Do the elderly benefit from annual physical examination? An example from Kaohsiung City, Taiwan

The impact of preventive behaviors on self-rated health, depression symptoms, and daily functioning among middle-aged and elderly Chinese: An empirical study

INTRODUCTION

With the intensifying issue of an aging population, the health of middle-aged and elderly individuals garners increased attention. Preventive behaviors are pivotal in enhancing life quality and extending healthy living. This study examines the effects of preventive behaviors on self-rated health, depression, and daily functioning among these populations.

MATERIALS AND METHODS

Drawing on data from the China Health and Retirement Longitudinal Study (CHARLS), this research applies a panel ordered probability model to scrutinize the influence of preventive behaviors on health outcomes among middle-aged and elderly populations. It utilizes self-rated health, depression, and daily functioning as pivotal health indicators to assess the effects.

RESULTS

Preventive behaviors exert a significant impact on self-assessed health and daily functioning among middle-aged and elderly populations. Engagement in social activities effectively reduces depression symptoms. Primary preventive measures, including physical and social activities, enhance health outcomes through medical consultations. Conversely, secondary preventive actions, such as undergoing physical examinations, facilitate early detection of diseases, enabling timely intervention and health advisories. It is noteworthy that individuals with higher incomes derive lesser benefits from these physical or social endeavors.

CONCLUSION

Sociodemographic determinants such as age, income, and educational attainment significantly modulate the efficacy of preventive behaviors on the health outcomes of middle-aged and elderly populations. This research underscores the pivotal role of physical examination services within primary healthcare frameworks and advocates for the tailoring of health promotion strategies to the accessible social needs and engagements of economically and educationally disadvantaged seniors.

Association between the utilization of senior centers and participation in health check-ups

The global older adult population is increasing. Early detection and intervention through health check-ups are crucial for successful aging, as they play a significant role in identifying and addressing diseases. This study explored the relationship between the utilization of senior centers and the promotion of health check-ups. It utilized data from 10,097 individuals aged 65 years and above, sourced from the 2020 Elderly Survey in South Korea. The primary variable of interest was classified into two groups: those who utilized senior centers and those who did not. Subgroups were further categorized based on the frequency of usage and the presence of family members among senior centers users. Logistic regression analyses were conducted to assess the association between the utilization of senior centers and participation in health check-ups. Both men and women utilizing senior centers demonstrated a higher likelihood of participating in health check-ups compared with those who did not use senior centers. Participants visiting senior centers in a week exhibited a progressively higher likelihood of engaging in health check-ups compared with those who visited such senior centers zero times a week. Senior centers can serve as effective intervention methods to enhance health check-ups among older adults. Furthermore, this can contribute to fostering successful aging among older adults.

Effect of social activities on health checkups and recommended doctor visits: a fixed-effects analysis in Japan

Health checkups are considered to promote occupational and public health. This study aimed to investigate the extent to which participation in social activities encourages middle-aged people to participate in health checkups and adhere to doctor-visit recommendations. We analyzed 337,024 longitudinal observational studies involving 33,420 individuals aged 50-59 yr in the baseline year (2005) derived from a nationwide, population-based, 14-wave survey. We estimated fixed-effects logistic models to elucidate how people's participation in health checkups and recommended doctor visits are affected by participation in social activities. Attending health checkups was positively associated with participation in social activities, with an odds ratio (OR) of 1.19 (95% confidence interval [CI]: 1.15-1.22) and a marginal effect of 3.3% (95% CI: 2.7%-3.9%). Adherence to doctor-visit recommendations was also positively associated with participation in social activities, with an OR of 1.15 (95% CI: 1.08-1.23) and a marginal effect of 3.3% (95% CI: 1.8%-4.8%), although the association was observed only among regular employees. These results provide new insights into the effectiveness of health checkups.

Home/Community-Based Medical and Elderly Care Services Utilization in China: A Cross-Sectional Study from the Middle-Aged and Elderly Population

Few studies have analyzed the acceptance of home/community-based medical and elderly care services in China. Therefore, we conducted a cross-sectional study to describe the acceptance of five services among people aged ≥ 45 years in the China mainland, and their influencing factors. The data were obtained from the database China Health and Retirement Longitudinal Study 2018. For each service, a binary logistics regression was adopted. A total of 9719 people were included, of whom 20.12% received services. The numbers of recipients (acceptance rates) of the five services, namely, comprehensive aged care services, regular physical examinations, onsite visits, health management, and entertainment, were 107 (1.10%), 1640 (16.87%), 323 (3.32%), 156 (1.61%), and 245 (2.52%), respectively. About 4% of people had received two or more services. The elderly aged 65-74 and those who were satisfied with the local medical services had higher acceptance of services. Urban hukou having health insurance, two or more chronic diseases, provincial economic welfare, and social welfare were positively associated with the acceptance of regular physical examination services. It is suggested that the government should gradually improve satisfaction with local medical services, and pay more attention to the needs of elderly people aged 65-74 for all kinds of home/community-based medical and elderly care services.

Should we abandon annual physical examination? - A meta-analysis of annual physical examination and all-cause mortality in adults based on observational studies

Several meta-analyses based on randomized clinical trials data have failed to find an association between the annual physical examination (APE) and reduced mortality; however, no comparable meta-analysis based on observational data exists. We conducted a meta-analysis of observational studies comparing APE versus non-APE in adults for all-cause mortality. English-language searches of four databases (PubMed, CINAHL, EMBASE, and Google Scholar) between the years 2000 to 2019 yielded seven observational studies that investigated APE versus non-APE in healthy adults in relation to all-cause mortality. Random effects models were used to calculate pooled hazard ratios and 95% confidence intervals (CI), and to incorporate variation between studies. During follow-up periods that ranged from two to 25 years, there were 35,055 deaths among 633,957 participants. APE was significantly associated with a 45% lower hazard of all-cause mortality, with pooled hazard ratio of 0.55 (95% CI 0.48 to 0.64, P < 0.01) for all participants. This meta-analysis of seven observational studies in the past 20 years provides evidence of an association between APE and a lower hazard of all-cause mortality, a finding that contrasts with findings based on meta-analyses of randomized clinical trials data. Nonetheless, at present the evidence available about the effectiveness or ineffectiveness of APE on all-cause mortality still needs further study.

Decomposition of income-related inequality in health check-ups services participation among elderly individuals across the 2008 financial crisis in Taiwan

Encouraging citizens to use health checkup services is a health promotion strategy. In nations with aging populations, ensuring equitable use of health check-ups by senior citizens is a public health concern. The objective of this research was to quantify income-related inequality and its effect on the use of health checkup services in Taiwan during the 2007-2008 global financial crisis. We used the 2005 and 2009 datasets of the Taiwan National Health Interview Surveys to assess how income-related inequality influenced health check-up use among older adults in Taiwan during the 2007-2008 financial crisis. Corrected concentration indices (CCIs) were calculated and decomposed to determine the influences of explanatory variables. The dependent variable was whether participants had used free senior health check-ups in the past year, and the determinant factors were health behavior, health situation, socioeconomic and demographic factors, and area health care resources accessibility factors. The study assessed 2,460 older adults from the 2005 dataset and 2,514 such individuals from the 2009 dataset. The utilization of health check-ups increased from 21.6% in 2005 to 34.0% in 2009. Income-related inequality in the use of health check-up services was generally tilted toward the higher income individuals among both women and men in 2005 and 2009, and income-related inequality decreased among women group and increased among men group with non significantly from 2005 to 2009 (women: CCI decreased from.0738 in 2005 to.0658 in 2009; men: CCI increased from.1068 in 2005 to.1256 in 2009). We analyzed the effect of explanatory factors on men's and women's intention to use health check-ups by using a probit model. After controlling for other factors, we determined that income significantly influenced women's health check-up service use in 2005 and men's in 2005 and 2009. Positive health behavior significantly increased health check-up services use among men and women group after the financial crisis, and negative health behavior significantly reduced health check-ups use among men across financial crisis. The 2008 global financial crisis strengthened the effect on health check-ups use of income-related inequality of elderly men, especially in older adults with negative health behaviors. Elderly men with negative health behaviors tended to contribute more income-related inequality in use health check-up services after the financial crisis. Health promotion initiatives should focus their efforts on elderly men with negative health behaviors.

General Health Checks in Adult Primary Care: A Review

IMPORTANCE

General health checks, also known as general medical examinations, periodic health evaluations, checkups, routine visits, or wellness visits, are commonly performed in adult primary care to identify and prevent disease. Although general health checks are often expected and advocated by patients, clinicians, insurers, and health systems, others question their value.

OBSERVATIONS

Randomized trials and observational studies with control groups reported in prior systematic reviews and an updated literature review through March 2021 were included. Among 19 randomized trials (906 to 59 616 participants; follow-up, 1 to 30 years), 5 evaluated a single general health check, 7 evaluated annual health checks, 1 evaluated biannual checks, and 6 evaluated health checks delivered at other frequencies. Twelve of 13 observational studies (240 to 471 415 participants; follow-up, cross-sectional to 5 years) evaluated a single general health check. General health checks were generally not associated with decreased mortality, cardiovascular events, or cardiovascular disease incidence. For example, in the South-East London Screening Study (n = 7229), adults aged 40 to 64 years who were invited to 2 health checks over 2 years, compared with adults not invited to screening, experienced no 8-year mortality benefit (6% vs 5%). General health checks were associated with increased detection of chronic diseases, such as depression and hypertension; moderate improvements in controlling risk factors, such as blood pressure and cholesterol; increased clinical preventive service uptake, such as colorectal and cervical cancer screening; and improvements in patient-reported outcomes, such as quality of life and self-rated health. In the Danish Check-In Study (n = 1104), more patients randomized to receive to a single health check, compared with those randomized to receive usual care, received a new antidepressant prescription over 1 year (5% vs 2%; P = .007). In a propensity score-matched analysis (n = 8917), a higher percentage of patients who attended a Medicare Annual Wellness Visit, compared with those who did not, underwent colorectal cancer screening (69% vs 60%; P < .01). General health checks were sometimes associated with modest improvements in health behaviors such as physical activity and diet. In the OXCHECK trial (n = 4121), fewer patients randomized to receive annual health checks, compared with those not randomized to receive health checks, exercised less than once per month (68% vs 71%; difference, 3.3% [95% CI, 0.5%-6.1%]). Potential adverse effects in individual studies included an increased risk of stroke and increased mortality attributed to increased completion of advance directives.

CONCLUSIONS AND RELEVANCE

General health checks were not associated with reduced mortality or cardiovascular events, but were associated with increased chronic disease recognition and treatment, risk factor control, preventive service uptake, and improved patient-reported outcomes. Primary care teams may reasonably offer general health checks, especially for groups at high risk of overdue preventive services, uncontrolled risk factors, low self-rated health, or poor connection or inadequate access to primary care.

Determining whether periodic health checkups have any preventive effect on deterioration in health among middle-aged adults: A hazards model analysis in Japan

OBJECTIVES

We aimed to examine the long-term impact of periodic health checkups (PHCs) on health outcomes among middle-aged adults.

METHODS

We used longitudinal data from 29 770 individuals (15 399 men and 14 371 women) aged 50-59 years in the baseline year (2005), obtained from a population-based 14-wave survey. PHC participants were defined as those who underwent PHCs for the first three consecutive waves, and we investigated the onset of inpatient care for five types of non-communicable diseases (diabetes, heart disease, stroke, hypertension, and dyslipidemia) as well as poor self-rated health and problems in the activities of daily living in the subsequent 11 waves. Cox-proportional hazards models were used to estimate the impact of PHCs on health outcomes by employing the propensity score matching (PSM) method.

RESULTS

Participation in PHCs was closely related to a respondent's socioeconomic status and health behavior. After controlling for these factors by PSM, the hazard models showed that PHCs postponed the onset of inpatient care for hypertension (hazard ratio, 0.56; 95% confidence interval: 0.36-0.85) among men, but PHCs had no impact on any other health outcomes in men or women.

CONCLUSIONS

The preventive impact of PHCs on health deterioration is generally limited among middle-aged adults. Future studies should address policy measures to enhance the effectiveness of PHCs.

Rural–urban differences in home-based care willingness among older adults: A cross-sectional study in Shandong, China

Objective

To examine the rural–urban disparities of home-based care willingness among older adults and identify the influencing factors.

Design

A cross-sectional study.

Setting

The data used in this cross-sectional study were conducted in Shandong province.

Study participants

7070 older adults (60 years and older) with complete data were included in this analysis from the 2017 Survey of the Shandong Elderly Family Health Service.

Intervention

N/A.

Main outcome measure

The data were analyzed using logistic regression models to examine whether socio-demographic characteristic, physical health, loneliness score and other factors were associated with home-based care willingness in rural and urban older adults. After exploring the factors, we compared the difference.

Results

Of 7070 participants, 66.9% were rural older adults and 33.1% were urban. The urban older adults less likely chose home-based care than the rural (OR = 0.667; P &lt; 0.05). Binary logistic regression analysis showed that age (P &lt; 0.05), income (P &lt; 0.05), current employment (P &lt; 0.05) and loneliness (P &lt; 0.05) were significantly associated with the home-based care willingness both in rural and urban residence. Besides, the number of family members (P = 0.010), education years (P = 0.026) and financial support from children (P = 0.017) were associated factors of rural respondents’ home-based care willingness. The bad self-reported-health-status-urban-older adults (P = 0.026) were more willing for home-based care.

Conclusions

The research we have done suggests that there is a residence difference toward home-based care willingness among older adults. Targeted policies and an age-friendly environment should be made for different subgroups of older adults.

Rural-urban difference in the use of annual physical examination among seniors in Shandong, China: a cross-sectional study

BACKGROUND

Regular physical examination contributes to early detection and timely treatment, which is helpful in promoting healthy behaviors and preventing diseases. The objective of this study is to compare the annual physical examination (APE) use between rural and urban elderly in China.

METHODS

A total of 3,922 participants (60+) were randomly selected from three urban districts and three rural counties in Shandong Province, China, and were interviewed using a standardized questionnaire. We performed unadjusted and adjusted logistic regression models to examine the difference in the utilization of APE between rural and urban elderly. Two adjusted logistic regression models were employed to identify the factors associated with APE use in rural and urban seniors respectively.

RESULTS

The utilization rates of APE in rural and urban elderly are 37.4% and 76.2% respectively. Factors including education level, exercise, watching TV, and number of non-communicable chronic conditions, are associated with APE use both in rural and urban elderly. Hospitalization, self-reported economic status, and health insurance are found to be significant (p < 0.05) predictors for APE use in rural elderly. Elderly covered by Urban Resident Basic Medical Insurance (URBMI) (p < 0.05, OR = 1.874) are more likely to use APE in urban areas.

CONCLUSIONS

There is a big difference in APE utilization between rural and urban elderly. Interventions targeting identified at-risk subgroups, especially for those rural elderly, are essential to reduce such a gap. To improve health literacy might be helpful to increase the utilization rate of APE among the elderly.

Health, healthy lifestyles and health examinations among the older people in Taiwan

AIM

This aim of this study was to examine the relationship between the utilisation of general health examinations and health and a healthy lifestyle.

METHODS

The data were from a 5-wave panel of older Taiwanese people. Health was defined as the absence of chronic diseases and physical function difficulties. A healthy lifestyle included no smoking, no alcohol consumption and engaging in regular exercise. Generalised linear modelling was applied.

RESULTS

The individuals with more chronic diseases were more likely to undergo health examinations, but the rate of change declined over time. Having more physical function disabilities may reduce the likelihood of undergoing health examinations. Individuals who engaged in regular exercise were more likely to undergo health examinations.

CONCLUSION

Health examination utilisation is related to health and healthy lifestyle among older people.

Sex-Specific Prevalence of Diabetes and Cardiovascular Risk Factors in the Middle-Aged Population of China: A Subgroup Analysis of the 2007-2008 China National Diabetes and Metabolic Disorders Study

The sex difference in the prevalence rates of diabetes and cardiovascular diseases (CVDs) among the middle-aged population in China remain largely unknown. Therefore, we analyzed differences in the prevalence of diabetes, self-reported CVDs, and some CVD risk factors among men and women in the middle-aged population (30-49 years) and in individuals aged 50 years and older using data from the China National Diabetes and Metabolic Disorders Study of 2007-2008. Middle-aged men appeared to have significantly a higher prevalence of diabetes and self-reported CVDs than middle-aged women (8.07% vs 5.06% for diabetes, P < 0.001; 0.64% vs 0.22% for CVDs, P < 0.001). Men also showed higher rates of central obesity, hypertension, and dyslipidemia than women (all P < 0.01). Compared with women, men were more likely to drink alcohol and smoke cigarettes but less likely to be under diet control. The sex-specific differences in prediabetes, CVD, and CVD risk factors between men and women were diminished or even reversed in the population aged 50 years and older. No sex-specific differences were found in the prevalences of a family history of diabetes, coronary heart disease, and hypertension (P > 0.05) in middle-aged population. Specific strategies to reduce modifiable risk factors for the prevention and control of diabetes and CVD may be warranted in this population.

Knowledge and Practice on Prevention of Respiratory Health Problems among Traffic Police in Kathmandu, Nepal

Introduction. Traffic police in Kathmandu are continuously exposed to air pollution and are at an increased health risk. This study aimed to assess the knowledge and practice regarding prevention of respiratory problems among traffic police in Kathmandu. Methods. A descriptive exploratory study was conducted among the traffic police (n = 83) working in six areas of the Kathmandu Metropolis from July to August 2013. Self-administered questionnaires were distributed to all the participants. Results. The mean age (±SD) of the respondents was 28.8 ± 4.3 years. More than half of the respondents had 6-10 years of work experience, the mean (±SD) years of experience being 7.9 (±3.6). The level of knowledge regarding the prevention of respiratory problems was better than the level of practice among the respondents. Education of the participants did not affect the level of practice of the respondents while there was association between working experience and level of practice (p = 0.04). Conclusion. Since the preventive practice is poor, the government should come up with plans such as distribution of antipollution masks to improve the level of practice among traffic police to prevent respiratory problems.

A Randomised Controlled Trial of an Sms-Based Mobile Epilepsy Education System

We evaluated an epilepsy education programme based on text messaging (SMS). Epilepsy outpatients from three hospitals in Malaysia were randomised into two groups: intervention and control. Patients in the control group were supplied with printed epilepsy educational material while those in the intervention group also received text messages from the Mobile Epilepsy Educational System (MEES). A total of 136 patients completed the study (mean age 31 years; 91% Malay; 51% with an illness duration of more than 5 years). A between-group analysis showed that the awareness, knowledge and attitudes (AKA) about epilepsy did not significantly differ between the groups at baseline ( P > 0.05). The intervention patients reported better AKA levels during follow-up compared to the control patients ( P < 0.05). A within-group analysis showed that in intervention patients, there were significant improvements in all AKA domains with larger effect sizes ( P < 0.01) while control patients also exhibited significant improvement in most domains except for Awareness but with smaller effect sizes. After controlling for possible confounding variables (age, gender, educational qualification, monthly income and baseline mean for each domain), the intervention group still reported significantly higher AKA than the control group particularly in Awareness ( P < 0.001) and Total AKA ( P = 0.003). There was also significantly better medication adherence and clinic attendance in the intervention group ( P < 0.05). The results suggest that the addition of the MEES to conventional epilepsy education is effective in improving AKA.

Nationwide periodic health examinations promote early treatment of hypertension, diabetes and hyperlipidemia in adults: experience from Taiwan

OBJECTIVES

To investigate the effectiveness of nationwide periodic health examinations in promoting early treatment of hypertension, diabetes and hyperlipidemia in adults aged ≥40 years.

STUDY DESIGN

Seven-year, retrospective, cohort study.

METHODS

Based on a large and representative claims dataset in Taiwan, cohort analysis was undertaken among three disease-free cohorts for hypertension, diabetes and hyperlipidemia (n = 26,661, 29,872 and 30,712 subjects, respectively) in 2000. Each cohort was observed from January 2001 to December 2007. Logistic regression, Cox proportional hazards analysis and the extended Cox model with counting process were employed in data analysis. Covariates such as age, gender, level of premium, beneficiary category, comorbidities and geographic factors were adjusted at baseline.

RESULTS

For the hypertension, diabetes and hyperlipidemia cohorts, those who had ever used the preventive service between 1998 and 2000 had higher probabilities of being treated as new patients for these target diseases; the hazard ratios were 1.65, 1.32 and 1.57, respectively. Using the extended Cox model, associations for use of each service with treatment within a 1-year follow-up period between 2001 and 2007 were 1.68, 2.41 and 3.48.

CONCLUSIONS

In adults who were initially disease-free, those who used the preventive service had higher probabilities of early treatment of these target diseases. These findings indicate the effectiveness of nationwide periodic health examinations.

Gender differences in trends in diabetes prevalence from 1993 to 2008 in Taiwan

We examined time trends in the prevalence of diabetes using nationally representative samples, with a focus on gender differences. Data were from the Nutrition and Health Survey in Taiwan (NAHSIT), 1993-1996 (n = 2700), and NAHSIT 2004-2008 (n = 2258). Participants aged 19 years or older with adequate fasting glucose data were included. When needed, rates were standardized to the year 2000 WHO 5-year interval population for comparisons. The prevalence increased significantly in men, whose standardized rate increased from 4.6% to 9.3%. In women, the age standardized prevalence decreased slightly from 7.9% to 6.4%. High triglycerides (≥ 150 mg/dL) was associated with diabetes with odds ratios (OR) of 2.14, and 2.69 (all with p<0.05) in the two surveys. High waist circumference (men ≥ 90 cm; women ≥ 80 cm) was also associated with diabetes with ORs of 2.52, and 1.93 (all with p < 0.05). We recommend the development of innovative health promotion programs targeting not only the general population, but also high risk groups such as men, to further reduce diabetes.

Clinical and laboratory predictors of all-cause mortality in older population

Although some clinical and laboratory tests have been studied on their individual relationship with total mortality or cause-specific mortality such as cardiovascular mortality, the overall effect of these indicators on mortality has rarely been evaluated. The purposes of this study were to assess the relationship of clinical and laboratory measures and all-cause mortality and to evaluate their potential clinical importance in mortality prediction in older adults. A sample of 2086 persons aged 65 and older participating the population-based health examination in 1995 and 1996 in Kaohsiung City, Taiwan was followed until the end of 2003. All participants completed medical history and underwent clinical assessment and laboratory tests. Measures selected for analysis were pulse rate, blood pressure, height, weight, serum level of cholesterol, triglyceride, creatinine, and uric acid, fasting blood glucose (FBG), hemoglobin (HG) and red (RBC) and white blood cell (WBC) counts. Cox regression was used to select measures significant to total mortality. All participants were further classified into risk groups, based on disease history and values of measures identified from analyses, to evaluate mortality risk. A total of 409 deaths occurred during an average of 8.2 years of follow-up time. Among all 14 measures assessed individually, five (systolic blood pressure=SBP, creatinine, uric acid, FBG, and HG) were statistically related to total mortality. SBP (hazard ratio (HR)=1.22; 95% confidence interval (CI)=1.09-1.36), FBG (HR=1.18; CI=1.08-1.29), and HG (HR=0.81; CI=0.73-0.91) were further identified to have independent effect on total mortality in the multivariate analysis. Age- and sex-adjusted total mortality HRs for disease risk (with disease history but with normal biomedical values), biomedical risk (without disease history but with abnormal biomedical values), and combined risk groups (with disease history and with abnormal biomedical values) were 1.94 (CI=1.22-3.10), 2.08 (CI=1.57-2.76), and 2.45 (CI=1.83-3.27) compared with low risk group (without diseases history and with normal biomedical values). Results from this study reveal the importance of incorporating clinical and laboratory measures on the assessment of mortality in older adults. Establishing mortality risk profile based on both diseases conditions and inexpensive biomedical measures (for example, SBP, FBG and HG identified in the study) may help physicians in evaluating older persons' prognosis.

Impact of health education and screening over all-cause mortality in Japan: evidence from a cohort study during 1984-2002

BACKGROUND

Health education and screening are two components of preventive health services in Japan since 1983. This study investigated their relationships with all-cause mortality as they are studied insufficiently in Hokkaido, Japan.

METHODS

This study enrolled 1,532 men and 1,653 women aged 40-97 years from 1,702 randomly selected households of 60 areas during 1984-1985 and followed them until 2002. At baseline survey, staffs of 45 health centers collected sociodemographic, medical, behavioral, and dietary information including health education and screening from study subjects with informed consent.

RESULTS

For men, age-adjusted Cox proportional hazard model indicated lower mortality for those who received health education (RR = 0.76, P < 0.01) and screening (RR = 0.83, P < 0.05) than those who did not. Health education showed lower mortality even after adjusting for many variables. Similarly for women, health education (RR = 0.66, P < 0.01) and screening (RR = 0.64, P < 0.001) revealed lower age-adjusted mortality. Almost similar results were found for both services when models were adjusted for many variables and when the deaths including lost to follow-up cases of the first 4 years of baseline survey are excluded.

CONCLUSIONS

This study shows protective effects of health education and screening over all-cause mortality for both sexes. However, further studies are needed to confirm the results.