ 80-year group. Conclusions: These findings suggest that childhood disadvantage affects functional decline but its effect varies by age cohort. The mechanisms underlying the association between childhood disadvantage and functional decline may be influenced by social and historical context.

Social Inequalities in Secondhand Smoke Among Japanese Non-smokers: A Cross-Sectional Study.

BACKGROUND: Secondhand smoke (SHS) causes many deaths. Inequalities in SHS have been reported in several countries; however, the evidence in Asian countries is scarce. We aimed to investigate the association between socioeconomic status (SES) and SHS at home and the workplace/school among non-smoking Japanese adults. METHODS: Cross-sectional data from the Miyagi Prefectural Health Survey 2014 were analyzed. Self-reported questionnaires were randomly distributed to residents ≥20 years of age and 2,443 (92.8%) responded. The data of the 1,738 and 1,003 respondents were included to the analyses for SHS in the past month at home and at the workplace/school, respectively. Ordered logistic regression models considering possible confounders, including knowledge of the adverse health effects of tobacco, were applied. RESULTS: The prevalence of SHS at home and the workplace/school was 19.0% and 39.0%, respectively. Compared with ≥13 years of education, odds ratios (ORs) and 95% confidence intervals (CIs) for SHS at home were 1.94 (95% CI, 1.42-2.64) for 10-12 years and 3.00 (95% CI, 1.95-4.60) for ≤9 years; those for SHS at the workplace/school were 1.80 (95% CI, 1.36-2.39) and 3.82 (95% CI, 2.29-6.36), respectively. Knowledge of the adverse health effects of tobacco was significantly associated with lower SHS at home (OR 0.95; 95% CI, 0.91-0.98) but it was not associated with SHS at the workplace/school (OR 1.02; 95% CI, 0.98-1.06). CONCLUSIONS: Social inequalities in SHS existed among Japanese non-smoking adults. Knowledge about tobacco was negatively associated with SHS at home but not at workplace/school.

Are Lowered Socioeconomic Circumstances Causally Related to Tooth Loss? A Natural Experiment Involving the 2011 Great East Japan Earthquake.

Oral health status is correlated with socioeconomic status. However, the causal nature of the relationship is not established. Here we describe a natural experiment involving deteriorating socioeconomic circumstances following exposure to the 2011 Great East Japan Earthquake and Tsunami. We investigated the relationship between subjective economic deterioration and housing damage due to the disaster and tooth loss in a cohort of community-dwelling residents (n = 3,039), from whom we obtained information about socioeconomic status and health status in 2010 (i.e., predating the disaster). A follow-up survey was performed in 2013 (postdisaster), and 82.1% of the 4,380 eligible survivors responded. We estimated the impact of subjective economic deterioration and housing damage due to the disaster on tooth loss by fitting an instrumental variable probit model. Subjective economic deterioration and housing damage due to the disaster were significantly associated with 8.1% and 1.7% increases in the probability of tooth loss (probit coefficients were 0.469 (95% confidence interval: 0.065, 0.872) and 0.103 (95% confidence interval: 0.011, 0.196), respectively). In this natural experiment, we confirmed the causal relationship between deteriorating socioeconomic circumstances and tooth loss.

Trajectory of social inequalities in the treatment of dental caries among preschool children in Japan.

OBJECTIVES: The longitudinal trend of dental health inequalities among preschool children has not been described. In this study, we aimed to measure the trajectory of both relative and absolute inequalities in caries treatment among preschool children in Japan. METHODS: We used data from the Longitudinal Survey of Babies in the 21st Century (LSB21), which is an ongoing national representative longitudinal study. The target population was families residing in Japan with newborn baby/babies born between 10 January and 17 January or 10 July and 17 July 2001. Data regarding caries treatment history and socioeconomic status (SES) were collected using a self-reported questionnaire. SES was assessed on the basis of the parents' educational attainment. In total, 35 260 children were followed from 2.5 to 5.5 years through annual surveys. To evaluate absolute and relative inequalities, we calculated the slope index of inequality (SII) and relative index of inequality (RII), respectively. RESULTS: The rate of caries treatment at the age of 2.5 years was <10% for all SES groups; this increased to more than 30% at 5.5 years of age. Children with lower SES received more frequent caries treatment, and both absolute and relative social inequalities were statistically significant. SII showed a significant increase throughout the follow-up period, with values of 4.13% (95% confidence interval [CI], 3.16; 5.09) and 15.50% (95% CI, 13.68; 17.32) at 2.5 and 5.5 years of age, respectively. In contrast, RII decreased with an increase in the treatment rate for all groups, with values of 1.83 (95% CI, 1.59; 2.11) and 1.53 (95% CI, 1.46; 1.61) at 2.5 and 5.5 years of age, respectively. CONCLUSION: Our results suggest that the rate of caries treatment is higher for preschool children with lower SES in Japan, with significant widening of absolute inequalities along with the growth of the children.

School-Based Fluoride Mouth-Rinse Program Dissemination Associated With Decreasing Dental Caries Inequalities Between Japanese Prefectures: An Ecological Study.

BACKGROUND: Dental caries inequalities still severely burden individuals' and society's health, even in countries where fluoride toothpastes are widely used and the incidence of dental caries has been decreasing. School-based fluoride mouth-rinse (S-FMR) programs, a population strategy for dental caries prevention, might decrease dental caries inequalities. This study investigated the association between S-FMR and decreasing dental caries prevalence and caries-related inequalities in 12-year-olds by Japanese prefecture. METHODS: We conducted an ecological study using multi-year prefecture-level aggregated data of children born between 1994 and 2000 in all 47 Japanese prefectures. Using two-level linear regression analyses (birth year nested within prefecture), the association between S-FMR utilization in each prefecture and 12-year-olds' decayed, missing, or filled permanent teeth (DMFT), which indicates dental caries experience in their permanent teeth, were examined. Variables that could explain DMFT inequalities between prefectures, such as dental caries experience at age 3 years, dentist density, and prefectural socioeconomic circumstances, were also considered. RESULTS: High S-FMR utilization was significantly associated with low DMFT at age 12 (coefficient -0.011; 95% confidence interval, -0.018 to -0.005). S-FMR utilization explained 25.2% of the DMFT variance between prefectures after considering other variables. Interaction between S-FMR and dental caries experience at age 3 years showed that S-FMR was significantly more effective in prefectures where the 3-year-olds had high levels of dental caries experience. CONCLUSIONS: S-FMR, administered to children of all socioeconomic statuses, was associated with lower DMFT. Utilization of S-FMR reduced dental caries inequalities via proportionate universalism.

Inequalities of dental prosthesis use under universal healthcare insurance.

BACKGROUND: Social inequalities in oral health exist in various countries. In Japan, a country with universal healthcare insurance policy, people can receive medical and dental care and pay only 10-30% of the total cost of treatment. Additionally, very poor Japanese can receive care without any charge, by the benefit of public assistance. These policies are considered to affect oral health inequalities. OBJECTIVES: This study examined the association between using a dental prosthesis and household income among older Japanese people. METHODS: Self-administered questionnaires were mailed to subjects as part of the Japan Gerontological Evaluation Study (JAGES) project in 2010. Of the 8576 people aged 65 years or more living in Iwanuma, Japan, 5058 responded. We used 4001 respondents with no missing values. We stratified into two groups by having 20 teeth or not. Then, cross-tabulation, univariate logistic regression, and multivariate logistic regression were conducted for these two groups. The covariates are sex, age, education, and size of household. RESULTS: Of the all respondents included in the analyses, poorer respondents tended to have lower proportions with 20 or more teeth, and 54.6% respondents used dental prostheses. In the respondents with 19 or fewer teeth, higher-income group tended to show significantly higher dental prosthesis use. But the poorest income group showed high prevalence of dental prosthesis use as same as highest income group. Multiple logistic regression among respondents with 19 or fewer teeth showed that after adjustment for sex, age, education, and size of household, compared with the respondents with annual incomes of US$ <5000, those with incomes of US$5000-9999 and US$10 000-14 999 had significantly lower odds ratios for using a dental prosthesis (OR = 0.48 [95% CI = 0.28-0.83], 0.56 [95% CI = 0.33-0.95], respectively). The other respondents did not show significant differences. CONCLUSIONS: Although universal healthcare insurance covered dental prostheses, a social gradient in dental prosthesis use was still observed. Low-income respondents tended to not use dental prosthesis, but the poorest respondents showed dental prosthesis utilization as high as the highest income group.