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

Exploring the Relationship Between Education, Living Environment, and Anxiety/Depression Among Stable Patients: Insights from the COPD-AD China Registry Study

Background

Education and living environment are related to mental health. But the independent and combined effects of them on mental health among patients with chronic obstructive pulmonary disease (COPD) are uncertain.

Methods

The independent and combined effects of education and living environment on mental health were assessed by binary logistic regression in 1064 COPD patients. Additive interaction was assessed with the relative excess risk ratio (RERI), attribution percentage (AP), and synergy index (SI).

Results

Our results shown that low education level and urban living environment were independently associated with higher risks for anxiety (odds ratio [OR]: 1.56, 95% confidence interval [CI] 1.06-2.29 and OR:2.15, 95% CI 1.51-2.05) or depression (OR:1.62, 95% CI 1.17-2.27 and OR: 2.01, 95% CI 1.46-2.75) among COPD patients. The combination effect of them was also associated with higher risks for anxiety (OR: 7.90, 95% CI 3.83-16.29, P < 0.001) or depression (OR: 11.79, 95% CI 5.77-24.10, P < 0.001) among these patients. Furthermore, we observed strong synergistic additive interactions between them for anxiety (SI: 11.57, 95% CI 1.41-95.27; RERI: 6.31, 95% CI 1.60-11.01; AP: 0.8, 95% CI 0.66-0.94) and depression (SI: 31.31, 95% CI 1.59-617.04; RERI: 10.44, 95% CI 2.66-18.23; AP: 0.89, 95% CI 0.8-0.97).

Conclusion

Low education levels and living in urban areas had an independent and synergistic effects on mental health among COPD patients.

Exploration of the Relationships between Men's Healthy Life Expectancy in Japan and Regional Variables by Integrating Statistical Learning Methods

A quantitative understanding of the relationship between comprehensive health levels, such as healthy life expectancy and their related factors, through a highly explanatory model is important in both health research and health policy making. In this study, we developed a regression model that combines multiple linear regression and a random forest model, exploring the relationship between men's healthy life expectancy in Japan and regional variables from open sources at the city level as an illustrative case. Optimization of node-splitting in each decision tree was based on the total mean-squared error of multiple regression models in binary-split child nodes. Variations of standardized partial regression coefficients for each city were obtained as the ensemble of multiple trees and visualized on scatter plots. By considering them, interaction terms with piecewise linear functions were exploratorily introduced into a final multiple regression model. The plots showed that the relationship between the healthy life expectancy and the explanatory variables could differ depending on the cities' characteristics. The procedure implemented here was suggested as a useful exploratory method for flexibly implementing interactions in multiple regression models while maintaining interpretability.

Alcohol Energy Intake Is Related to Low Body Mass Index in Japanese Older Adults: Data from the 2010-2011 National Health and Nutrition Survey

OBJECTIVE

The objective of this study was to identify lifestyle and nutritional factors associated with low BMI in Japanese older adults, with a focus on alcohol energy intake.

DESIGN

Cross-sectional study.

PARTICIPANTS

Data from 1,093 respondents (711 men and 382 women) to the National Health and Nutrition Survey aged 65 years and older were included in this study.

MEASUREMENTS

Data were analyzed for associations between BMI and lifestyle, energy, and nutrient intake. Alcohol energy intake was calculated from total energy and participants were categorized into BMI quartiles. Energy-adjusted nutrient intakes were calculated as residuals from a regression model, with BMI as the independent variable and lifestyle factors and nutrient intake as dependent variables. Between-BMI quartile differences were assessed for each sex using multivariate logistic regression analysis. In addition, the nutrient intakes of men consuming more than 280 kcal and less than 280 kcal of alcohol energy per day were compared.

RESULTS

Men and women in the lowest BMI quartile had lower total energy intake but higher alcohol energy intake than men in the other BMI quartiles. In multivariate logistic regression analysis, the lowest BMI quartile was associated with total energy (OR: 0.81, p = 0.0310) and alcohol energy intake (OR: 1.22, p = 0.0472) in men. In men, protein, carbohydrate, fat, calcium, iron, and vitamin intakes were less in those that consumed ≥ 280 kcal than in those that consumed < 280 kcal of alcohol per day.

CONCLUSION

Our results demonstrate an association between alcohol energy intake and low BMI in older Japanese individuals.

Associations of all-cause mortality with census-based neighbourhood deprivation and population density in Japan: a multilevel survival analysis

Background

Despite evidence that neighbourhood conditions affect residents' health, no prospective studies of the association between neighbourhood socio-demographic factors and all-cause mortality have been conducted in non-Western societies. Thus, we examined the effects of areal deprivation and population density on all-cause mortality in Japan.

Methods

We employed census and survival data from the Japan Public Health Center-based Prospective Study, Cohort I (n = 37,455), consisting of middle-aged residents (40 to 59 years at the baseline in 1990) living in four public health centre districts. Data spanned between 1990 and 2010. A multilevel parametric proportional-hazard regression model was applied to estimate the hazard ratios (HRs) of all-cause mortality by two census-based areal variables —areal deprivation index and population density—as well as individualistic variables such as socioeconomic status and various risk factors.

Results

We found that areal deprivation and population density had moderate associations with all-cause mortality at the neighbourhood level based on the survival data with 21 years of follow-ups. Even when controlling for individualistic socio-economic status and behavioural factors, the HRs of the two areal factors (using quartile categorical variables) significantly predicted mortality. Further, this analysis indicated an interaction effect of the two factors: areal deprivation prominently affects the health of residents in neighbourhoods with high population density.

Conclusions

We confirmed that neighbourhood socio-demographic factors are significant predictors of all-cause death in Japanese non-metropolitan settings. Although further study is needed to clarify the cause-effect relationship of this association, the present findings suggest that health promotion policies should consider health disparities between neighbourhoods and possibly direct interventions towards reducing mortality in densely populated and highly deprived neighbourhoods.

Healthy life expectancy for 187 countries, 1990-2010: a systematic analysis for the Global Burden Disease Study 2010

BACKGROUND

Healthy life expectancy (HALE) summarises mortality and non-fatal outcomes in a single measure of average population health. It has been used to compare health between countries, or to measure changes over time. These comparisons can inform policy questions that depend on how morbidity changes as mortality decreases. We characterise current HALE and changes over the past two decades in 187 countries.

METHODS

Using inputs from the Global Burden of Disease Study (GBD) 2010, we assessed HALE for 1990 and 2010. We calculated HALE with life table methods, incorporating estimates of average health over each age interval. Inputs from GBD 2010 included age-specific information for mortality rates and prevalence of 1160 sequelae, and disability weights associated with 220 distinct health states relating to these sequelae. We computed estimates of average overall health for each age group, adjusting for comorbidity with a Monte Carlo simulation method to capture how multiple morbidities can combine in an individual. We incorporated these estimates in the life table by the Sullivan method to produce HALE estimates for each population defined by sex, country, and year. We estimated the contributions of changes in child mortality, adult mortality, and disability to overall change in population health between 1990 and 2010.

FINDINGS

In 2010, global male HALE at birth was 58·3 years (uncertainty interval 56·7-59·8) and global female HALE at birth was 61·8 years (60·1-63·4). HALE increased more slowly than did life expectancy over the past 20 years, with each 1-year increase in life expectancy at birth associated with a 0·8-year increase in HALE. Across countries in 2010, male HALE at birth ranged from 27·9 years (17·3-36·5) in Haiti, to 68·8 years (67·0-70·4) in Japan. Female HALE at birth ranged from 37·1 years (26·9-43·7) in Haiti, to 71·7 years (69·7-73·4) in Japan. Between 1990 and 2010, male HALE increased by 5 years or more in 42 countries compared with 37 countries for female HALE, while male HALE decreased in 21 countries and 11 for female HALE. Between countries and over time, life expectancy was strongly and positively related to number of years lost to disability. This relation was consistent between sexes, in cross-sectional and longitudinal analysis, and when assessed at birth, or at age 50 years. Changes in disability had small effects on changes in HALE compared with changes in mortality.

INTERPRETATION

HALE differs substantially between countries. As life expectancy has increased, the number of healthy years lost to disability has also increased in most countries, consistent with the expansion of morbidity hypothesis, which has implications for health planning and health-care expenditure. Compared with substantial progress in reduction of mortality over the past two decades, relatively little progress has been made in reduction of the overall effect of non-fatal disease and injury on population health. HALE is an attractive indicator for monitoring health post-2015.

FUNDING

The Bill & Melinda Gates Foundation.

Associations of household expenditure and marital status with cardiovascular risk factors in Japanese adults: analysis of nationally representative surveys

Background

Socioeconomic inequalities in health and social determinants of health are important issues in public health and health policy. We investigated associations of cardiovascular risk factors with household expenditure (as an indicator of socioeconomic status) and marital status in Japan.

Methods

We combined data from 2 nationally representative surveys—the Comprehensive Survey of Living Conditions and the National Health and Nutrition Survey, 2003–2007—and analyzed sex-specific associations of household expenditure quartiles and marital status with cardiovascular risk factors, including obesity, hypertension, dyslipidemia, and diabetes, among 6326 Japanese adults (2664 men and 3662 women) aged 40 to 64 years.

Results

For men, there was no statistically significant association between household expenditure and cardiovascular risk factors. For women, lower household expenditure was significantly associated with obesity, hypertension, diabetes, and the presence of multiple risk factors: the ORs for the lowest versus the highest quartile ranged from 1.39 to 1.71. In a comparison of married and unmarried participants, the prevalence of cardiovascular risk factors was higher among married women and lower among married men.

Conclusions

Lower socioeconomic status, as indicated by household expenditure, was associated with cardiovascular risk factors in Japanese women. Socioeconomic factors should be considered in health promotion and prevention of cardiovascular disease.

Geographic inequalities in all-cause mortality in Japan: compositional or contextual?

Background

A recent study from Japan suggested that geographic inequalities in all-cause premature adult mortality have increased since 1995 in both sexes even after adjusting for individual age and occupation in 47 prefectures. Such variations can arise from compositional effects as well as contextual effects. In this study, we sought to further examine the emerging geographic inequalities in all-cause mortality, by exploring the relative contribution of composition and context in each prefecture.

Methods

We used the 2005 vital statistics and census data among those aged 25 or older. The total number of decedents was 524,785 men and 455,863 women. We estimated gender-specific two-level logistic regression to model mortality risk as a function of age, occupation, and residence in 47 prefectures. Prefecture-level variance was used as an estimate of geographic inequalities in mortality, and prefectures were ranked by odds ratios (ORs), with the reference being the grand mean of all prefectures (value  = 1).

Results

Overall, the degree of geographic inequalities was more pronounced when we did not account for the composition (i.e., age and occupation) in each prefecture. Even after adjusting for the composition, however, substantial differences remained in mortality risk across prefectures with ORs ranging from 0.870 (Okinawa) to 1.190 (Aomori) for men and from 0.864 (Shimane) to 1.132 (Aichi) for women. In some prefectures (e.g., Aomori), adjustment for composition showed little change in ORs, while we observed substantial attenuation in ORs in other prefectures (e.g., Akita). We also observed qualitative changes in some prefectures (e.g., Tokyo). No clear associations were observed between prefecture-level socioeconomic status variables and the risk of mortality in either sex.

Conclusions

Geographic disparities in mortality across prefectures are quite substantial and cannot be fully explained by differences in population composition. The relative contribution of composition and context to health inequalities considerably vary across prefectures.

Understanding pathways for scaling up health services through the lens of complex adaptive systems

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.

Health inequalities in Rio de Janeiro, Brazil: lower healthy life expectancy in socioeconomically disadvantaged areas

OBJECTIVES

We investigated deprivation and inequalities in life expectancy and healthy life expectancy by location in Rio de Janeiro, Brazil.

METHODS

We conducted a health survey of 576 adults in 2006. Census tracts were stratified by income level and categorization as a slum. We determined health status by degree of functional limitation, according to the approach proposed by the World Health Organization. We calculated healthy life expectancies by Sullivan's method with abridged life table.

RESULTS

We found the worst indicators in the slum stratum. The life expectancy at birth of men living in the richest parts of the city was 12.8 years longer than that of men living in deprived areas. For both men and women older than age 65 years, healthy life expectancy was more than twice as high in the richest sector as in the slum sector.

CONCLUSIONS

Our analysis detailed the excess burden of poor health experienced by disadvantaged populations of Rio de Janeiro. Policy efforts are needed to reduce social inequalities in health in this city, especially among the elderly.

Diferenciais intra-urbanos de vulnerabilidade da população idosa

Foi examinada a adequação de um Índice de Vulnerabilidade à Saúde (IVS) para identificar diferenciais intra-urbanos de vulnerabilidade da população idosa. Os participantes do estudo (n = 1.055) foram selecionados por meio de amostra probabilística de residentes no Município de Belo Horizonte, Minas Gerais, Brasil, com mais de 60 anos de idade (média = 70,1 anos). O IVS é composto por medidas das condições socioeconômicas e por indicadores da mortalidade precoce do setor censitário. Com base no escore do IVS, o local de residência dos participantes foi classificado em estrato de riscos baixo, médio e alto. Os resultados da regressão logística ordinal multivariada mostraram associações graduadas e estatisticamente significantes entre o estrato de risco da área de residência e o ambiente físico e social, condições de saúde, comportamentos em saúde e necessidades de serviços de saúde (razões de prevalência variando entre 1,17; IC95%: 1,02-1,34 e 1,65; IC95%: 1,45-1,88). O IVS parece ser um instrumento útil para a identificação de áreas com maior necessidade de serviços sociais e de saúde entre os idosos.

Regional variations in and correlates of disability-free life expectancy among older adults in China

Background

Considerable socioeconomic and health inequalities have been reported in China. However, because of a lack of appropriate data, limited research has been conducted on variations in disability-free life expectancy (DFLE) among older adults. This study aimed to use the most up-to-date disability survey data to explore geographical variations in DFLE at age 60 in China and to identify the socioeconomic and health care factors that partially account for these variations.

Methods

This study used 2006 mortality data extrapolated from the 1990 and 2000 Census and disability data from a national disability survey conducted in 2006. Disability was performance based and was diagnosed by trained physicians. DFLE was calculated by region using the Sullivan method. Multiple linear regression models by gender were conducted to explore correlates of DFLE.

Results

DFLE at age 60 varied widely by region, from 11.2 to 20.8 years in 2006. Per capita gross domestic product, proportion of urban residents, and access to health care were the primary factors associated with geographical variations in DFLE.

Conclusion

The pattern of differences in DFLE by region mirrors the pattern of regional economic development in China. Countermeasures to decrease regional differences in DFLE include accelerating regional economic development and improving health care distribution.

Interpersonal trust and quality-of-life: a cross-sectional study in Japan

Background

There is growing interest in psychosocial factors with positive attitudes, such as interpersonal trust, as determinants for Quality-of-life (QOL) or subjective well-being. Despite their longevity, Japanese people report a relatively poor subjective well-being, as well as lower interpersonal trust. Our aim in this study was to evaluate the possible association between interpersonal trust and QOL among Japanese people.

Methodology and Principal Findings

Based on the cross-sectional data for Japanese adults (2008), we analyzed the relationship between interpersonal trust and each of four domains of the WHOQOL-BREF. Interpersonal trust was assessed using three scales for trust in people, in human fairness and in human nature. In a total of 1000 participants (mean age: 45 years; 49% women), greater trust was recognized among women (vs. men), those aged 60–69 (vs. 20–29), or the high-income group (vs. low-income). Each of three trust scales was positively correlated with all domains of QOL. Multiple linear-regression models were constructed for each of QOL and the principal component score of the trust scales, adjusted for age, gender, area size of residence, income, education, and occupation. For all QOL domains, interpersonal trust was significantly and positively associated with better QOL with p<0.001 for all four domains including physical, psychological, social, and environmental QOL. Other factors associated with QOL included gender, age class, area size of residence, and income. Education and occupation were not associated with QOL.

Conclusions and Significance

Greater interpersonal trust is strongly associated with a better QOL among Japanese adults. If a causal relationship is demonstrated in a controlled interventional study, social and political measures should be advocated to increase interpersonal trust for achieving better QOL.

Health Promotion for Successful Aging

The rising costs of health and social support systems for an aging population will become unsustainable without proactive steps to create individual and environmental changes that promote successful aging. Unfortunately, many older adults do not currently have a healthy lifestyle and are at risk for poor health outcomes, including chronic illnesses and mortality. The authors review the behavioral and psychosocial correlates of health and well-being, which include resilience, self-efficacy, smoking, physical activity, diet, good sleep, and having a strong social network, and linked them to the concept of successful aging. They discuss the unique challenges of maintaining health behaviors among older adults over time and review 3 of the most common approaches to lifestyle intervention in older adults (ie, social cognitive theory, the transtheoretical model, and social ecological models). They conclude that initiation and maintenance of behaviors require perceptions of control (self-efficacy), a belief in the positive health outcomes for performing these behaviors, and a value for the outcome (outcome expectancy) for successful aging to be realized. Moreover, more research is needed that takes a broader ecological perspective that makes use of multilevel strategies to behavior change in older adults.

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.

Regional differences in multidimensional aspects of health: findings from the MRC cognitive function and ageing study

BACKGROUND

Differences in mortality and health experience across regions are well recognised and UK government policy aims to address this inequality. Methods combining life expectancy and health have concentrated on specific areas, such as self-perceived health and dementia. Few have looked within country or across different areas of health. Self-perceived health, self-perceived functional impairment and cognitive impairment are linked closely to survival, as well as quality of life. This paper aims to describe regional differences in healthy life expectancy using a variety of states of health and wellbeing within the MRC Cognitive Function and Ageing Study (MRC CFAS).

METHODS

MRC CFAS is a population based study of health in 13,009 individuals aged 65 years and above in five centres using identical study methodology. The interviews included self-perceived health and measures of functional and cognitive impairment. Sullivan's method was used to combine prevalence rates for cognitive and functional impairment and life expectancy to produce expectation of life in various health states.

RESULTS

The prevalence of both cognitive and functional impairment increases with age and was higher in women than men, with marked centre variation in functional impairment (Newcastle and Gwynedd highest impairment). Newcastle had the shortest life expectancy of all the sites, Cambridgeshire and Oxford the longest. Centre differences in self-perceived health tended to mimic differences in life expectancy but this did not hold for cognitive or functional impairment.

CONCLUSION

Self-perceived health does not show marked variation with age or sex, but does across centre even after adjustment for impairment burden. There is considerable centre variation in self-reported functional impairment but not cognitive impairment. Only variation in self-perceived health relates to the ranking of life expectancy. These data confirm that quite considerable differences in life experience exist across regions of the UK beyond basic life expectancy.