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Background Engagement in leisure activities among older people is associated with a lower risk of mortality. However, no studies have been conducted focusing on the difference of associations with mortality risk among multiple types of leisure activities. Methods We examined prospectively the association of engagement in leisure activities with all-cause mortality in a cohort of older Japanese adults. The Japan Gerontological Evaluation Study included 48,216 participants aged 65 years or older. During a mean follow-up period of 5.6 years, we observed 5,575 deaths (11.6%). We investigated the total number of leisure activities, as well as combinations of 25 different leisure activities with Cox proportional hazards models, adjusting for potential confounding factors. Results We found a linear relationship between the total number of leisure activities and mortality hazard (adjusted hazard ratio 0.93; 95% CI, 0.92-0.95). Furthermore, engagement in leisure activities involving physical activity, as well as group-based interactions, showed the strongest associations with lowered mortality. By contrast, engagement in cultural leisure activities and solitary leisure activities were not associated with all-cause mortality. Conclusions Although we cannot rule out residual confounding, our findings suggest that encouraging engagement in physically-active group-based leisure activities may promote longevity in older adults.

Background In 2012, the Korean National Health Insurance extended its coverage to include denture services for older adults. We examined whether the new policy resulted in improved chewing ability in the eligible population. Method We used interrupted time-series (ITS) analysis, a quasi-experimental design, to analyze the effect of the policy. We used data from the Korea National Health and Nutrition Examination Survey conducted from 2007 to 2016-2018. The study population consisted of two groups: the treatment group, aged 65 years or older and eligible for the dental insurance benefit; and the control group, those younger than 65 years and ineligible. The main evaluated outcome was self-reported chewing difficulty. Results The ITS analysis showed that chewing difficulty decreased annually by 0.93% (95% CI -1.30 to -0.55) and 0.38% (95% CI -0.59 to -0.16) after the policy extension in the older than 65 and younger than 65 groups, respectively. However, we could not conclude that the insurance extension affected chewing difficulty because there was a decrease in the control group as well. Conclusions Chewing ability improved in both older and younger adults regardless of dental insurance coverage for older adults. Other exogenous factors probably led to the improvements in chewing ability as well as dental insurance benefits.

Background: In 2009, the South Korean government expanded universal health insurance to include oral health services. In the present study, we sought to examine whether improved access resulted in a reduction in income-based self-reported oral health inequalities. Methods: We analyzed repeated cross-sectional data from the Korea National Health and Nutrition Examination Survey (KNHANES) waves IV through VI (2007–2015). We analyzed self-reported oral health status among 68,431 subjects. Changes in oral health inequalities across four income levels (low, middle-low, middle-high, and high) were assessed with the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). Results: The average oral health status of children and adolescents improved the most over the observation period. The absolute magnitude of oral health inequalities (measured by the SII) improved for most groups, with the notable exception of young male adults. By contrast, the ratio of poor oral health between high- and low-income groups (measured by the RII) changed little over time, indicating that relative inequalities remained resistant to change. Conclusions: The expansion of dental health insurance may not be sufficient to move the needle on self-reported oral health inequalities among adults.

Background Socioeconomic mobility affects health throughout the life course. However, it is not known whether there are gender differences in the association between life-course subjective socioeconomic status (SSS) mobility and mortality at older ages. Methods Participants were 16,690 community-dwelling adults aged 65-100 years in the Japan Gerontological Evaluation Study (JAGES). Baseline information including demographic characteristics, depression, and lifestyle factors were collected in 2010. Participants' vital status was confirmed in 2013 via linkage to death records. We categorized life-course socioeconomic mobility into the following categories: 'persistently high', 'downward mobility', 'upward mobility', and 'persistently low'. Cox proportional hazard modeling was used to estimate hazard ratios (HR) for all-cause mortality. Results Mortality HRs for the 'downward' group were 1.37 (95% confidence interval [CI], 1.08-1.74) among men and 1.27 (95% CI, 0.94-1.71) among women in comparison with the 'persistently high' group. Compared to the 'persistently low' group, the HRs for the 'upward' group were 0.54 (95% CI, 0.35-0.83) among women and 0.91 (95% CI, 0.73-1.24) among men. Associations were not changed after adjusting for objective socioeconomic status but were attenuated by depression. Conclusions 'Downward' mobility was associated with mortality among men, but not among women. Depression appeared to mediate the association. A protective effect of upward mobility was observed among women but not among men.

BACKGROUND In 2012, the Korean government expanded dental insurance for the elderly to promote improved access to dental care. We examined the causal effect of this policy on dental care needs, focusing on low-income older adults. METHODS We compared data before and after policy implementation using double difference (DD) and triple difference (DDD) analyses. We used the nationally representative data from the Korea National Health and Nutrition Examination Survey from 2010 and 2016-2018. Individuals aged ≥65 years were included in the treatment group, and individuals aged

Background: Previous studies have identified poor dietary intake as a health risk affecting survivors of the 2011 Great East Japan Earthquake and Tsunami. We examined the association between different social factors (eg, living conditions and perceptions of community social capital) and dietary intakes among disaster-affected survivors. Methods: We studied 6,724 survivors in four municipalities of Iwate Prefecture 3 years after the disaster. Social capital was assessed via four items inquiring about respondents’ perceptions of social cohesion in their communities. Good dietary intake was defined according to the following criteria: intake of staple food ≥three times a day; intake of meat, fish and shellfish eggs, or soybean products ≥twice a day; vegetable intake ≥twice a day; and intake of fruit or dairy products ≥once a day. An individual who did not meet any of these criteria was defined as having poor dietary intake. We adjusted for covariates, including socioeconomic status, marital status, and residential area. Results: Poor dietary intake was reported by 31.6% of respondents. Poisson regression analyses revealed that the following factors were related to poor dietary intake: age

Background: Active engagement in intellectually enriching activities reportedly lowers the risk of cognitive decline; however, few studies have examined this association, including engagement in traditional cultural activities. This study aimed to elucidate the types of cultural engagement associated with lower risk of cognitive impairment. Methods: We examined the association between cultural engagement and cognitive impairment using Cox proportional hazards models in a cohort of 44,985 participants (20,772 males and 24,213 females) aged 65 years or older of the Japan Gerontological Evaluation Study from 2010 to 2016. Intellectual activities (eg, reading books, magazines, and/or newspapers), creative activities (eg, crafts and painting), and traditional cultural activities (eg, poetry composition [haiku], calligraphy, and tea ceremony/flower arrangement) were included among cultural engagement activities. Results: Over a follow-up period of 6 years, incident cognitive disability was observed in 4,198 respondents (9.3%). After adjusting for potential confounders, such as depression and social support, intellectual activities were protectively associated with the risk of cognitive impairment (hazard ratio [HR] for those who read and stated that reading was their hobby, 0.75; 95% confidence interval [CI] 0.66–0.85 and HR for those who read but did not consider reading a hobby, 0.72; 95% CI, 0.65–0.80). Engagement in creative activities was also significantly correlated with lower risk of cognitive impairment (crafts: HR 0.71; 95% CI, 0.62–0.81 and painting: HR 0.80; 95% CI, 0.66–0.96). The association between traditional cultural activities and the risk of cognitive impairment was not statistically significant. Conclusions: Engagement in intellectual and creative activities may be associated with reduced risk of dementia.

Background: There is little longitudinal evidence on the impact of specific living arrangements (ie, who individuals live with) on mental health among older adults, and no studies have examined the modifying effect of residential social cohesion level on this association. We aimed to examine the association between living arrangements and depressive symptoms and whether this association varies with residential neighborhood social cohesion level among 19,656 men and 22,513 women aged 65 years and older in Japan. Methods: We analyzed the association between baseline living arrangements in 2010 and depressive symptoms in 2013. We calculated gender-specific odds ratios (ORs) of living arrangements for depressive symptoms using a logistic regression and conducted subgroup analyses by neighborhood social cohesion level. Results: Among men (but not women), living alone (OR 1.43; 95% confidence intervals [CI], 1.18–1.73) and living with spouse and parent (OR 1.47, 95% CI, 1.09–1.98) were associated with increased odds of depressive symptoms compared with living with a spouse only. Living with spouse and child was a risk for men in the young age group but a protective factor for women. We also identified that the negative impact of living arrangements on depressive symptoms was attenuated in neighborhoods with higher levels of social cohesion. Conclusions: Living arrangements are associated with risk of depressive symptoms among men and women; these associations differ by gender and neighborhood social cohesion level. Our results suggest the need to pay more attention to whether individuals live alone, as well as who individuals live with, to prevent depressive symptoms among older adults.

Background Previous studies suggest that neighborhood social capital is associated with children's mental health. The purpose of this study was to examine the association between neighborhood collective efficacy and children's psychosocial development. Methods We used data on children and their parents (n = 918) who were part of the Japanese study of Stratification, Health, Income, and Neighborhood (JSHINE) from 2010 to 2013 (wave 1 and wave 2). Households were recruited from the Tokyo metropolitan area through clustered random sampling. Changes in children's psychosocial development (assessed using a child behavioral checklist) between waves 1 and 2 were regressed on parents' perceptions of changes in neighborhood collective efficacy (social cohesion and informal social control). Results Change in perception of neighborhood social cohesion was inversely associated with change in child total problems (β = −0.22; 95% confidence interval [CI]: −0.37 to −0.001; effect size d = −0.03). Change in perceptions of neighborhood informal social control was inversely associated with change in children's externalizing problems (β = −0.16; 95% CI: −0.30 to −0.03; d = −0.02). Conclusions The results of these fixed-effects models suggest that strengthening neighborhood collective efficacy is related to improvements in child psychosocial development., Highlights • The fixed-effects model can control for time-invariant confounding factors. • Neighborhood social cohesion was inversely associated with child total problems. • Neighborhood informal social control was inversely associated with child problems. • Neighborhood collective efficacy prevents child psychosocial problems.

Background: We sought to evaluate the associations between frequency of daily laughter with heart disease and stroke among community-dwelling older Japanese women and men. Methods: We analyzed cross-sectional data in 20 934 individuals (10 206 men and 10 728 women) aged 65 years or older, who participated in the Japan Gerontological Evaluation Study in 2013. In the mail-in survey, participants provided information on daily frequency of laughter, as well as body mass index, demographic and lifestyle factors, and diagnoses of cardiovascular disease, hyperlipidemia, hypertension, and depression. Results: Even after adjustment for hyperlipidemia, hypertension, depression, body mass index, and other risk factors, the prevalence of heart diseases among those who never or almost never laughed was 1.21 (95% CI, −1.03–1.41) times higher than those who reported laughing every day. The adjusted prevalence ratio for stroke was 1.60 (95% CI, 1.24–2.06). Conclusions: Daily frequency of laughter is associated with lower prevalence of cardiovascular diseases. The association could not be explained by confounding factors, such as depressive symptoms.

Background In industrialized countries, assessment of the causal effect of physician supply on population health has yielded mixed results. Since the scope of child vaccination is an indicator of preventive health service utilization, this study investigates the correlation between vaccination coverage and pediatrician supply as a reflection of overall pediatric health during a time of increasing pediatrician numbers in Japan. Methods Cross-sectional data were collected from publicly available sources for 2010. Dependent variables were vaccination coverage for measles and diphtheria, pertussis, and tetanus (DPT) by region. The primary predictor of interest was number of pediatricians per 10 000-child population (pediatrician density) at the municipality level. Multivariate logistic regression models were used to estimate associations of interest, conditional on a large range of demographic and infrastructure-related factors as covariates, including non-pediatric physician density, total population, per capita income, occupation, unemployment rate, prevalence of single motherhood, number of hospital beds per capita, length of roads, crime rate, accident rate, and metropolitan area code as urban/rural status. The percentage of the population who completed college-level education or higher in 2010 was included in the model as a proxy for education level. Results Pediatrician density was positively and significantly associated with vaccination coverage for both vaccine series. On average, each unit of pediatrician density increased odds by 1.012 for measles (95% confidence interval, 1.010–1.015) and 1.019 for DPT (95% confidence interval, 1.016–1.022). Conclusions Policies increasing pediatrician supply contribute to improved preventive healthcare services utilization, such as immunizations, and presumably improved child health status in Japan.

Objectives: To explore determinants of change in pediatrician supply in Japan, and examine impacts of a 2004 reform of postgraduate medical education on pediatricians’ practice location choice. Methods: Data were compiled from secondary data sources. The dependent variable was the change in the number of pediatricians at the municipality (“secondary tier of medical care” [STM]) level. To analyze the determinants of pediatrician location choices, we considered the following predictors: initial ratio of pediatricians per 1000 children under five years of age (pediatrician density) and under-5 mortality as measures of local area need, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004. Basic comparisons of pediatrician coverage in the top and bottom 10% of STMs were conducted to assess inequality in pediatrician supply. Results: Increased supply was inversely associated with baseline pediatrician density both in the pre-period and post-period. Estimated impact of pediatrician density declined over time (P = 0.026), while opposite trends were observed for measures of residential quality. More specifically, urban centers and the SES composite index were positively associated with pediatrician supply for the post-period, but no such associations were found for the preperiod. Inequality in pediatrician distribution increased substantially after the reform, with the best-served 10% of communities benefitting from five times the pediatrician coverage compared to the least-served 10%. Conclusions: Residential quality increasingly became a function of location preference rather than public health needs after the reform. New placement schemes should be developed to achieve more equity in access to pediatric care.

Background: This article presents an overview of the concept of social capital, reviews prospective multilevel analytic studies of the association between social capital and health, and discusses intervention strategies that enhance social capital. Methods: We conducted a systematic search of published peer-reviewed literature on the PubMed database and categorized studies according to health outcome. Results: We identified 13 articles that satisfied the inclusion criteria for the review. In general, both individual social capital and area/workplace social capital had positive effects on health outcomes, regardless of study design, setting, follow-up period, or type of health outcome. Prospective studies that used a multilevel approach were mainly conducted in Western countries. Although we identified some cross-sectional multilevel studies that were conducted in Asian countries, including Japan, no prospective studies have been conducted in Asia. Conclusions: Prospective evidence from multilevel analytic studies of the effect of social capital on health is very limited at present. If epidemiologic findings on the association between social capital and health are to be put to practical use, we must gather additional evidence and explore the feasibility of interventions that build social capital as a means of promoting health.

Background We developed and validated an instrument to measure community-level social capital based on data derived from older community dwellers in Japan. Methods We used cross-sectional data from the Japan Gerontological Evaluation Study, a nationwide survey involving 123,760 functionally independent older people nested within 702 communities (i.e., school districts). We conducted exploratory and confirmatory factor analyses on survey items to determine the items in a multi-dimensional scale to measure community social capital. Internal consistency was checked with Cronbach's alpha. Convergent construct validity was assessed via correlating the scale with health outcomes. Results From 53 candidate variables, 11 community-level variables were extracted: participation in volunteer groups, sports groups, hobby activities, study or cultural groups, and activities for teaching specific skills; trust, norms of reciprocity, and attachment to one's community; received emotional support; provided emotional support; and received instrumental support. Using factor analysis, these variables were determined to belong to three sub-scales: civic participation (eigenvalue = 3.317, α = 0.797), social cohesion (eigenvalue = 2.633, α = 0.853), and reciprocity (eigenvalue = 1.424, α = 0.732). Confirmatory factor analysis indicated the goodness of fit of this model. Multilevel Poisson regression analysis revealed that civic participation score was robustly associated with individual subjective health (Self-Rated Health: prevalence ratio [PR] 0.96; 95% confidence interval [CI], 0.94–0.98; Geriatric Depression Scale [GDS]: PR 0.95; 95% CI, 0.93–0.97). Reciprocity score was also associated with individual GDS (PR 0.98; 95% CI, 0.96–1.00). Social cohesion score was not consistently associated with individual health indicators. Conclusions Our scale for measuring social capital at the community level might be useful for future studies of older community dwellers., Highlights • Most study failed to capture multiple dimensions of community-level social capital. • We developed and validated 11-item health related community social capital scale. • The scale assessed civic participation, social cohesion, and reciprocity.

Background: The longevity of Japanese is thought to be associated with psychosocial factors such as sense of coherence, social support, and social capital. However, the actual factors responsible and the extent of their contribution to individual health status are not known. Methods: The Aichi Gerontological Evaluation Study (AGES) 2003 Cohort Study is a prospective cohort study of community-dwelling, activities of daily living-independent people aged 65 or older living in 6 municipalities in Chita peninsula, Aichi Prefecture, Japan. Information on psychosocial factors and other individual- and community-level factors was collected in the second half of 2003 using a baseline questionnaire. Vital status and physical and cognitive decline have been followed using data derived from long-term care insurance certification. Geographical information on the study participants was also obtained. Results: A total of 13310 (6508 men; 6802 women) study participants were registered in the study. For an interim report, we followed the cohort for 48 months, yielding 24753 person-years of observation among men and 26456 person-years among women. Conclusions: The AGES 2003 Cohort Study provides useful evidence for research in social epidemiology, gerontology, and health services.