Regional Differences in the Effects of Social Relations on Depression Among Korean Elderly and the Moderating Effect of Living Alone / 예방의학회지

Objectives@#Socioeconomic disadvantages interact with numerous factors which affect geriatric mental health. One of the main factors is the social relations of the elderly. The elderly have different experiences and meanings in their social lives depending on their socio-cultural environment. In this study, we compared the effects of social relations on depression among the elderly according to their living arrangement (living alone or living with others) and residential area. @*Methods@#We defined social relations as “meetings with neighbors” (MN). We then analyzed the impact of MN on depression using data from the Korean Longitudinal Study of Aging Panel with the generalized estimating equation model. We also examined the moderating effect of living alone and performed subgroup analysis by dividing the sample according to which area they lived in. @*Results@#MN was associated with a reduced risk of depressive symptoms among elderlies. The size of the effect was larger in rural areas than in large cities. However, elderly those who lived alone in rural areas had a smaller protective impact of MN on depression, comparing to those who lived with others. The moderating effect of living alone was significant only in rural areas. @*Conclusions@#The social relations among elderlies had a positive effect on their mental health: The more frequent MN were held, the less risk of depressive symptoms occurred. However, the effect may vary depending on their living arrangement and environment. Thus, policies or programs targeting to enhance geriatric mental health should consider different socio-cultural backgrounds among elderlies.

The Impact of Technology Utilization on Health Research and Development: Case Studies of the Development of Medical Device / 보건행정학회지

Background@#Based on that the key function of health technology is improving the quality of healthcare services, our study purports to explore the process of medical device development in detail and to discuss its policy implications. @*Methods@#A total of 12 in-depth interviews were conducted with four groups of industry, hospital, academia, and civil society. All of the interviewees except those from civil society were involved in the new medical device development between 2009 and 2018. We performed a text network analysis and content analysis of the interview data. @*Results@#The frequency and the degree centrality rankings suggested a close association between the utilization issue and the technology development. Similarly, the results of the content analysis showed that the appropriate intervention in the utilization of technology has a direct impact on the progress of development. Under the continuous industrial effort to boost profits by developing new technology, service providers and citizens should be knowledgeable of and make good use of the new technology for the provision of better services. @*Conclusion@#As the development itself would not guarantee the improvement of service quality and better health outcomes, health technology policies should take a more comprehensive view to serve the unmet needs and even to facilitate the technology development.

Critical Analysis of Unmet Healthcare Needs Index for Addressing Regional Healthcare Inequality / 보건행정학회지

Background@#Unmet healthcare needs have many advantages for measuring inequalities in healthcare use. However, the existing indicator is difficult to capture the reality of unmet healthcare needs sufficiently and is not quite appropriate in comparing regional inequality. The purpose of this study is to critically analyze the utilization of the unmet healthcare need indicator for regional healthcare inequalities research. @*Methods@#We used the level of healthcare accessibility and healthcare need to categorize the regions that are known to cause differences in healthcare utilization between regions and verified how existing unmet healthcare need indicator is distributed at the regional level. @*Results@#Four types of regions were classified according to the high and low levels of healthcare needs and accessibility. The hypothesis about the regional type expected to have the highest unmet healthcare need was not proved. The hypothesis about the lowest expected regional type was proved, but the difference in the average rate of unmet healthcare needs among regional types was not significant. The standard deviation of the rate of unmet healthcare needs among regions within the same type was also higher than the overall regional variation, which also disproved the whole frame of hypothesis. @*Conclusion@#Failure to prove the hypothesis means the gap between the supposed meaning of the indicator and the reality. In order to understand the current state of healthcare utilization of people in various regions of Korea and to resolve inequality, fundamental research on the in-depth structure and mechanisms of healthcare utilization is needed.

Effects of the Out-of-pocket Payment Exemption in the Public Health Center on Medical Utilization of the Korean Elderly / 예방의학회지

Objectives@#The distribution of hospitals in Korea is unbalanced in terms of accessibility. Many local public health centers (PHCs) exempt out-of-pocket payments (OOPs) based on local government laws to increase coverage. However, this varies across administrative regions, as many make this exemption for the elderly, while others do not. This study aimed to evaluate the effects of the OOP exemption at local PHCs among elderly individuals. @*Methods@#This study used online data on Korean national law to gather information on individual local governments’ regulations regarding OOP exemptions. Individual-level data were gathered from the 2018 Community Health Survey and regional-level data from public online sources. @*Results@#The study analyzed 132 regions and 44 918 elderly people. A statistical analysis of rate differences and 2-level multiple logistic regression were carried out. The rate difference according to whether elderly individuals resided in areas with the OOP exemption was 1.97%p (95% confidence interval [CI], 1.07 to 2.88) for PHC utilization, 1.37%p (95% CI, 0.67 to 2.08) for hypertension treatment, and 2.19%p (95% CI, 0.63 to 3.74) for diabetes treatment. The regression analysis showed that OOP exemption had an effect on hypertension treatment, with a fixed-effect odds ratio of 1.25 (95% CI, 1.05 to 1.48). @*Conclusions@#The OOP exemption at PHCs can affect medical utilization in Korea, especially for hypertension treatment. The OOP exemption should be expanded to improve healthcare utilization in Korea.

Effects of the Out-of-pocket Payment Exemption in the Public Health Center on Medical Utilization of the Korean Elderly / 예방의학회지

Objectives@#The distribution of hospitals in Korea is unbalanced in terms of accessibility. Many local public health centers (PHCs) exempt out-of-pocket payments (OOPs) based on local government laws to increase coverage. However, this varies across administrative regions, as many make this exemption for the elderly, while others do not. This study aimed to evaluate the effects of the OOP exemption at local PHCs among elderly individuals. @*Methods@#This study used online data on Korean national law to gather information on individual local governments’ regulations regarding OOP exemptions. Individual-level data were gathered from the 2018 Community Health Survey and regional-level data from public online sources. @*Results@#The study analyzed 132 regions and 44 918 elderly people. A statistical analysis of rate differences and 2-level multiple logistic regression were carried out. The rate difference according to whether elderly individuals resided in areas with the OOP exemption was 1.97%p (95% confidence interval [CI], 1.07 to 2.88) for PHC utilization, 1.37%p (95% CI, 0.67 to 2.08) for hypertension treatment, and 2.19%p (95% CI, 0.63 to 3.74) for diabetes treatment. The regression analysis showed that OOP exemption had an effect on hypertension treatment, with a fixed-effect odds ratio of 1.25 (95% CI, 1.05 to 1.48). @*Conclusions@#The OOP exemption at PHCs can affect medical utilization in Korea, especially for hypertension treatment. The OOP exemption should be expanded to improve healthcare utilization in Korea.

Association Between Convenience of Transportation and Unmet Healthcare Needs of Rural Elderly in Korea / 예방의학회지

OBJECTIVES@#In rural areas of Korea, where public transportation infrastructure is lacking and alternative systems are poor, the elderly experience inconveniences in using healthcare, although their need is high. This study aimed to analyze the association between the convenience of transportation and unmet healthcare needs among the rural elderly.@*METHODS@#The data used were collected in the 2016 Community Health Survey among rural elderly individuals aged 65 or older. Dependent variable was the unmet healthcare needs, explanatory variable was the convenience of transportation. The elderly were divided into 3 groups: with no driver in the household, with a driver, and the elderly individual was the driver (the self-driving group). Covariates were classified into predisposing, enabling, and need factors. They included gender, age, education, income, economic activity, household type, motor ability, subjective health level, number of chronic diseases, anxiety/depression, and pain/discomfort. The data were analyzed using logistic regression and stratification.@*RESULTS@#A significant association was found between the convenience of transportation and unmet healthcare needs. When examined unadjusted odds ratio of the group with a driver in the household, using the group with no driver as a reference, was 0.61 (95% confidence interval [CI], 0.54 to 0.68), while that of the self-driving group was 0.34 (95% CI, 0.30 to 0.38). The odds ratios adjusted for all factors were 0.69 (95% CI, 0.59 to 0.80) and 0.79 (95% CI, 0.67 to 0.91).@*CONCLUSIONS@#We confirmed a significant association between inconvenient transportation and unmet healthcare needs among the rural elderly even after adjustment for existing known factors. This implies that policies aimed at improving healthcare accessibility must consider the means of transportation available.

Medical Experiences and Unmet Health Care Perception among Elderly People with Chronic Disease / 보건행정학회지

BACKGROUND: The purpose of this study is to elucidate the context of medical experience and the perception of unmet healthcare of elderly people with chronic diseases based on in-depth interview data. METHODS: We carried out in-depth interviews with 10 elderly people with chronic diseases using semi-structured questionnaires based on literature review. The in-depth interview data were analyzed using thematic analysis; one qualitative research methodology, three core meaning categories, and four attributes associated with unmet healthcare were ultimately derived. RESULTS: The context of the medical experience were based on the following three categories: (1) discomfort due to diseases and high medical needs, (2) the poor community medical environment and difficulties in accessing to metropolitan medical institutions, and (3) inconvenience caused by long waiting time and side effects of medicine. In addition, the elderly with chronic disease realized the unmet healthcare as (1) the availability related to the desired medical institutions at the right time, (2) the affordability related to their economic capacity, (3) the effectiveness of the medical services they experienced, and (4) the appropriateness related to receiving medical services in a pleasant environment. CONCLUSION: The perception of unmet healthcare among the elderly with chronic disease is the result of interaction of multi-level and multi-dimensional factors related with their medical experience.

Factors Affecting the Insured Organizations Participation in Decision Making Process in Health Insurance Policy Committee / 보건행정학회지

BACKGROUND: Due to the asymmetry of information and knowledge and the power of bureaucrats and medical professionals, it is not easy for citizens to participate in health care policy making. This study analyzes the case of the insured organization participating in the Health Insurance Policy Committee (HIPC) and provides a basis for discussing methods and conditions for better public participation. METHODS: Qualitative analysis was conducted using the in-depth interviews with the participants and document data such as materials for HIPC meetings. Semi-structured interviews were conducted with purposively sampled six participants from organizations representing the insured in HIPC. The meanings related to the factors affecting participation were found and categorized into major categories. RESULTS: The main factors affecting participating in the decision making process were trust and cooperation among the participants, structure and procedure of governance, representation and expertise of participants, and contents of issues. Due to limited cooperation, participants lacked influence in important decisions. There was an imbalance in power due to unreasonable procedures and criteria for governance. As the materials for meetings were provided inappropriate manner, it was difficult for participants to understand the contents and comments on the meeting. Due to weak accountability structure, opinions from external stakeholders have not been well received. The participation was made depending on the expertise of individual members. The degree of influence was different depending on the contents of the issues. CONCLUSION: In order to meet the values of democracy and realize the participation that the insured can demonstrate influence, it is necessary to have a fair and reasonable procedure and a sufficient learning environment. More deliberative structure which reflects citizen's public perspective is required, rather than current negotiating structure of HIPC.

Recognition of the Concept of Publicness in Healthcare: a Content Analysis of Korean Newspapers

The traditional boundaries between public and private sectors has been blurred, and questions raised regarding how publicness could be conceptualized. The empirical study on the concept of publicness can reveal greatly diversified views on publicness, and help to reduce confusion over publicness. For the content analysis, 750 news articles of 8 national Korean newspapers were retrieved from the Korea Integrated News Database System. The articles were coded by the inductive category for the topic of the paragraph, the concept related to publicness, and the overall tone toward publicness. Publicness was addressed in a number of different issues, and diverse and specific statuses or actions were associated with the realization of publicness. The most frequent concept was “government,” which represented the main agent of healthcare provision and the owner of institutions for “the vulnerable.” Issues of industrialization of healthcare/healthcare industry and reform of the national healthcare system mentioned publicness in a normative sense, which laid stress on “not-for-profit” service and the right of “universal access” to service for publicness. Articles of health/disease information or global health regarded “the population/public” as the main targets or beneficiaries of healthcare services. Occasionally, publicness was not related to specific concepts, being used unclearly or as a routine. The fulfillment of the specific actions or status may lead to the enhancement of publicness. However, publicness itself could not be reduced to the specific concepts suggested. The use of publicness in healthcare delivered only its normative sense without substantive meaning.

Public Health Policy and Health Equity / 보건행정학회지

Equity-focused public health policy has solid theoretical and practical basis, in addition to ethical one. In the Republic of Korea (hereafter Korea), however, equity in health has not had a high priority in policy goals, regardless of policy areas and particular actors or approaches. Equitable health has been only a minor concern in most public health issues and their decision-making. Generic public health policies are needed to reduce inequity in health, but the importance of a firm basis for sound policy-making cannot be overemphasized. Health equity should be ‘mainstreamed’ in all public health policies. Potential approaches include intersectoral collaboration, health impact assessment, and ‘Health in All Policies’. Public policy agendas for equitable health cannot be formulated without measurement and recognition of the problem. Korea is still suffering from the lack of reliable information on the current status of health inequity, resulting in a relatively weak awareness of the problem among both the general public and policy-makers. More information is needed to increase recognition and awareness that will increase intervention and actions. The absence of decision-making and actions should not be justified even by the lack of information on determinants and pathways of health inequities. Generic plausible solutions can often work in the real world according to political and social commitment. I have discussed several aspects of public health policy from the perspective of health equity, focusing on current status and plausible explanation. Policy process, agenda setting in particular, is highlighted and theories and concepts are presented along with analysis and description of current situation.

Exploratory Study of Publicness in Healthcare Sector through Text Network Analysis / 보건행정학회지

BACKGROUND: The publicness concept in healthcare has been built to its social consensus relying on historical context, with the result that the meaning of publicness has a great diversity and heterogeneous nature in Korea. Thus it needs to be addressed to clarify the meaning and boundary of the publicness concept in healthcare, so as to discuss its social implication. METHODS: In order to investigate whether or how the publicness concept is used in healthcare, we conducted a text network analysis in 779 news articles from 8 Korean daily newspapers over a recent 5-year period. RESULTS: The publicness concept was closely related to medicine and medical institution, and formed a conceptual network with public health, medicine, welfare, patient, government, Jin-ju city, and health. Keywords relating publicness tended to be similar between four major newspapers; however, the association with Jin-ju city, government, and society was noticeable in Kyunghyang Shinmun and Hankyoreh, and so was patient and service in Dong-A Ilbo. CONCLUSION: Publicness and medicine was closely associated, and government seemed to remain as a main actor for public interest. Publicness was related with a variety of actors and values, with its expanded boundary. The different contexts of publicness by newspapers might reflect each ideological inclination. The textual importance of publicness was relatively low in part, which suggests that publicness was used in a loose sense or as a routine.

Civic Participation and Self-rated Health: A Cross-national Multi-level Analysis Using the World Value Survey / 예방의학회지

OBJECTIVES: Civic participation, that which directly influences important decisions in our personal lives, is considered necessary for developing a society. We hypothesized that civic participation might be related to self-rated health status. METHODS: We constructed a multi-level analysis using data from the World Value Survey (44 countries, n=50 859). RESULTS: People who participated in voting and voluntary social activities tended to report better subjective health than those who did not vote or participate in social activities, after controlling for socio-demographic factors at the individual level. A negative association with unconventional political activity and subjective health was found, but this effect disappeared in a subset analysis of only the 18 Organization for Economic Cooperation and Development (OECD) countries. Moreover, social participation and unconventional political participation had a statistically significant contextual association with subjective health status, but this relationship was not consistent throughout the analysis. In the analysis of the 44 countries, social participation was of borderline significance, while in the subset analysis of the OECD countries unconventional political participation was a stronger determinant of subjective health. The democratic index was a significant factor in determining self-rated health in both analyses, while public health expenditure was a significant factor in only the subset analysis. CONCLUSIONS: Despite the uncertainty of its mechanism, civic participation might be a significant determinant of the health status of a country.

The User Fee Introduction and Its Effect in the Health System of Low and Middle Income Countries: An Exploratory Study Using Realist Review Method / 보건행정학회지

BACKGROUND: The purpose of this exploratory study is to explain where, when and how the introduction of user fee system works in low and middle income countries using context, mechanism, and outcome configuration. METHODS: Considering advanced research in realist review approach, we made a review process including those following 4 steps. They are identifying the review question, initial theory and mechanism, searching and selecting primary studies, and extracting, analyzing, and synthesizing relevant data. RESULTS: User fee had a detrimental effect on medical utilization in low and middle income countries. Also previous and current interventions and community participation were critical context in user fee system. Those contexts were associated with intervention initiation and recognition and coping strategies. Such contexts and mechanisms were critical explanatory factors in medical utilization. CONCLUSION: User fee is a series of interventions that are fragile and dynamic. So the introduction of user fee system needs a comprehensive understanding of previous and new intervention, policy infrastructure, and other factors that can influence on medical utilization.

Public Participation in the Process of Local Public Health Policy, Using Policy Network Analysis / 예방의학회지

OBJECTIVES: To assess the current public participation in-local health policy and its implications through the analysis of policy networks in health center programs. METHODS: We examined the decision-making process in sub-health center installations and the implementation process in metabolic syndrome management program cases in two districts ('gu's) of Seoul. Participants of the policy network were selected by the snowballing method and completed self-administered questionnaires. Actors, the interactions among actors, and the characteristics of the network were analyzed by Netminer. RESULTS: The results showed that the public is not yet actively participating in the local public health policy processes of decision-making and implementation. In the decision-making process, most of the network actors were in the public sector, while the private sector was a minor actor and participated in only a limited number of issues after the major decisions were made. In the implementation process, the program was led by the health center, while other actors participated passively. CONCLUSIONS: Public participation in Korean public health policy is not yet well activated. Preliminary discussions with various stakeholders, including civil society, are needed before making important local public health policy decisions. In addition, efforts to include local institutions and residents in the implementation process with the public officials are necessary to improve the situation.

Association Between Local Government Social Expenditures and Mortality Levels in Korea / 예방의학회지

OBJECTIVES: We examined the association between social expenditures of the local government and the mortality level in Korea, 2004 to 2010. METHODS: We used social expenditure data of 230 local governments during 2004 to 2010 from the Social Expenditure Database prepared by the Korean Institute for Health and Social Affairs. Fixed effect panel data regression analysis was adopted to look for associations between social expenditures and age-standardized mortality and the premature death index. RESULTS: Social expenditures of local governments per capita was not significantly associated with standardized mortality but was associated with the premature death index (decline of 1.0 [for males] and 0.5 [for females] for each expenditure of 100 000 Korean won, i.e., approximately 100 US dollar). As an index of the voluntary effort of local governments, the self-managed project ratio was associated with a decline in the standardized mortality in females (decline of 0.4 for each increase of 1%). The share of health care was not significant. CONCLUSIONS: There were associations between social expenditures of the local government and the mortality level in Korea. In particular, social expenditures per capita were significantly associated with a decline in premature death. However, the voluntary efforts of local governments were not significantly related to the decline in premature death.

Role of physician in reducing health inequity

The role of physicians in reducing health inequity has been regarded only partial and anecdotal by most policymakers. Clinicians, primary care physicians in particular, do not have sufficient opportunities to be engaged in activities dealing with health equity. However, physicians are playing a key role in providing health care and health-related programs, usually interwoven with inequities in health and health care utilization. As a result, a more active role for physicians must be identified under the scheme of a comprehensive strategy in combating inequity in health. From the perspective of mediating factors linking social determinants of health and inequitable outcomes in health and health care, health behaviors, access, and processes of care are identified as potential areas for physicians' engagement. 'Health equity capacity' is emphasized as a cross-cutting tool to empower physicians to address inequity in their clinical practices. More broadly, practicing physicians are able to support their colleagues and communities through diverse activities and participation: technical assistance, research and education, community involvement, and advocacy. Among them, raising awareness and changing perceptions are indicated as crucial factors facilitating physicians' contribution to minimizing inequity.

Disparities in Health Care Utilization Among Urban Homeless in South Korea: A Cross-Sectional Study / 예방의학회지

OBJECTIVES: We examined health care disparities in Korean urban homeless people and individual characteristics associated with the utilization of health care. METHODS: We selected a sample of 203 homeless individuals at streets, shelters, and drop-in centers in Seoul and Daejeon by a quota sampling method. We surveyed demographic information, information related to using health care, and health status with a questionnaire. Logistic regression analysis was adopted to identify factors associated with using health care and to reveal health care disparities within the Korean urban homeless population. RESULTS: Among 203 respondents, 89 reported that they had visited health care providers at least once in the past 6 months. Twenty persons (22.5%) in the group that used health care (n = 89) reported feeling discriminated against. After adjustment for age, sex, marital status, educational level, monthly income, perceived health status, Beck Depression Inventory score, homeless period, and other covariates, three factors were significantly associated with medical utilization: female sex (adjusted odds ratio [aOR, 15.95; 95% CI, 3.97 to 64.04], having three or more diseases (aOR, 24.58; 95% CI, 4.23 to 142.78), and non-street residency (aOR, 11.39; 95% CI, 3.58 to 36.24). CONCLUSIONS: Health care disparities in Seoul and Daejeon homeless exist in terms of the main place to stay, physical illnesses, and gender. Under the current homeless support system in South Korea, street homeless have poorer accessibility to health care versus non-street homeless. To provide equitable medical aid for homeless people, strategies to overcome barriers against health care for the street homeless are needed.

The Financial Burden of Asthma: A Nationwide Comprehensive Survey Conducted in the Republic of Korea

PURPOSE: Asthma-related morbidity and mortality are increasing, and the financial burden imposed by this condition will substantially increase. Nevertheless, little information is available regarding the nature and magnitude of the burden due to asthma at the national level. This study was conducted to characterize the financial burden imposed by asthma in the Republic of Korea at the national level. METHODS: The overall prevalence of asthma and the costs of related medical services were determined using data from the National Health Insurance Corporation, which is responsible for the National Health Insurance scheme. Indirect costs, including expenditures on complementary and alternative medicines, and the economic impact of an impaired quality of life (intangible costs) were estimated by surveying 660 asthmatics, and these estimates were transformed to the national level using the prevalence of asthma. RESULTS: The prevalence of asthma and total costs related to the disease in 2004 were 4.19% and $2.04 billion, respectively. Direct costs and indirect costs contributed equally to total costs (46.9% and 53.1%, respectively). However, when intangible costs were included, total costs rose to $4.11 billion, which was equivalent to 0.44% of the national gross domestic product in 2004. CONCLUSIONS: The results provide evidence that asthma is a major health cost factor in the Republic of Korea and that intangible costs associated with asthma are significant cost drivers.

Participation Determinants in the DRG Payment System of Obstetrics and Gynecology Clinics in South Korea / 예방의학회지

OBJECTIVES: The Diagnosis Related Group (DRG) payment system, which has been implemented in Korea since 1997, is based on voluntary participation. Hence, the positive impact of this system depends on the participation of physicians. This study examined the factors determining participation of Korean obstetrics & gynecology (OBGYN) clinics in the DRG-based payment system. METHODS: The demographic information, practice-related variables of OBGYN clinics and participation information in the DRG-based payment system were acquired from the nationwide data from 2002 to 2007 produced by the National Health Insurance Corporation and the Health Insurance Review & Assessment Service. The subjects were 336 OBGYN clinics consisting of 43 DRG clinics that had maintained their participation in 2003-2007 and 293 no-DRG (fee-for-service) clinics that had never been a DRG clinic during the same period. Logistic regression analysis was carried out to determine the factors associated with the participation of OBGYN clinics in the DRG-based payment system. RESULTS: The factors affecting participation of OBGYN clinics in the DRG-based payment system were as follows (p<0.05): (1) a larger number of caesarian section (c/sec) claims, (2) higher cost of a c/sec, (3) less variation in the price of a c/sec, (4) fewer days of admission for a c/sec, and (5) younger pregnant women undergoing a c/sec. CONCLUSIONS: These results suggest that OBGYN clinics with an economic practice pattern under a fee-for-service system are more likely to participate in the DRG-based payment system. Therefore, to ensure adequate participation of physicians, a payment system with a stronger financial incentive might be more suitable in Korea.

High Risk Groups in Health Behavior Defined by Clustering of Smoking, Alcohol, and Exercise Habits: National Heath and Nutrition Examination Survey / 예방의학회지

OBJECTIVES: We investigated the clustering of selected lifestyle factors (cigarette smoking, heavy alcohol consumption, lack of physical exercise) and identified the population characteristics associated with increasing lifestyle risks. METHODS: Data on lifestyle risk factors, sociodemographic characteristics, and history of chronic diseases were obtained from 7,694 individuals > or =20 years of age who participated in the 2005 Korea National Health and Nutrition Examination Survey (KNHANES). Clustering of lifestyle risks involved the observed prevalence of multiple risks and those expected from marginal exposure prevalence of the three selected risk factors. Prevalence odds ratio was adopted as a measurement of clustering. Multiple correspondence analysis, Kendall tau correlation, Man-Whitney analysis, and ordinal logistic regression analysis were conducted to identify variables increasing lifestyle risks. RESULTS: In both men and women, increased lifestyle risks were associated with clustering of: (1) cigarette smoking and excessive alcohol consumption, and (2) smoking, excessive alcohol consumption, and lack of physical exercise. Patterns of clustering for physical exercise were different from those for cigarette smoking and alcohol consumption. The increased unhealthy clustering was found among men 20-64 years of age with mild or moderate stress, and among women 35-49 years of age who were never-married, with mild stress, and increased body mass index (>30 kg/m2). CONCLUSIONS: Addressing a lack of physical exercise considering individual characteristics including gender, age, employment activity, and stress levels should be a focus of health promotion efforts.