Impact of the 2011 Great East Japan Earthquake on community health: ecological time series on transient increase in indirect mortality and recovery of health and long-term-care system.

BACKGROUND: The objectives were to clarify the trend in the cause-specific mortality rate and changes in health and long-term-care use after the Great East Japan Earthquake in 2011. METHODS: We obtained the following data from national sources: the number of deaths by cause, age and month; the amount of healthcare insurance expenditures by type of services, age and month; the amount of long-term-care insurance expenditures by type of services, age, care need and month. We estimated increase in standardised mortality rate postearthquake compared with pre-earthquake, and change in the standardised amount of health and long-term-care insurance expenditures post-earthquake compared with pre-earthquake in three severely affected prefectures, Iwate, Miyagi and Fukushima, by the adjustment for trends in the other prefectures. RESULTS: The risk of indirect mortality increased in the month of the earthquake (relative risk (RR) with 95% CI 1.20 (1.13 to 1.28) for those 60-69 years of age, 1.25 (1.17 to 1.32) for 70-79 years, and 1.33 (1.27 to 1.38) for 80 years and older). The amount of health and long-term-care insurance expenditures decreased among elderly persons in the month of the earthquake, and recovered to 95% of usual level within 1-5 months. Among cities and towns hit by tsunami, higher percentage of households flooded was associated with higher risk of indirect mortality (p<0.001), lower expenditures for outpatient medical care (p<0.001), and lower expenditures for home-care services (p<0.001). CONCLUSIONS: This study showed transient increase in indirect mortality and recovery of health and long-term-care system after the earthquake.

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.

Out-of-pocket Costs of Disabilities and Their Association with Household Socioeconomic Status Among School-aged Children in Vietnam.

OBJECTIVE: The aim of this study was to assess the economic burden of disability of school-aged children and to evaluate the association between disabilities and household socioeconomic status, as well as the economic burden of disability and household socioeconomic status in Vietnam. MATERIALS AND METHODS: Nationally representative data for 9,882 children aged 6 to 17 years from the Vietnam Household Living Standard Survey 2006 were used. Disabilities were measured in six basic functional domains, including vision, hearing, remembering or concentrating, mobility, self-care, and communication. We evaluated the association between area, household income, educational attainment, or occupation of household head, and each difficulty. The ratio of health-care expenditure to per capita household income was compared by presence of a disability as well as household socioeconomic status. RESULTS: The prevalence of difficulty was 1.9% for vision and 2.3% for at least one of the other five domains. Difficulty in vision was more prevalent in the richer households (p=0.001), whereas difficulty in the other five domains was more prevalent in the poorer households (p=0.002). The ratio of health-care expenditure to per capita household income was greater than 0.05 in 4.6% of children. The adjusted odds ratio of children with difficulty in vision having a health-care expenditure share greater than 0.05 compared with children without difficulty was 4.78 (95% CI: 2.95, 7.73; p<0.001), and that for difficulty in the other five domains was 3.13 (95% CI: 2.04, 4.80; p<0.001). Among children with difficulty in at least one of the five domains other than vision, the proportion of children with a health-care expenditure share greater than 0.05 was higher among children from the poorer households (p=0.033). CONCLUSIONS: Children with a disability spent more on health care relative to their income than those without. Visual disability was more prevalent among children from the richer households, whereas other disabilities were more prevalent among children from the poorer households.

Purchase of Antimicrobials in Retail Pharmacies When a Prescription is Not Required.

OBJECTIVES: The patterns of purchasing prescription antimicrobials with or without a prescription from retail pharmacies in Ulaanbaatar, Mongolia, were examined in relation to purchasers' socioeconomic status and price of the product. METHODS: A survey was conducted at 250 randomly selected pharmacies in Ulaanbaatar. A total of 619 customers were interviewed, and the medicines they bought at the stores were examined by medical doctors. The use of prescriptions and advice in purchasing medicines and sociodemographic characteristics of the subjects were determined. RESULTS: Interviews were conducted with 297 customers who purchased prescription antimicrobials in front of the store in which they made their purchase. Among these 297 customers, only 19.5% (n=58) purchased medicine with a formal prescription, and 37.4% (n=111) purchased medicines on their own initiative and without the guidance of medical professionals. Purchase without a prescription was not associated with the subjects' gender, age, educational status or area of residence. Lower-priced antimicrobials were purchased without prescriptions more frequently than those with a higher price (P<0.05). CONCLUSION: The purchase of antimicrobials without prescriptions is common across all sociodemographic strata in Ulaanbaatar, Mongolia. Considering the increases in number of retail pharmacies and in sales of antimicrobials associated with economic development, measures to enforce regulations and to promote education among the general public and pharmacy professionals are required.

Health-care provision factors associated with child immunization coverage in a city centre and a rural area in Kabul, Afghanistan.

A total of 1327 households were surveyed in Kabul province, Afghanistan to evaluate child immunization coverage and its association with distance to health facilities, attendance at antenatal care, the place of delivery and contact by outreach activity. The proportion of fully immunized children, those who had received at least 1 dose of BCG, 3 doses of DPT, and 1 dose of measles vaccine, was 84.5% in the city centre and 60.7% in the rural area. Fully immunized status was positively associated with close proximity to a health facility (odds ratio [OR]=1.92, [95%CI, 1.08, 3.39]), and attendance at antenatal care (OR=1.39, [95%CI, 1.00, 1.93]) in the city centre, and outreach contact (OR=11.6, [95%CI, 6.92, 19.4]) in the rural area after adjustment for demography, socio-economic factors, participation in health education and experiences of hardship. Attendance at antenatal care in the rural area (OR=1.91, [95%CI, 1.35, 2.72]), and institutional delivery in the city centre and rural area (OR=2.83, [95%CI, 1.20, 6.71]; OR=2.17, [95%CI, 1.01, 4.64], respectively) were positively associated with antigen specific coverage. Improving multiple community conditions including health-care provision and socio-economic factors through close partnership among various sectors promotes the immunization program.

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.

Cohabitation with farm animals in urban households with and without occupational farm work: associations between participation in educational activities and good hygiene practices in at-risk households cohabiting with farm animals.

OBJECTIVES: This study was performed to investigate patterns of cohabitation with farm animals in urban households in Vientiane, Lao People's Democratic Republic, with regard to animal-to-human disease transmission. We also investigated the association between participation in hygiene-related educational activities and good hygiene practices in households with or without cohabitation with animals. METHODS: A survey regarding cohabitation with animals, socioeconomic characteristics and participation in educational activities was conducted among 1,497 households randomly sampled from urban districts of Vientiane in 2001. Rates of satisfactory performance of recommended good hygiene practices according to a program commencing in 1996 were compared among households cohabiting with animals with or without participation in educational activities (reference group). RESULTS: Even among households not engaged in agriculture as a major source of income, 54.4, 34.9, 7.9, 3.1 and 35.7% cohabited with chickens, ducks, cattle, buffaloes and dogs, respectively. The percentage of households fulfilling the recommendations for good hygiene practices was 56.7%. The rates of satisfactory hygiene practices among households participating in health education and cohabitating with chickens, ducks or cattle were greater than those in the reference group (OR = 1.7, 95%CI = 1.2, 2.3; OR = 2.0, 95%CI = 1.3, 3.0; OR = 2.3, 95%CI = 1.0, 4.9) regardless of socioeconomic factors. Households cohabiting with animals showed poorer rates of satisfactory hygiene practices than those without animals. CONCLUSIONS: Cohabitation with farm animals is common in urban Vientiane regardless of household involvement in agriculture. Further effort is required to improve hygiene conditions, despite some positive effects of health education even in households cohabiting with animals.

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.

Higher mortality in areas of lower socioeconomic position measured by a single index of deprivation in Japan.

OBJECTIVES: To formulate an index representing area deprivation and elucidate the relation between the index and mortality in Japan. STUDY DESIGN: Ecological study for prefectures (N=47) and municipalities (N=3366) across Japan. METHODS: Based on socioeconomic indicators of seven domains of deprivation (i.e. unemployment, overcrowding, low social class and poverty, low education, no home ownership, low income and vulnerable group), an index was formulated using the z-scoring method. The relation between the index and mortality was examined by correlation analysis, hierarchical Poisson regression and comparison of standardized mortality ratio according to the index. RESULTS: The deprivation index ranged from -7.48 to 10.98 for prefectures and from -16.97 to 13.82 for municipalities. The index was significantly positively correlated with prefectural mortality, especially in the population aged under 74 years: r=0.65 for men and r=0.41 for women. At the municipal level, hierarchical Poisson regression showed a significant positive coefficient of the index to mortality for both men and women, and excess mortality in the most deprived fifth compared to the least deprived fifth was 26.4% in men and 11.8% in women. CONCLUSIONS: We formulated a deprivation index, which was substantially related to mortality at the prefectural and municipal levels. This study highlights the higher risk of dying among populations in socially disadvantaged areas and encourages the use of indices representing area socioeconomic conditions for further studies of area effects on health.

Association of household demographic variables with child mortality in Côte d'Ivoire.

The associations between household demographic variables and mortality of children aged less than five years were investigated using data from the 1998 Demographic and Health Survey (DHS) of the Republic of Côte d'Ivoire, Western Africa. Of the total of 1992 children born to women included in the study population during the 5-year period preceding the survey, 260 (13%) had died and 1732 (87%) were alive at the time of the survey. Logistic regression analyses used to compare biosocial variables between the deceased and living children showed that the sex of the child, birth interval and mother's occupation were associated with child's survival status. After adjusting for their effects, household demographic variables (i.e. number of household members, number of household members under 5 years [HM-5Y], number of household members 5 years or older [HM+5Y], the proportion of HM-5Y among all household members, and the ratio of HM-5Y to HM+5Y) were shown to be associated with the child's survival status. This study provided insight into the effects of intra-household competition among children and availability of care-givers as potential determinants of child survival. The results indicate that improvement of the childcare environment and reproductive intervention are necessary to reduce child mortality in West African countries.

Health and environment in the context of urbanization.

This paper introduces a series of research projects designed to fulfill the societal role of environmental health studies by investigating (1) the dynamic and complex relationships between environmental conditions and (2) health in an urban setting. Research in this first category has revealed the existence of the combined influence of multiple physical environmental factors on health and its mechanisms. In the second category, there have been a number of studies of the integrated influence of social environmental factors on health employing an aggregate modeling of multiple determinants of health and studies of individual topics related to social determinants of health. These research projects have contributed to the formulation of specific remedies and the development of comprehensive health policies. Participatory approaches have been used to enhance capacity building opportunities and to ensure that research results reflect the actual conditions in urban societies. Healthy Cities projects and programs have been developed in close collaboration with this type of research. Urban societies have become interdependent and share the same issues globally. Further research into the relationships between health and the environment in the context of urbanization will expand the base of evidence applicable to the complex realities in modern societies.

Association of parental and children behaviors with the health status of preschool children.

BACKGROUND: Parental and children behaviors can be associated with health promotion and illness prevention in preschool children. METHODS: We interviewed mothers of 804 out of 1000 households with children aged 3 to 5 years randomly sampled in Tokyo, in 1997. Child health status was categorized as: "good", that is, good general health with no sick days; "poor", that is, fair to poor with frequent sick days; or "moderate". RESULTS.: Good health status was associated with playing outside (OR=1.19, 95% CI: 1.03, 1.37) and family income (OR=1.38-1.78, depending on family income). Mothers of children with poor health were less likely to have good health behavior themselves (OR=0.76, 95% CI: 0.64, 0.90) and were more often sick (OR=1.55, 95% CI: 1.24, 1.94). CONCLUSION: Outdoor playing, good health practice of the mother and high income are associated with a better health status of urban preschool children.

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.

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.

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.

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.