TTHE INHE IN THE INTEERNARNA ERNATTIITIOONAL …mental.m.u-tokyo.ac.jp/sdh/pdf/abstractbook.pdf ·...

2011

THE INTERNATIONAL CONFERENCE ON SOCIAL

STRATIFICATION AND HEALTH

THE INTERNATIONAL THE INTERNATIONAL CONFERENCE ON SOCIAL CONFERENCE ON SOCIAL

STRATIFICATION AND HEALTH STRATIFICATION AND HEALTH

Social Strati fi cati on and Health: Looking into the Future Research Agenda

August 6 & 7, 2011 Tokyo, Japan

Published by:

Th e Grant-in-Aid for Scientifi c Research on Innovative Areas from the Ministry of Education, Science, Sports and Culture, Japan “Elucidation of social stratifi cation mechanism and control over health inequality in contemporary Japan: New interdisciplinary area of social and health sciences” (Th e Project “Social Stratifi cation and Health”)

C/O Department of Mental Health, Graduate School of Medicine, Th e University of Tokyo 7‒3‒1 Hongo, Bunkyo-ku, Tokyo 113‒0033 JapanTel: +81‒3‒5841‒3364 Fax: +81‒3‒5841‒3392

Printed by:

Edo Create Co.,Ltd.Sansyo Building, 3F3‒40‒10 Hongo, Bunkyo-ku, Tokyo 113‒0033 JapanTel: +81‒3‒3814‒1225 Fax: +81‒3‒3814‒3215

Copyright © 2011 by the Project “Social Stratifi cation and Health.” All rights reserved.

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WelcomeTh e International Conference on Social Stratifi cation and Health 2011

O n behalf of the organizing committee, I would like to express my warm welcome for everyone to

the International Conference on Social Stratifi cation and Health 2011 (ICSSH2011) in Tokyo, Japan, on 6–7 August 2011. Th e conference was organized by the research project “Elucidation of social stratifi cation mechanism and control over health inequality in con-temporary Japan: New interdisciplinary area of social and health sciences” (abbreviated as the Project “Social Stratifi cation and Health”), a fi ve-year interdisciplinary research project (2009–2013) funded by the Grant-in-Aid for Scientifi c Research on Innovative Areas from the Ministry of Education, Science, Sports, and Culture, Japan. Th is interdisciplinary project aims to develop and expand research to elucidate mechanisms underlying the social disparity in health and establishment of measures to control over it. Also it intends to form a new inter-disciplinary academic fi eld integrating social sciences (sociology, psychology & behavioral science, economics, political science, etc.) and health sciences (public health, health science, brain sciences, etc.).

Th is particular international conference is planned as a milestone in the middle of the research project, to review the current achievement of the project, as well as state-of-the-art research in this area, and to clarify the priorities in future research in the fi eld of social dispar-ity in health and, more generally, social determinants of health. Refl ecting rising social concerns on the social disparity in health, extensive research has been done in the last two or three decades to develop relevant theories

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and accumulate evidence in this fi eld. Th e current project is also producing outcomes replicating and expanding past fi ndings. However, much work still remains to be done, e.g., to understand bio-psycho-social pathways from social disparities and other social determinants to health and also to establish a strategy to control the impact of these factors. New perspectives in theories, con-cepts, and methodology of research in this fi eld might be needed. Th ree keynote lectures by invited international speakers, eight symposia, and a workshop are planned to address these issues. Th e fi nal goal of the conference is to set up a future research agenda for social disparity in health and social determinants of health within the next decade.

Th e other focus of the conference is to connect researchers and develop a network for the future research. Researchers from many diff erent fi elds, such as pubic health, sociology, economics, and psychology, and from diff erent countries are encouraged to interact and discuss an opportunity for the future collaboration. Also an interaction among established researches and researchers in their early career and graduate students is also strongly encouraged, e.g., at poster sessions to help these younger generations to commit more to this fi eld and develop their careers in this fi eld.

I sincerely do hope that the conference will contribute to establishing out priorities and developing international and intergenerational research networks in this fi eld.

Norito Kawakami, MD, DMScHead Investigator of the Project “Social Stratifi cation and Health”

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Organizing Committee

Norito KawakamiAkihito Shimazu

Shizuko YanagisawaKazuo Katase Naoki KondoMaki UmedaChie Kaneto

Hideki HashimotoTakashi Oshio

Yasuki KobayashiYasuko NakanishiHaruhiko InadaKeiko Nikami

• • •

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Contents

Conference Informati on 6

Access Guide 8

Floor Guide 9

Conference Schedule 10

Program 11

Workshop Guide 15

Abstracts 17

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CONFERENCE INFORMATION

General Informati on:Dates: August 6 (Sat) & 7 (Sun), 2011Venue: Tetsumon Memorial Hall (14th Floor) and Seminar Rooms 5 & 6 (13th Floor),

Faculty of Medicine Experimental Research Building (医学部教育研究棟 ), Hongo Campus, The University of Tokyo

Registrati on Fee: NoneOffi cial Language: English

Policies:• Pre-registrati on is required to att end the conference.• Smoking, eati ng and drinking are prohibited at the venue.• Cellular phones must be turned off or put in silent mode during sessions.• Stairs, not elevators, must be used in case of earthquake.

Recepti on Desk:• The recepti on desk is open at 8:30 on both days.• The desk is located in front of Tetsumon Memorial Hall on the 14th Floor.• An abstract book and a name tag (with voti ng cards for Poster Award) will be

provided upon check-in.• Banquet fee needs to be paid upon check-in on August 6. On-site registrati ons for the

banquet are also welcomed.

Banquet fee for the Project members: 6,000 yenBanquet fee for the Young members & related researchers: 5,000 yen

Banquet:• The banquet is held on August 6 (starti ng at 18:30) at Capo PELLICANO, an Italian

restaurant located on the 13th Floor of the same building.

Coff ee Break• During Poster Sessions, drinks are served on the 13.5th Floor.

Lunch Break• A “Where to Eat” map showing nearby restaurants, cafes and convenience stores will

be provided at the recepti on desk.

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Informati on for Chairs and Speakers• All chairs and speakers are asked to check in at the “Chair & Speaker Check-in” desk in

Seminar Room 8 on the 13th Floor at least one hour before their scheduled sessions, except for Keynote Lectures 1 & 3 (30 minutes before the sessions).

• Aft er check-in, speakers are asked to preview their presentati on data at the PC Center in Seminar Room 8. Morning session speakers are encouraged to register their presentati on data by the day before the session.

• Presentati on data need to be prepared using Microsoft PowerPoint 2003/2007 and saved as “<Presentati on number> <Speaker’s name>” (e.g., “1–5 Yamada”) in a blank USB memory sti ck. All presentati on fi les will be deleted at the end of the conference unless permission has been granted.

• Chairs and speakers are allowed to have pre-session meeti ngs in Seminar Room 8.• Chairs and speakers are expected to be seated in the “Next Chair” or “Next Speaker”

seat at least fi ve minutes before their scheduled sessions.• During presentati ons, speakers themselves are responsible for operati ng a PC.• In all sessions, chairs are responsible for ti me keeping.

Informati on for Poster Presenters• Poster presenters of the day are asked to put up their posters by 9:00 in the Elevator

Hall on the 14th Floor. Posti ng magnets will be provided at the site.• A poster board (180 cm × 90 cm) with a poster number (20 cm × 20 cm) at the top

left corner will be allocated to each presentation. Presenters are responsible for preparing a poster and a title banner (20 cm × 70 cm) including the name(s) and affiliation(s) of author(s).

• During Poster Sessions, presenters are expected to be available to discuss their posters with conference att endees.

• Presenters are required to remove their own posters by 17:00 each day.

Poster Award• Every conference att endee will be provided with two voti ng cards. Each day,

att endees can vote for their favorite poster of the day.• A ballot box will be placed in the Elevator Hall on the 14th Floor unti l 17:00 on the

fi rst day (August 6) and unti l 16:00 on the second day (August 7).• In the Closing ceremony, the “Best Poster Award” will be given to two poster

presenters who receive the largest number of votes.

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ACCESS GUIDE

Nearest Stati ons

Hongo-sanchome 8 minutes walk(Subway Marunouchi Line)

Hongo-sanchome 6 minutes walk(Subway Oedo Line)

From Haneda Airport to the University

Airport → Hamamatsu-cho 22 minutes(Tokyo Monorail)

Hamamatsu-cho → Tokyo 8 minutes(JR Yamanote Line)

Tokyo → Hongo-sanchome 8 minutes(Subway Marunouchi Line)

From Narita Airport to Central Tokyo

Airport → Tokyo 1 hour(JR Narita Express)orAirport → Keisei-Ueno 45 minutes(Keisei Skyliner)orAirport → Various desti nati ons(Airport Limousine)

Marunouchi Line

Oedo Line

Sobu Line

Chuo Line

Yamanote Line

Keihin-Tohoku Line

Namboku Line

Chiyoda Line

Keisei-Ueno Stati on

Hongo-sanchome(Marunouchi Line)

Hongo-sanchome

(Oedo Line)

Exit 5

Exit 2

Faculty of Medicine Experimental

Research Building

Campus Map

Exit 4

Kaitoku Gate

The University of Tokyo7–3–1 Hongo, Bunkyo-ku, Tokyo 113–0033 Japan

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FLOOR GUIDE

13th Floor

14th Floor

Capo PELLICANO Seminar Room 6

Seminar Room 5

Seminar Room

8

Seminar Room

7

WC WCEV EV

EV EV

EV EV

EV EVWC

WC

WC

Elevator Hall

Tetsumon Memorial Hall

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CONFERENCE SCHEDULE

Testumon Memorial Hall(14th Floor)

Seminar Room 5(13th Floor)

Seminar Room 6(13th Floor)

Elevator Hall(14th Floor)

Saturday, August 6

09:00–09:15 Opening

09:15–10:15 Keynote Lecture 1

10:15–10:45 Poster Session A

10:45–12:15 Symposium 1

12:15–13:45 Lunch Break


14:45–16:45 Symposium 2

17:00–18:30 Workshop

18:30– Banquet (Capo PELLICANO)

Sunday, August 7


10:00–10:30 Poster Session B

10:30–12:00 Symposium 3 Symposium 4 Symposium 5

12:00–13:30 Lunch Break

13:30–15:00 Symposium 6 Symposium 7 Symposium 8

15:15–17:00 Overall Discussion

17:00– Closing

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PROGRAM (Saturday, August 6)

OpeningTetsumon Memorial Hall (14th Floor)

Keynote Lecture 1 – Professor Ichiro KawachiChair: Professor Takashi Oshio

Tetsumon Memorial Hall (14th Floor)

Lessons Learned from Cross-National Research on Health Inequalities

Poster Session AElevator Hall (14th Floor)Drinks are served on the 13.5th Floor.

Symposium 1 – Chair: Professor Norito Kawakami


Social Stratifi cation, Social Class and Health: Evidence from Japan

Lunch Break

Keynote Lecture 2 – Professor Ana V. Diez-RouxChair: Professor Hideki Hashimoto


Old and New Challenges in Understanding the Social Determinants of Health

09:00–09:15

09:15–10:15

10:15–10:45

10:45–12:15

12:15–13:45

13:45–14:45

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PROGRAM (Saturday, August 6) Conti nued

Symposium 2 – Chair: Professor Hideki Hashimoto


Socioeconomic Position and Health: Preliminary Findings from the Japanese Study of Stratifi cation, Health, Income, and Neighborhood (J-SHINE)

WorkshopSeminar Rooms 5 & 6 (13th Floor)

What is the Future Research Agenda for Social Determinants of Health?

BanquetCapo PELLICANO (13th Floor)

17:00–18:30

18:30–

14:45–16:45

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PROGRAM (Sunday, August 7)

Keynote Lecture 3 – Professor Tung-liang ChiangChair: Professor Yasuki Kobayashi


Th e Rise, Fall and Re-emergence of Social Paradigm in Public Health

Poster Session BElevator Hall (14th Floor)Drinks are served on the 13.5th Floor.



Education and Training to Address Social Determinants of Health

Symposium 4 – Chair: Professor Hidehiro Sugisawa

Seminar Room 5 (13th Floor)

Social Capital and Health

Symposium 5 – Chair: Dr. Takeo Fujiwara


Early Life Experience and the Life Course Approach

Lunch Break

09:00–10:00

10:00–10:30

10:30–12:00

12:00–13:30

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Symposium 6 – Chair: Professor Hideki Ohira


Biological and Behavioral Mechanisms Underlying Association between Socioeconomic Status and Health

Symposium 7 – Chair: Professor Akizumi Tsutsumi


Cross-Cultural Methodology of Research on Social Determinants of Health

Symposium 8 – Chair: Dr. Naoki Kondo


Social Determinants of Health: Intervention and Policy

Overall DiscussionTetsumon Memorial Hall (14th Floor)

1. Symposium Summary Reports2. Summary Discussion of the Future Research Agenda3. Comments from Foreign Guests

ClosingTetsumon Memorial Hall (14th Floor)

13:30–15:00

15:15–17:00

17:00–

PROGRAM (Sunday, August 7) Conti nued

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WORKSHOP GUIDE

Aims:This workshop aims to clarify the future research agenda(s) concerning social inequity in health and social determinants of health, based on a small group discussion and brainstorming among parti cipants.

Groups:1) Three groups will be formed.2) Principal investi gators and co-investi gators of the Project “Social Strati fi cati on and

Health” may choose one of the three topics and parti cipate in a relevant group for the discussion.

3) Guest researchers outside Japan will be assigned to one of the three groups by the workshop coordinator.

4) Other parti cipants may parti cipate in a group(s) as an observer, if they wish.

Topics for Discussion:The following topics are assigned to each group as a theme of discussion:

Group A: Inter-disciplinary communicati onGroup B: Bridging research and practi ceGroup C: New research horizon

Each group is asked to discuss a given topic for 60 minutes and to summary a list of 5–10 agendas for future research and other acti viti es related to the topic.

Rooms:All parti cipants will fi rst gather in Seminar Room 6. A room assigned to each group will be announced. Each room will be given blank papers, pens, a PC and an assistant.

Schedule:August 6 (Sat)

17:00–17:10 Choose a group and move to a room17:10–18:10 Select a moderator and a reporter for each group, and start

discussion.18:10–18:30 Stop the discussion and prepare a PowerPoint slide for

presentati on.

August 7 (Sun)

15:15–17:00 In the Overall Discussion session, a reporter from each group will present a summary of the discussion to parti cipants, followed by questi ons and comments, to develop the overall future research agenda.

What is the Future Research Agenda for Social Determinants of Health?17:00–18:30, August 6 (Sat)

Seminar Rooms 5 & 6 (13th Floor)

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AbstractsKeynote Lectures 19

Symposia 25

Poster Sessions 63

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KEYNOTELECTURES

Keynote Lecture 1 – Professor Ichiro KawachiChair: Professor Takashi Oshio

09:15–10:15, August 6 (Sat)Tetsumon Memorial Hall (14th Floor)

Lessons Learned from Cross-National Research on Health Inequalities

Keynote Lecture 2 – Professor Ana V. Diez-RouxChair: Professor Hideki Hashimoto


Old and New Challenges in Understanding the Social Determinants of Health

Keynote Lecture 3 – Professor Tung-liang ChiangChair: Professor Yasuki Kobayashi

09:00–10:00, August 7 (Sun)Tetsumon Memorial Hall (14th Floor)

Paradigm Shift in Public Health: Re-emerging of Social Determinants

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Keynote Lecture 1Lessons Learned from Cross-Nati onal Research on Health Inequaliti es

Ichiro Kawachi, MD, PhDHarvard School of Public Health

T he 2008 asset bubble collapse in the United States has prompted comparisons with the Japanese asset

bubble collapse of the 1990s. In several respects, the two economic crises share similarities. Both countries experienced a banking crisis accompanied by a sharp rise in unemployment. In both countries, the government attempted to engage in a massive economic stimulus program, but with relatively little impact on consumer spending or confi dence. In the case of Japan, the asset bubble collapse was followed by a prolonged period of economic stagnation, now being referred to as “the Lost Two Decades.” In the United States, unemployment remains close to 10 percent three years after the onset of the recession. However, the parallels between the two countries stop there. In many respects, the Japanese were better prepared to weather the economic storm owing to their system of safety nets. Th us, access to health insur-ance in Japan is not tied to employment as it is in America for working-aged adults. Th e Japanese had a high rate of consumer saving prior to their economic crisis, in contrast to Americans who had zero (or negative) savings and which turned positive only after the crisis, thereby exacerbating the recession. In America even before the 2008 crisis, income inequality had already reached levels exceeding those last witnessed during the 1920s, whereas income inequality increased in Japan in the two decades after the bubble collapse.

In this presentation, I will focus on some of the lessons learned from cross-national comparative research con-trasting Japan and the USA on the costs and consequences of these broad economic trends from a population health perspective. My starting point is the research of Harvard sociology professor, Mary Brinton, whose work, “Lost in Transition. Youth, Education, and Work in Postindustrial Japan” (translated into Japanese as “失われた場を探して：ロストジェネレーションの社会学,” October 2010) contends that the Japanese pattern of unemployment following economic recession displayed a pattern that is in marked contrast to the United States. During tough economic times, U.S. workers across diff erent ages are equally aff ected in terms of job loss. By contrast, Japanese employers have sought

to protect the job security of existing employees by either not hiring new recruits (school leavers), or hiring new employees only as temporary or contingent workers. Th e result has been a sharp rise in unemployment rates among school leavers in Japan, as well as a sharp increase in the number of non-standard workers. Largely unremarked in the west, these trends have spelled the end of Japan’s vaunted post-War system of the “lifetime employment guarantee” (shuushin koyou). Th e social contract has been broken.

As I will argue in my presentation, the two trends (high youth unemployment and the rising ranks of non-standard workers) pose daunting challenges for the future health security of Japan. High youth unemployment rates have been accompanied by rising numbers of “freeters” (people engaged in occasional freelance work, without a prospect for a long-term career) and “parasite singles” (people living at home into their 30s, relying on their parents’ pensions). In turn, truncated job prospects for youth have contributed to declining marriage rates in Japan, and by extension, the below-replacement fertility rates. Th e declining birth rate, combined with popula-tion aging, presents a looming challenge for the future long-term care of aging individuals in Japan.

I will present recent research from Japan exploring the consequences of long-term elder care in Japan. Our fi nd-ings indicate that the burden of long-term care exhibits a gendered pattern. According to analyses of the JPHC cohort study, Japanese working women living in mul-tigenerational households are at twice to three-times the risk of subsequent coronary heart disease (CHD) compared to women living with just their spouses (Ikeda et al., 2009). By contrast, Japanese males living in multi-generational household do not exhibit any excess of CHD risk. When we turn to the experience of care recipients, we fi nd that Japanese elders receiving care from their kin exhibit starkly diff erent patterns of survival according to the sex of the recipient (Nishi et al., 2010). Older men receiving care from their daughters-in-law experience better survival compared to those receiving care from their wives. By contrast, older women receiving care

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from their kin experience diff erential survival according to their relationship with the care-giver. In descend-ing order, the best survival rates are found for those being cared by: biological daughter, husband, followed by daughter-in-law. Taken together, these studies paint a portrait of the Japanese kinship-based system of elder care that is experiencing strain from the combination of inadequate support from the formal sector and the persistence of traditional gender norms concerning the division of labour.

Th e Japanese are justly celebrated for their post-War achievement in increasing the lifespan of citizens. Japanese society has many sources of resilience, including the strong social cohesion and family stability rooted in traditional values. However, the pattern of economic recovery during the past twenty years (the Lost Two Decades) pose serious threats to that health achievement – including the threats of rising job insecurity, declining fertility, as well as a looming long-term care crisis.

KEYWORDS: Interdisciplinary study; Social determinants of health; Cohort studies; Health and social policy

REFERENCES:

Ikeda A, Iso H, Kawachi I, Yamagishi K, Inoue M, Tsugane S. Living arrangement and coronary heart disease. Th e JPHC Study. Heart 2009; 95(7): 577–83.

Nishi A, Tamiya N, Kashiwagi M, Takahashi H, Sato M, Kawachi I. Mothers and daughters-in-law: A prospective study of informal care-giving arrangements and survival in Japan. BMC Geriatrics 2010; 10: 61.

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Keynote Lecture 2Old and New Challenges in Understanding the Social Determinants of Health

Ana V. Diez-Roux, MD, PhD, MPHCenter for Social Epidemiology and Population Health,

University of Michigan

T his lecture will review conceptual and meth-odologic challenges related to understanding the

social determinants of health. Issues to be emphasized will include: (1) the importance and relevance of concep-tual models of social determinants to study design, data collection, and analysis; (2) the challenges of measure-ment; (3) the challenges in drawing causal inferences from observational studies as well as novel methodologic approaches that can be used to address these limitations; (4) the role of alternative designs and complementary analytical approaches; and (5) the potentialities and limitations of systems approaches.

KEYWORDS: Methods; Social determinants; Health inequali-ties; Health disparities

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Keynote Lecture 3Paradigm Shift in Public Health: Re-emerging of Social Determinants

Tung-liang Chiang, ScD College of Public Health, National Taiwan University

T he mind is the world. What we do depends on how we see and believe the world, or our paradigm. Th is

is also true for people in the fi eld of public health. Since public health came into being in the nineteenth century, its causal thinking has shifted from the miasma theory to the germ theory, the concept of lifestyle, and recently to the social determinants of health paradigm. In this presentation, I will review the history of paradigm shift in public health, and discuss the future of the social determinants of health paradigm.

THE MIASMA THEORYTh e birth of modern public health is an consequence of the industrial revolution. Th e poor living conditions of workers in the early 19th century gave rise of social medicine and public health. In the beginning, the terms of social medicine and public health were used inter-changeably. Th ey studied the social origin of illness and advocated the state’s responsibility for tackling social inequalities in health. Yet, with the defeat of 1848 revolu-tion, social medicine movement came to a quick end, and the broad scope of public health movement was trans-formed into a more limited program of sanitary reform.

Th e sanitary reform began in England and spread out in Europe and America. It was based on the “sani-tary idea” developed by Edwin Chadwick, the father of modern public health. Th e sanitary idea consists of three elements: (1) the miasma theory: disease was caused by unpleasant odors from trash and sewers; (2) public health measure: mainly self-fl ushing sewers, lined with glazed brick, to remove the unpleasant odors; and (3) Bentham’s utilitarianism: the role of government to realize “the greatest happiness of the greatest number.”

Th e word “miasma” came from ancient Greek and meant “pollution.” Th e miasma theory is now discred-ited. Yet, mortality in England remarkably decreased along with the sanitary reform movement. Th is was in part due to many of the sources of infectious diseases were removed after cleaning up the environment. But, regretfully, the earlier ideological controversy of health inequalities was reduced to questions of water supplies and sewer lines under sanitary reform.

THE GERM THEORYWhen Koch’s postulates were published in 1890, the miasma theory was seriously challenged by the germ theory. Th e postulates are: (1) an organism can be found in a host suff ering the disease; (2) the organism can be isolated and cultured in the laboratory; (3) the organism causes the same disease when introduced into another host; and (4) the organism can be re-isolated from that host. Th e germ theory was validated in the late 19th century and is now a cornerstone of modern medicine.

Based on the germ theory, the discovery of penicillin and steroid in the 1940s started the golden age of modern medicine. Th ey changed the everyday practice of medi-cine, but also off ered positive proof of “the possibilities of medical science” that one day apparently insoluble health problems would be overcome. Yet, the medical achievements were coincident with the coming of welfare state reforms in Western Europe. For public health, then, the answer to excess illness and death among the poor was conceived as some form of national health service or national health insurance to increase their access to modern medicine.

THE CONCEPT OF LIFESTYLEHowever, the epidemic of cancers, cardiovascular diseases and chronic respiratory diseases started quiet suddenly, and by the 1940s the non-communicable diseases had replaced communicable diseases as major killers in most of industrialized countries. Regretfully, modern medicine knew very little about the causes of non-communica-ble diseases and failed to solve these emerging health problems. As a result, many large-scale prospective epidemiologic studies were conducted coincidently to fi nd out possible causes. While risk factor was coined and “multiple causation” became the cannon of modern epidemiology, the Hill criteria were applied for causal judgment instead of the germ theory. According to the Hill criteria, a statistical association can be considered as a cause by its consistency, strength, specifi city, temporal relationship, and coherence.

Th anks to epidemiologists, we now know many and many risk factors for chronic diseases. For example, major

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In August 2008, the fi nal report of the Commission on Social Determinants of Health was presented to the WHO Director General, Margaret Chan. In the launch ceremony, the Director General Chan remarked that

“Th is (CSDH Final Report) ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But, let me emphasize, it is factors in the social environment that determine access to health services and infl uence lifestyle choices in the fi rst place.” Next year, the 62nd World Health Assembly passed the resolution on reducing health inequalities through action on social determinants of health.

THE FUTURENow the social determinants of health paradigm has come back. But will it be just a dream or a dream which can be realized? What can we learn from the history of paradigm shift in public health?

KEYWORDS: Public health paradigm; Th e miasma theory; Th e germ theory; Th e concept of lifestyle; Social determinants of health

REFERENCES:

Friel S, Marmot MG. Action on the social determinants of health and health inequities goes global. Annual Review of Public Health 2011; 32: 225–36.

Kickbusch I. The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health 2003; 93: 383–388.

Le Fanu J. Th e rise and fall of modern medicine. London: Little, Brown & Co., 1999.

Rosen G. A history of public health (expanded edition). Baltimore, Md: Johns Hopkins University Press, 1993.

Irwin A, Scali E. Action on the social determinants of health: learning from previous experiences. Social Determinants of Health Discussion Paper 1. Geneva: WHO, 2000. Available from: http://www.who.int/social_determinants/resources/action_sd.pdf.

Syme SL. Social determinants of health: the community as an empowered partner. Preventing Chronic Disease: Public Health Research, Practice, and Policy 2004; 1: 1–5.

risk factors for coronary heart diseases at least includes: high blood cholesterol, high blood pressure, diabetes, overweight and obesity, smoking, lack of physical activ-ity, stress, and poor diet, in addition to sex, age, and family history. Importantly, risk factors often involve decisions and behaviors of an individual, which together constitute one’s lifestyle. Th us, by 1974 when Marc Lalonde proposed his new health fi eld concept, lifestyle had already been considered as major element of health determinant. Th e other three elements of the health fi eld concept are: human biology, environment, and health care organization.

To tackle lifestyle risk factors, public health has undertaken behavioral modifi cation and community interventions as critical strategies for health promotion. Yet, the evidence indicates that many community-based health promotion programs have had only modest impact. Th ree major problems were identifi ed. First, too many risk factors to fi nd. Second, individuals have diffi culties to change their behavior. Th ird, we rarely examine and intervene on those forces in the community that cause the problem in the fi rst place.

THE SOCIAL DETERMINANTS OF HEALTHAfter the fi rst International Conference on Health Promotion was held in Ottawa in 1986, however, the strategies of health promotion shifted from individual behavior orientation to social model approach. Th e Ottawa Charter lists fi ve action means to achieve the goal of “Health for All”: build healthy policy, create supportive environments, strengthen community action, develop personal skills and reorient health services.

Importantly, the Ottawa conference was built in the progress of the “Health for All” movement, initiated by the WHO under the leadership of Halfdan Mahler in the 1970s. Th e Health for All movement adopted the strategy of comprehensive primary health care, with an emphasis of grass root participation and intersectoral collabora-tion. In addition, it also considered economic and social development as fundamental to the fullest attainment of health for all and to the reduction of health inequalities, as documented in the Alma Ata Declaration of 1978.

Regretfully, the “Health for All” movement had been substantially weakened by the restrictive interpretation of “selective primary health care” and by the pressure of neo-liberal economic and health policy since the 1980s. And it was not until J. W. Lee took offi ce as Director General of the WHO in 2003 that the movement became reinvigorated. Two years later, the Director General Lee set up the WHO Commission on Social Determinants of Health with an aim to bring together evidence on what can be done to achieve better and more fairly distributed health worldwide, and to promote a global movement to achieve this.

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SYMPOSIA

Symposium 1 – Chair: Professor Norito Kawakami


Social Stratifi cation, Social Class and Health: Evidence from Japan



Socioeconomic Position and Health: Preliminary Findings from the Japanese Study of Stratifi cation, Health, Income, and Neighborhood (J-SHINE)



Education and Training to Address Social Determinants of Health

Symposium 4 – Chair: Professor Hidehiro Sugisawa

10:30–12:00, August 7 (Sun)Seminar Room 5 (13th Floor)

Social Capital and Health

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Symposium 5 – Chair: Dr. Takeo Fujiwara


Early Life Experience and the Life Course Approach

Symposium 6 – Chair: Professor Hideki Ohira


Biological and Behavioral Mechanisms Underlying Association between Socioeconomic Status and Health

Symposium 7 – Chair: Professor Akizumi Tsutsumi


Cross-Cultural Methodology of Research on Social Determinants of Health

Symposium 8 – Chair: Dr. Naoki Kondo


Social Determinants of Health: Intervention and Policy

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Symposium 1Social Strati fi cati on, Social Class and Health: Evidence from Japan

Chair: Norito Kawakami, MD, DMScHead Investigator of the Project “Social Stratifi cation and Health,”

Department of Mental Health, School of Public Health, Th e University of Tokyo

1–1 Economic Perspectives of Social Disparity in Japan T. Oshio

1–2 Issues and Problems of Social Inequality in Japan K. Seiyama

1–3 Inequalities in Access to Health Care and Utilization of Services in Japan Y. Kobayashi

T he research project “Elucidation of social stratifi -cation mechanism and control over health inequality

in contemporary Japan: New interdisciplinary area of social and health sciences” (abbreviated as the Project

“Social Stratifi cation and Health”) is funded for fi ve years (September 2009–March 2014) by the Grant-in-Aid for Scientifi c Research on Innovative Areas from the Ministry of Education, Science, Sports, and Culture, Japan. Th is interdisciplinary project intends to develop and expand research to elucidate mechanisms underly-ing the social disparity in health and establishment of measures to control over it. Also it intends to form a new interdisciplinary academic fi eld integrating social sciences (sociology, psychology & behavioral science, economics, political science, etc.) and health sciences (public health, health science, brain sciences, etc.).

Th e current symposium, as one of the key symposia of the International Conference on “Social Stratifi cation and Health: Looking into the Future Research Agenda,” is organized to give an overview of the current evidence on social stratifi cation, social class, and health in Japan. Speakers are selected from diff erent academic areas which have been closely related to the topic: sociology, economics, and medicine. First, Dr. Kazuo Seiyama, Professor of Sociology, the University of Tokyo, will talk about the recent trend in social inequality in Japan,

particularly challenging to a question “if social inequality increases in the Japanese society.” Second, Dr. Takashi Oshio, Professor of Institute of Economic Research, Hitotsubashi University, will talk his fi ne analysis of factors underlying widening income inequality in Japan, with international perspectives, as well. Finally, Dr. Yasuki Kobayashi, Professor of Public Health, the University of Tokyo, will talk about social stratifi cation and access to medical care in Japan.

All these talks from the distinguish speakers will be a good basis of further discussions during the confer-ence. While both social inequity and social inequity in health might be smaller in Japan, there is increased awareness and concerns among people and profession-als of social inequity in health in Japan. What should research contribute to? In the process of the research, how can diff erent academic areas and disciplines work together to explore the truth of social inequity in health in Japan? How can we contribute to the research in this area in the world from studies in Japan? Th ese issues will be discussed later in symposia this conference.

KEYWORDS: Interdisciplinary study; Social determinants of health; Health & social policy; Japan

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Economic Perspecti ves of Social Disparity in JapanTakashi Oshio

Institute of Economic Research, Hitotsubashi University

W idening inequality is now one of the most serious economic and social concerns in Japan.

Income inequality has kept widening over the past couple of decades, as the country faced both the asset infl ation-led bubble expansion of the late 1980s and the subsequent long recession. Recent cross-country analyses by the Organization for Economic Co-operation and Development (OECD) reveal that Japan is now among the countries in which income is the most unevenly dis-tributed. Equally striking is the fact that the poverty rate in Japan is now one of the highest in the OECD area. Rising income inequality and poverty have stimulated debates in Japan as to whether the country is moving toward becoming a more unequal and stratifi ed society.

Discussions about income inequality are directly linked to assessments of the recent policy directions by the government in Japan. Policymakers in the country promoted deregulation and other structural reforms during the post bubble recession in the 1990s, which arguably led to a more uneven distribution in income. A cyclical upturn of the economy per se is likely to reduce income inequality through a rise in average household income. However, it remains uncertain whether the momentum for widening inequality will fade smoothly, especially if the causes of widening inequality are struc-tural and lasting.

Widening inequality seems to be attributable to several factors whose relative emphasis varies from researcher to researcher. Some tend to emphasize the impact of recent market-oriented economic policies on income distribu-tion. Combined with severe competition with China and other Asian countries under ongoing globalization, these policies may have put strong cost-cutting pressures on fi rms, which have led to an increase in non-regular workers with lower wages. Others tend more to stress demographic and sociological backgrounds, downplaying

economic factors. Th e rapid pace of population aging is adding to an overall income inequality, especially given the high proportion of the labor force in the older age group, which is characterized by greater wage variations. In addition, a reduction in the average household size seems to have contributed to a rise in household income inequality.

We will give an overview of trends in income dis-tribution and examine the driving forces behind them in Japan, which is sometimes left out of cross-country comparisons. Most of all, we would like to emphasize the following three points:

• Income inequality in Japan is widening to a degree that requires serious concern;

• Th ere are structural and long lasting aspects to pov-erty; and

• Social security programs and taxation need to be more eff ective in reducing income inequality and poverty problems.

Almost all industrial economies have experienced some increase in income inequality in recent years, and various factors have been associated with rising inequal-ity. Th ere is, however, no consensus yet on the relative importance of each factor, which is also likely to diff er substantially from country to country. Our empirical analyses are expected to provide important information about income distribution in Japan, a country which has experienced high industrialization but which is still based on several East Asian features.

KEYWORDS: Income inequality; Poverty; Income redistribu-tion

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Issues and Problems of Social Inequality in JapanKazuo Seiyama

Department of Sociology, University of Tokyo

During the last decade, social inequality has been one of the major public concerns in Japan.

Not only academic scholars but politicians, journalists and ordinary people have been amazingly enthusiastic in discussing, talking and complaining about the “increase of social inequality in Japanese society.” But, to say the truth, the fact is not clear. Th ere has been no defi nite evidence that social inequality as a whole in Japan is indeed increasing. For example, detailed examinations make clear that the most of recent increase in the overall income inequality measured by Gini coeffi cient is caused merely by the increase in the population share of elderly people among whom income inequality has been higher than other age cohorts. Especially, among those between 30s, 40s and 50s in their age, there is no clear trend of inequality expansion.

Th e reason for the upsurge of inequality concern among Japanese people which began at around 2000 is obvious. For several years since 1991, Japan had been suff ering from long-lasting recession caused by the breaking down of the late 1980s bubble economy. Th en the Asian fi nancial crisis struck the already weakened Japanese economy, and triggered a further deterioration. Th e GDP continuously declined in nominal base. Th e unemployment rate which had always been less than 3 percent in days gone by increased to 5 percent or more, and especially for young people it reached to more than 10 percent. Th e job market for new university graduates went into “the ice age.” Many young people had to be reconciled to part-time jobs. Th e restructuring, which is a word particularly Japanese meaning in reality dismiss-als of redundant personnel, outsourcing, and personnel management by accomplishment, became dominant in the management policy of companies. Th us, many

Japanese people suff ered from diffi cult economic situa-tion and became afraid of further deterioration of life. Under this situation the fear of “collapse of middle class” or “bipolarization” captured the people’s imagination, and any suggestions that social inequality is expanding appeared for them as if it were the real and hidden cause of the severity of life they were faced with.

Th is does not mean, of course, that there is no issue or problem of social inequality in Japanese society. But, it would not be a real issue whether or not a certain inequality in a certain social sphere is increasing. For scholars, it will be always possible to fi nd some data that would show a certain increasing trend of social inequal-ity in a certain sphere. For example, it will be found that income inequality between Tokyo and some rural area is increasing, or that the diff erence in educational opportunity for children between diff erent social strata origin is increasing in some aspect. But merely collecting and reporting these data has very little signifi cance for the study of social inequality.

Th e real issue should be concerned with; what kind of inequality is socially unjust and is to be abolished? I would suggest in this paper that this kind of inequal-ity is related to “unjustifi able structural discrimination and deprivation of opportunity,” which is not a mere existence of inequality. Th en I will take up some spheres of inequality as such unjustifi able structural inequality, and analyze their trends and mechanisms.

KEYWORDS: Inequality; Income; Opportunity; Strata

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Inequaliti es in Access to Health Care and Uti lizati on of Services in Japan

Yasuki Kobayashi Department of Health Policy,

School of Public Health, Th e University of Tokyo

T here are two aspects of equity in health care; the one is “access for equal need,” and the other “utiliza-

tion for equal need.” In this presentation, the author will discuss these issues, taking the case of Japan.

Although access to health care is the most important issue of health policy, people’s access to health care is often hampered by various factors, such as geographic locations and socioeconomic stat us which one belongs to. In the 1960s, both physicians and medical facilities were insuffi cient and geographically mal-distributed in Japan. As a result, a considerable number of people had diffi culties in access to physician services in spite of the universal health insurance system of Japan. In addition, most of the elderly could hardly receive adequate services because of high copayment rate (i.e., 50%). Both central and local governments in Japan, together with medical societies, have attempted to tackle these issues. In order to improve the mal-distribution of health providers, they have provided scholarships for medical students to work in the areas where there was a physician shortage and established public clinics and hospitals in remote rural areas. However, our previous and recent studies sug-gested that these eff orts were not very successful because of several reasons.

On the other hand, the 50% copayment rate was gradually lowered to 30% between 1961 and 1968. Furthermore, some municipalities started to pay for the elders’ copayment through general revenues, and this movement expanded all over the country. Finally, the central government introduced “free care” system for

the elderly (those 70 years and over) in 1973, which led to signifi cant increases in their utilization of health services. Th erefore, removing economic barriers is the most powerful measures for improving access for equal need, except for the mal-distribution of health providers. However, such situations might be somewhat changed because of the repeated increases in copayment since the late 1980s.

Another issue is the diff erences in utilization of ser-vices for equal need, under the conditions of equal access. Th is might be partly due to the diff erences in health literacy by individuals, and partly because of personal preferences of non-medical services over medical services. Th e former problem should be solved or eased by appro-priate health education and information. Our recent study showed that those females who had a husband and/or a child (children), better life-style (i.e., regular exercise, quitting smoking), and clinical history and/or family history of cancer regularly received cervical cancer screen-ing. While those females with obesity and/or skipping a breakfast did not regularly receive such screening. Th ese facts would suggest the relationship among utilization of health services, socioeconomic status, and the degree of health literacy.

KEYWORDS: Inequalities; Access to health care; Utilization of services; Health policy

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Symposium 2Socioeconomic Positi on and Health: Preliminary Findings from the Japanese Study of Strati fi cati on, Health, Income, and Neighborhood (J-SHINE)

Chair: Hideki Hashimoto, MD, DPHUniversity of Tokyo School of Public Health

2–1 Does Social Disparity Aff ect Access to Health Care? S. Toyokawa & K. Murakami

2–2 Diff erential Health Eff ects of Individual-Level Bonding, Bridging and Linking, Social Capital H. Sugisawa

2–3 Working Conditions and Health Outcomes H. Kanbayashi

2–4 Maternal Employment and Child’s Health A. S. Oishi

I n this symposium, a fi rst comprehensive report of the fi rst wave of the Japanese Study of Stratifi cation,

Health, Income, and Neighborhood (J-SHINE), a panel study of young/middle age adults in urban community, will be presented by an interdisciplinary research team. Th e J-SHINE started since 2010 in four cities in and around the Tokyo metropolitan, of which purpose was to identify the mechanism of health gradient across socio-economic conditions in households and their surrounding community. Th e survey was the fi rst of its kind in this country that conducted comprehensive measurement of health, social, economic, and psychological aspects of community residents, specifi cally targeting on social gradient of health. Th e research team was composed of a variety of scholars including medical scientists, psycholo-gists, economists, social psychologist, health services researchers, and sociologists. Th is interdisciplinary team shared a common dataset to overcome “language barriers” between specialties, collaboratively develop new theoreti-cal and analytic frameworks, and reach new theories and understanding of causal mechanism linking health and socio-economic lives in the community.

Professor Hashimoto, the principal investigator of the survey, will fi rst present the design and descriptive statis-tics of the fi rst wave survey. From the health policy team,

Dr. Toyokawa will present whether there exists a social gradient in access to healthcare under Japan’s universal coverage system, which enjoys its 50 year anniversary this year. Professor Sugisawa, the leading scholar on health and social relationship among the elderly, extends his research to young/middle age adults to see the impact of social capital on people’s health. Dr. Kanbayashi will focus on working conditions and health from sociology context, and scrutinize the impact of social and physical working conditions in shaping social gradient of health across occupational types and class. Dr. Oishi will present her econometric analysis on the impact of employment status of the mother onto the health of her children, and whether supportive conditions in the work place such as fl exible working time and childcare leave aff ect the impact.

KEYWORDS: Community; Family; Socioeconomic position; Health gradient

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Does Social Disparity Aff ect Access to Health Care?Satoshi Toyokawa, Keiko Murakami

Graduate School of Medicine, University of Tokyo

I NTRODUCTION: Access to health care contributes to the improvement of health. Access to health care

is a right of all people and should not be aff ected by income or wealth. Socio-economic status is associated with gradations in health status, and needs for health care. European countries, which are more likely to have universal coverage health systems, have found pro-rich inequities in health care spending for specialty visits. Th e principle of horizontal equity states that people with the same needs for health care should be treated equally, regardless of diff erences in income, education, occupation, health insurance, or other determinants of the demand for health care. Aim of our research group is to assess the eff ect of social stratifi cation on access to health care, including dental service, preventive medicine and social welfare in order to discuss how to manage health care system to cope with the social stratifi cation. We are trying to show the gradient in access to health care, focusing on horizontal equity of the dental service.METHODS: Th e current study used data collected in two cities of all four sampled cities in Japanese Study of Stratifi cation, Health, Income, and Neighborhood (J-SHINE). Th e survey for J-SHINE was conducted in four cities in the Kanto region. Subjects were 13,920 people aged from 25 through 50 and randomly sam-pled from the basic residence registrations. Answers were collected through computer assisted personal interview. Equivalent household income was applied for the indicator of income, which is household income divided by the square root of the number of person in the household. Individual income substituted the defi cit of household income. Th e indicator of access to dental service comprised of care and prevention. Th e indica-tor of access to dental care was experience of receiving

care and dental prevention including removing tartar, application of fl uorine, or orthodontic treatment for past one year. Concentration index (CI) was applied for the inequality index for access to health care against income. Horizontal-inequity index (HI) was defi ned as the diff erence between total socioeconomic inequality in access (CI) and the contribution to total inequality in the need for health care, estimated by age, sex and oral health condition.RESULTS: Of 4,381 samples (return rate 31.5%) collected correctly answered questionnaire, 3,755 samples whose answers were complete for aforementioned items, were applied for analyzing (application rate for analyze 27.0%). CI showed positive value (care: 0.020, prevention: 0.076), indicating pro-rich inequality, that high income group have better access to dental service. HI also showed posi-tive values (care: 0.030, prevention: 0.074), indicating pro-rich inequity tendency, especially in access to dental prevention.DISCUSSION: Our pilot analysis showed the gradient in access to dental service in Japan. Pro-rich inequity emerges with respect to the probability of access to dental prevention. Since Japanese health insurance does not cover some of dental prevention, further study is neces-sary to explain whether the reason of the gradient is the eff ect of income or other preferences based on the socio-economic status.

KEYWORDS: Access to health care; Social disparity; Concen-tration index; Horizontal-equity index; Dental care

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Diff erenti al Health Eff ects of Individual-Level Bonding, Bridging and Linking, Social Capital

Hidehiro Sugisawa J. F. Oberlin University Graduate School

O BJECTIVES: Social capital can be conceptualized as multidimensional. In most empirical studies,

social capital has been operationalized as structural and cognitive. In recent years, new concepts of bonding, bridging, and linking social capital have been proposed. Bonding social capital comprises relationships between members of a network who are similar in terms of their shared social identity. Bridging social capital refers to relations between people who are dissimilar in some socio-demographic sense. Linking social capital encom-passes relationships between people who are interacting across formal, or institutionalized power, or authority gradients. It is important to clarify the dimensions of social capital that has an impact on health outcomes. However, only a few studies have attempted to do this. Th e objectives of this study were: (1) to identify dimen-sions of individual-level social capital that has a strong impact on health, and (2) to investigate whether these eff ects diff er according to gender and social status.METHODS:

Dependent variables: Self-rated health and the K6, a screening tool for severe psychological distress were used as a health indicators.

Independent variables: (1) Individual-level bonding and bridging social capital: Respondents were asked about community organization that they belonged to and whether their participation was voluntary. In addition, respondents who voluntarily participated in at least one community organization were asked whether the other members in the organizations were similar to themselves in terms of sex, occupational status and age. We catego-rized those that responded “yes” as having bonding social capital and those that responded “no” as having bridging social capital, whereas those that answered “don’t know” were assigned to the “don’t know” category. Respondents

without voluntary affi liations in community organiza-tions were assigned to the low social capital group. (2) Linking social capital: A dichotomous variable was cre-ated by the response to a question inquiring whether respondents had acquaintances in organizations such as neighborhood associations, volunteer associations, and the regional government, which had formal or insti-tutionalized power. (3) Other variables: sex, age, and educational attainment were used as control variables.

Statistical methodology: We used a hierarchical mul-tiple regression analysis. We fi rst entered social capital and other variables and then all interaction terms: social capital variables × sex and social capital variables × social status, as independent variables.RESULTS AND CONCLUSIONS: Both individual-level bonding and bridging social capital had a signifi cant impact on self-rated health; however, the eff ects of bond-ing social capital were stronger than those of bridging social capital. Linking social capital did not have a sig-nifi cant relationship with self-rated health. Moreover, signifi cant interactions were observed between bonding social capital and sex, with the eff ects of bonding social capital being stronger for men. Results of the K6 health indicator were nearly identical to the results of self-rated health. Th ese results suggest that individual-level bond-ing social capital has more benefi cial eff ects on health than either bridging, or linking social capital. Moreover, the eff ects of bonding social capital diff ered by sex.

KEYWORDS: Bonding social capital; Bridging social capital; Linking social capital; Self-rated health; K6 scale

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Working Conditi ons and Health OutcomeHiroshi Kanbayashi

Faculty of Liberal Arts, Tohoku Gakuin University

I NTRODUCTION: Working conditions intermedi-ate between occupation (or social class) and health

inequalities. Th erefore, many researchers have focused on the infl uences of working conditions on health outcomes.

Th e labor market situation or employment cus-toms in Japan has been changing such as an increase in non-regular employment workers and a decline of the long term employment system. Th e impact of these changes has been widely researched and discussed. Some researchers pointed out working conditions (especially those of periphery workers) are getting worse: instabil-ity of employment, low wage, working overtime, tough competition, and so on. How do the recent changes of labor market or working conditions infl uence on health outcomes?

Th e purpose of this study is to investigate the relation-ship between working conditions and health outcomes in Japan.DATA AND METHOD: Data from the fi rst wave of the Japanese Study of Stratifi cation, Health, Income, and Neighborhood (J-SHINE) are used. Th e data contain many items on occupational characteristics and working conditions (subjective or cognitive working conditions) as well as health related variables. In this study, infl uences of occupational characteristics on working conditions and impacts of working conditions on health outcomes are examined.

Variables are as follows: (1) occupational character-istics: occupation, employment status, characteristics of workplace, etc.; (2) working conditions: eff ort-reward imbalance, work demand-control, work-life confl ict, etc.; (3) other control variables: age, marital status, years of education, family income, etc.; and (4) health outcomes: subjective health, quality of sleeping, obesity, depression, QOL, etc.

In this study, men and women are analyzed separately.

RESULTS: Results of preliminary analyses are summa-rized in four points.1) Occupational characteristics infl uences on working

conditions. However, eff ects of occupational variables are generally weak.

2) Direct eff ects of occupational characteristics on health outcomes are almost zero when working conditions and other variables are controlled.

3) Working conditions aff ect health outcomes as previous studies have shown. Th ree variables have consistent eff ects on many health outcomes; eff ort-reward imbal-ance and work-life confl ict have negative eff ects and support by colleagues has positive eff ects on health outcomes.

4) Although infl uences of working conditions are basically common between men and women, some interesting gender diff erences were found. For example, in the case of men, the most common factor for health outcomes was eff ort-reward imbalance. On the other hand, in the case of women, work-life confl ict was the most frequent factor.

CONCLUSION: Th ese results are rough and incomplete. More detailed analyses are needed (for example, scrutiny of interaction eff ects between objective occupational characteristics and working conditions). Th e J-SHINE has a great deal of information on working conditions and health. Investigating this data will bring us many useful insights on social inequality and health.

KEYWORDS: Occupation; Working conditions; Eff ort-reward imbalance; Work-life confl ict

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Maternal Employment and Child’s HealthAkiko S. Oishi

Faculty of Law and Economics, Chiba University

P ast decade has seen a remarkable increase in the proportion of mothers with jobs in Japan. Even

among mothers with children reaching school-age, the proportion of those with jobs has risen by 15 points between 1999 and 2009 (Ministry of Health, Labour and Welfare, 2009). Economic theory suggests that maternal employment aff ects child’s health in various ways. First, increased household income enables parents to demand for healthier children, holding other things being equal. If this is the case, we should expect working mothers to be more careful about their children’s nutrition. Second, higher opportunity cost of mothers’ time may lead to fewer maternal time spent on children to play with out-side. In addition, working mothers may substitute their time with children by purchasing prepared food or asking for help from their husbands or other family members. Th ird, mothers with jobs might be more likely to engage in unhealthy behavior (such as drinking and smoking)

due to psychological stress associated with work which may be harmful to child’s health.

Despite the extensive literature on the eff ect of maternal employment on child’s health in the U.S. and elsewhere, few studies have been undertaken in Japan. Using a newly developed panel data of people living in urban areas in Tokyo, I examine how mother’s employ-ment aff ects her child’s health. Preliminary investigation of the data suggests that mothers with jobs are less likely to concern nutrition and more likely to engage in smok-ing and drinking. Th e infl uence of maternal employment in the early stage of child’s life and implications for work-life-balance will be also considered.

KEYWORDS: Female labor

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Symposium 3Educati on and Training to Address Social Determinants of Health

Chair: Hideki Hashimoto, MD, DPHUniversity of Tokyo School of Public Health

3–1 Global Needs on Training and Human Development for Social Determinants of Health Policy and Practice H. Hashimoto & T-L Chiang

3–2 Social Determinants of Health Seminar and Educational Program in Osaka University K. Honjo

3–3 Teaching the Social Determinants of Health in Taiwan T-L Chiang

3–4 What Helps Young Public Health Students to Address Social Determinants of Health in Research and Practice? H. Inada

T his symposium will focus on skill and human capi-tal development to address social determinants of

health (SDH) as an emerging theme in public health practice and research. In spite of increasing reception of social determinants of health as a powerful concept in public health, what constitutes a core discipline to address SDH in public health policy and research remains poorly defi ned, and training program to raise capable human capital meeting this new challenge is only in its embry-onic stage. In this symposium, speakers invited from domestic and international public health institutes will present their current activities in education and training, and will exchange with the fl oor their thoughts and ideas to reach the next step towards realizing the concept of SDH in real-world practice and advanced research.

Professor Hashimoto with help of Professor Chiang will start with reporting recent activities in Asian-Pacifi c HealthGAEN (Global Action for health Equity Network), an international network of researchers and practitioners in the Asian Pacifi c region that has been sprung out from a local network of the WHO’s Commission for Social Determinants of Health. As SDH and health equity have been set in a central agenda of health policy since WHO’s general resolution in 2009, demands for skill training and human development are emerging from government and non-government organizations. Th e HealthGAEN currently collaborates with several regional activities to develop a sharable training program and educational materials.

Dr. Honjo will report a summer seminar jointly organized by Osaka University and University College London on SDH starting from 2010. Th e department of public health in Osaka University has long achieved fame for its contribution on practice, education, and research on public health, and the seminar extends its tradition to tackle with the issue of SDH.

Professor Chiang follows with his report on the cur-rent educational programs in the College of Public Health in National Taiwan University. As a leading scholar on SDH and infl uential adviser to the government’s health sector in Taiwan, he will present how the government of Taiwan currently addresses SDH in public health policy, and how the academic institution can contribute to the design, implementation, and evaluation of SDH policies through education and research.

Finally, Dr. Inada will present, from the viewpoint of young scholars willing to address SDH in their career development, what is necessary to help them pursue the theme in research and practice; e.g., analytic skills, guiding theories, opportunities for practice, etc. After the presentation, discussion among speakers will be fol-lowed by open discussion with the fl oor.

KEYWORDS: Education; Training; Practice; Research; Skill development

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Global Needs on Training and Human Development for Social Determinants of Health Policy and Practi ce

Hideki Hashimoto1, Tung-liang Chiang2

1University of Tokyo School of Public Health2College of Public Health, National Taiwan University

Achieving equity in health for all has been a long lasting theme in the discipline of public health, and

has recently become a central agenda in international and domestic health policy debate since the Commission on Social Determinants of Health (CSDH) brought the theme in a new light. Since the impact of social determi-nants of health (SDH) is broad and complex, however, eff ectively addressing it into policy and action requires a strong guidance based on fi rm knowledge, iterative and continuous process of planning, implementation, and evaluation, quantitative and qualitative skills of knowl-edge building, and empowerment techniques including persuasive communication and political tactics. Building such comprehensive human capital and knowledge asset makes an enormous challenge.

In this presentation, we will report recent activities in Asian-Pacifi c HealthGAEN (Global Action for health Equity Network), an international network of research-ers and practitioners in the Asian Pacifi c region that has been sprung out from a local network of the WHO’s Commission for Social Determinants of Health. Th e HealthGAEN currently collaborates with several regional activities to develop a sharable training program and edu-cational materials. Th rough intensive discussion among regional experts on health policy and practice, following emerged as themes:

• Knowledge gap and lack of training must be overcome to address social determinants of health for achieving health equity;

• A balance between theory and practice, and mutual and continuous communication between science and practice in the fi eld are required for synthesiz-ing knowledge assets and enabling context-specifi c yet global measures in order to tackle socioeconomic structural determinants; and

• Several core competencies are required for capacity building, which further needs strategic planning and multi-sectoral multi-disciplinary collaboration.

A range of training programmes have been discussed by the Steering Committee: summer workshops on the social determinants of health and health inequities mainly to train trainers in the region; publishing an under-graduate level textbook on social determinants of health and inequities; training materials for modules and workshops, to be used by trainers in their own countries that are sharable through internet with aff ordable cost. In order to develop the training programmes, it was felt that a core curriculum should be identifi ed as a prior-ity. We would like to open discussion with the fl oor to identify what should be included as a core discipline for addressing SDH in research and practice of public health.

KEYWORDS: Education; Training; Research

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Social Determinants of Health Seminar and Educati onal Program in Osaka University

Kaori HonjoOsaka University Global Collaboration Center

O saka Public Health Seminar (OPHS) is orga-nized by the Public Health Department, Osaka

University Graduate School of Medicine in collaboration with the Department of Epidemiology and Public Health, University College London (UCL). OPHS is a three day-intensive summer seminar, started in 2010. Th e main theme of the seminar is to understand the mechanisms of social determinants of heath in Japan.

Osaka University off ers a master level health educa-tion programme, which is open to both medical graduate students and public health practitioners and researchers who are aspiring to gain advanced knowledge in public health in Japan. It is called “Development of medical and health related problem-solving capability” and OPHS is tied to this programme.

Not a long ago, Osaka University and UCL signed offi -cial agreement on the university-to-university exchange scheme. We have been actively working on collaborative research projects and are also exchanging post-doctoral researchers and graduate students with UCL. UCL off ers an established educational summer seminar of social determinants of health. Mirroring this UCL summer seminar, we have planned to open a Japanese version of summer seminar on social determinants of health, OPHS, as a collaborative educational project with UCL.

Main target audiences for the OPHS are graduate students and early career researchers in various fi elds such as public health, medical science, health sciences and related fi elds, and public health practitioner. Main objectives of the OPHS are: (1) to exchange knowledge in factors related to social determinants in health and (2) to promote understanding in the mechanism of health inequalities. Th is seminar off ers credits certifi ed by the Japanese Society of Public Health, useful to public health professionals.

OPHS off ers series of symposium, lectures, and workshops. Main topics of the seminar are the eff ects of socioeconomic positions, income inequality and working conditions on health, social-biological translation, health related psychosocial factors, gender diff erence/inequal-ity in health, social capital, Health Impact Assessment (HIA), and life-course epidemiology. OPHS is led by the lecturers from UCL and Osaka University. We also invited leading social epidemiologists in Japan as our guest lecturers and speakers. Together, we deliver funda-mental knowledge of social determinants of health that is applicable to practice to tackle with health inequalities in Japan.

At the inaugural seminar last July, Professor Sir Marmot delivered a keynote lecture, “Closing the gap”, presenting problems of global health inequalities and possible approaches for the solutions. His keynote lecture was followed by a series of symposiums and lectures on health inequalities and social determinants of health in Japan. We had 75 participants consisted of graduate students (n=36), researchers (n=21) from various fi eld, medical practitioners (n=3), public health practitioner (n=10) and others (n=5). All feedback obtained from the participants were favourable to us.

We will have the second OPHS in this July; our pre-sentation will also address the outcome of the second seminar.

KEYWORDS: Education; Training; Research

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Teaching the Social Determinants of Health in TaiwanTung-liang Chiang, ScD

College of Public Health, National Taiwan University

T he social determinants of health have become one of dominant schools in the education of public

health in the world. Yet, the progress in Taiwan has been slow. Th e Taiwan Ministry of Health has been proud of the achievement of universal health coverage, but little attention has been paid to the issue of health equity and social determinants of health until the release of the white paper: “2020 Healthy People” in 2008, which considered promoting health equity as one of two national objectives. Th e other is to increase healthy life expectancy.

Importantly, the National Taiwan University took the lead in teaching social determinants of health courses in Taiwan since the beginning of the 21st century. I started to teach the course: Introduction to Society and Health in 2001, followed by my colleagues: Professor Yawen Cheng, and Professor Duan-Rong Chen. Professor Cheng is a social epidemiologist focusing on work and health; Professor Chen focuses on social networking and medical geography. Th ere are other faculty members who off er one or two classes in their courses including Professor Chueh Chang and Professor Chih-Ying Ting. Professor Chang is interested in gender equity and mental health; Professor Ting teaches health behavioral sciences and medical anthropology.

In 2008, I, together with Professor Cheng and Professor Chen, decided to initiate a concentration on society and health. Th e concentration consists of three core courses: Introduction to Society and Health, Society and Health: Th eory and Policy, and Social Epidemiology: Principles and Methods. Th e introduction course is for all students, including undergraduate and graduate students, but the other two courses are for graduate students only. Th ere are other related courses off ered

in the College of Public Health include: Public Health Ethics, Current Issues in Society and Health, Analysis of Occupational Policy, Historical Analysis of Public Health, Social Network and Spatial Analysis, Gender and Health, and so on.

Outside the National Taiwan University, there are eight universities to date off er courses on social determi-nants of heath. Th ey are National Yangming University, National Chen Kung University, National Chung Cheng University, Taipei Medical University, China Medical University, Chang Gung University, Fu Jein University, and I Shou University. All of them usually have only one faculty member to teach social determinants of health courses, either in social epidemiology or in society and health.

To promote the research and education of social determinants, we invited Professor Ichiro Kawachi to host a workshop in Taipei as early as in 2000, followed by other well-known scholars including Sir Michael Marmot, Professor Hideki Hashimoto, Professor Norito Kawakami, Professor Sharon Friel, and so on. And Since the inauguration of Asia Pacifi c Hub of HealthGEAN in Taipei in 2009, we have hold one workshop on society and health every year as a social platform for those who are interested in teaching social determinants of health in Taiwan.

KEYWORDS: Social determinants of health; Society and health concentration; Education for public health; Taiwan

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3–4

What Helps Young Public Health Students to Address Social Determinants of Health in Research and Practi ce?

Haruhiko Inada Doctoral candidate, Graduate school of Medicine, University of Tokyo

T he association for young researchers in social determinants of health (SDH) was established in

Japan in 2009, and it has attracted over 90 graduate students and researchers throughout the country in the last two years. As a refl ection of multidisciplinary nature of SDH research, the members’ diversifi ed backgrounds include public health, medicine, sociology, psychology, economics, and other related disciplines. Th e association has succeeded in off ering its members opportunities to attend seminars and workshops and nurture networks to better achieve their career and academic development in SDH.

Fascinating research domain is SDH, with its semi-comprehensiveness to elucidate the multilevel mech-anisms by which health is aff ected, possible development of highly eff ective interventions based on its fi ndings, and the public’s growing interest in the stratifi cation of the Japanese society, however, novice students could easily be overwhelmed by the vastness of the frontier wilder-ness. What stand them in good stead in a long time are motivation, education, and mentors and fellows.

For beginners to get motivated, understanding the signifi cance and possible goals of SDH research is of vital importance. Guiding seminars and introductory textbooks that also deal with major research themes, theories, fi ndings, and application to policy help them grasp the outlines of SDH and attract greater number of students and researchers from related disciplines.

Th ere have been successive establishments of gradu-ate schools of public health in the last decade in Japan, which provide students with intensive and systematic lectures and learning opportunities of public health, e.g., epidemiology, biostatistics, data analysis, health policy, and health economics. Focusing on SDH make it a little easier for students to choose what they should learn. On top of the coursework in early stage of their career, active interactions with mentors and fellow researchers help them further enhance their research skills and become productive. Establishing a center for SDH research would facilitate the continual fostering of future researchers and it might also contribute to management of large-scale data for research.

Finally, since SDH addresses politically sensitive topics such as social class, stratifi cation, disparity, and deprivation, even the results of descriptive works may trigger debate among the public. Learning underlying values, or philosophy and moral issues are indispensable for young students.

KEYWORDS: Association; Motivation; Education; Mentor; Philosophy

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Symposium 4Social Capital and Health

Chiair: Hidehiro SugisawaJ. F. Oberlin University Graduate School

4–1 Th e Eff ects of Social Capital on Health: Evidence from a Survey in Tokyo Metropolitan Area K. Harada

4–2 Does Social Participation Improve Self-Rated Health in the Older Population? An Instrumental Variable Analysis Y. Ichida

4 –3 Social Capital and Generosity in the Community N. Yamauchi

I n western societies, a growing body of empirical research has explored individual-level and area-level

social capital and their relationship to a variety of out-comes including health. Moreover, studies on factors related to the mobilization of social capital, as well as intervention studies to mobilize social capital have been conducted. On the other hand, in Japan, only a few empirical studies have analyzed the eff ects of social capi-tal. Th is symposium presents three studies that have investigated the eff ects of social capital on health and other outcomes. Th e main objectives of the symposium are: (1) to present up to date fi ndings about the relation-ship between social capital and a variety of outcomes

including health in Japan, (2) to elucidate intervention strategies to mobilize social capital, (3) to evaluate the extent to which available evidence on these relation-ships can be translated into viable policies to close health inequality between social groups, and (4) to clarify poten-tial issues for further research.

KEYWORDS: Individual-level social capital; Area-level social capital; Health; Intervention

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The Eff ects of Social Capital on Health: Evidence from a Survey in Tokyo Metropolitan Area

Ken Harada Faculty of Humanities and Social Sciences,

Jissen Women’s University

O BJECTIVES: Th ere is a growing recognition regard-ing the social determinants of health. Th e eff ects

of social capital on health have drawn the attention of Japanese researchers in recent years. Some studies have suggested associations between social capital indices and perceived health at individual and community levels. However, the eff ect of diff erent forms of group participa-tion on mental health remains unclear. Eff ects of group participation, particularly as community level social capital on mental health were investigated.METHODS: Data were obtained from a probability sample survey of 2,108 men and 2,568 women aged 25 years and older living in 30 communities in Tokyo, Chiba, Kanagawa and Saitama area of Japan. Th e depen-dent variable was mental health, which was measured using the Japanese version of the K6, an indicator of psychological distress. Th e independent variable was social capital, which was assessed by the frequency of individual and community level of participation in group activities. Th e eff ects of three types of group participa-tion (neighborhood associations, sports and hobby clubs, consumer cooperative and volunteer groups) were exam-ined using multilevel regression models. Individual level demographic status (age and sex) and socioeconomic status (educational attainment and family income) were included as control variables. All statistical analyses were performed using HLM 6.08.RESULTS: Multilevel regression analyses of K6 scores showed that a high level of individual participation in neighborhood associations, sports and hobby clubs, co-op and volunteer groups were associated with lower psycho-logical distress. After adjusting for individual level group

participation, high community level participation in sports and hobby clubs was associated with lower levels of psychological distress. In a model that included interac-tions between community level group participation and socioeconomic status, interactions between community level participation in the co-op, as well as in volunteer groups, and education was signifi cant. Th is indicated that disparities in psychological distress caused by education were reduced in communities with higher participation in co-op and volunteer groups.CONCLUSION: Results of multilevel analyses suggested that individuals residing in communities with higher levels of social capital had better mental health, after controlling for individual level demographic and socio-economic status. Results also indicated that community level social capital modifi ed the eff ects of individual level education on mental health. Th is study focused on group participation, which is just one aspect of social capital. It is suggested that the fi ndings of this study would aid investigations using other important dimensions of social capital, including collective effi cacy, reciprocal exchange, and informal sociability.

KEYWORDS: Social capital; Mental health; Group participa-tion; Multilevel analysis

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Does Social Parti cipati on Improve Self-Rated Health in the Older Populati on? An Instrumental Variable Analysis

Yukinobu Ichida Center for Well-being and Society,

Nihon Fukushi University, Nagoya, Japan

T he purpose of the present study is to describe an intervention that has been adopted within one

municipality of Japan to boost social participation among older individuals as a way of preventing long-term disabil-ity. Social participation – as well as the broader concept of “social capital” – have been promoted in the past as a way of maintaining functional independence and healthy aging. Our specifi c intervention focuses on the town of Taketoyo on Chita Peninsula (south of the city of Nagoya, Japan), which attempted to provide a venue for social participation via the creation of “salons” (or com-munity centers) where older residents could congregate and engage in a variety of social activities.

We carried out baseline survey in July, 2006 for all older people, community intervention at the three sites in 2007 and ex post-evaluation panel survey in February, 2008. In the present study, we used 1,554 samples with complete data on self-rated health, age, sex, and partici-pation in the salons.

Our main dependent variable was self-rated health in 2008, and the main explanatory variable is the par-ticipation to the salons. By both of the estimation of an instrument variable model and a bivariate probit model,

we observed a signifi cant linkage between better self-rated health in 2008 and participation in salon instrumented by the inverse of distance from each residence of samples to the nearest salon, after adjusting for self-rated health in 2006, age, sex, and equivalized income in 2006.

In summary, our study utilizing an instrumental variable estimation approach, found that social partici-pation (via community-based salons) is associated with an improvement in self-rated health among participants over time. Our study provides novel empirical support for the notion that interventions to promote social participation can enhance the health of older residents. It remains to be seen whether these benefi cial changes translate over time into maintenance of functional and cognitive status over time, and hence, the prevention of long-term care dependency.

KEYWORDS: Social participation; Community-salon interven-tion; Instrumental variable analysis; Preventing long-term disability

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Social Capital and Generosity in the CommunityNaoto Yamauchi

Osaka School of International Public Policy, Osaka University

I n this paper, we exemplifi ed the determinant fac-tors aff ecting generosity in the community, namely

charitable giving and volunteering decision, particularly paying attention to the impact of social capital on the behavioral capacity for giving and volunteering. We are interested in whether and how the act of giving and volunteering as a mode of expressing private initiatives for public goods provision is aff ected by social capital which is accumulated by subjective and personal prefer-ences and sense of values.

We have used the micro-dataset with the sample size of approximately 5,000, collected by the national survey on giving and volunteering conducted for the quantitative and analytical part of “Giving Japan 2010.” Our empiri-cal result demonstrates that generalized trust, confi dences in social particular subjects and civic-minded inclination aff ects his behavioral capacity for philanthropy. However, it shows that their impacts are not the same over the type of causes and activities, supposedly depending on their demands for and perceptions about public services in terms of their nature.

Our study is considered to contribute to this research fi eld with empirical approaches due to the following points. First, our unique dataset making it possible to generate variables for social capital, as well as specifi c fi gures of the level of giving and volunteering, and to test the relationship between social capital and pro-social behavior more precisely than ever. Second, at the same time, our study will raise the discussion again about measurement of social capital for the development of the pragmatic approach to empirical research on social capi-tal, and derive policy implications taking into account the current economic and social issues. Th ird, our stud-ies have important policy implications for the nonprofi t

management, the practice of philanthropy, and com-munity development especially in Japan. Th e situation of research on nonprofi ts and philanthropy in Japan is still developing in terms of accumulating systematic and statistically advanced empirical approaches. We are able to secure a space here of adding a specifi c value of our analysis. Also, fi ndings from the studies, with unique and valuable datasets and the breakdown of the objects of the analysis, contribute to obtain more specifi c and strategic suggestions and to implement policies and programs in the actual situations.

Overall, this study provides several unique and valu-able fi ndings for a better understanding of philanthropy and social capital. However, there are some limitations and unsolved issues. Due to the data availability, dis-cussion of the causality issues remains in our studies. Investigating a recursive relation between giving and volunteering participation and a response or change of individual preferences in philanthropic behavior is important. Th e outputs of inter-sectoral comparisons of public service provision and behavioral analysis on philanthropy will serve a better approach and strategy for policy design, as well as a better comparative institu-tional analysis. For the future development of research, it is expected to deal with these remained issues and carry out exhaustive examinations for more accurate comprehension of nonprofi ts and philanthropy.

KEYWORDS: Social capital; Community; Charitable giving; Volunteering; Philanthropy

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Symposium 5Early Life Experience and the Life Course Approach

Chair: Takeo FujiwaraDepartment of Social Medicine, National Research Institute for

Child Health and Development, Tokyo, Japan

5–1 Association between Fetal Environment and Childhood Growth K. Suzuki

5–2 Th e Association of Body Physique and Intelligence Quotient in Children with Family Income in Tohoku Study of Child Development N. Kurokawa

5–3 An Analysis of Health and Socioeconomic Status of Children in Japan: Is Th ere Health Disparity among Children in Japan? A. Abe

5–4 Impact of Educational Level on Blood Pressure Change during Pregnancy and Pregnancy Induced Hypertension: Hospital-Based Japanese Birth Cohort Study S. C. Jwa & T. Fujiwara

I f Barker hypothesis is true, it is likely that pregnant mothers who suff ered from poverty cannot eat enough

food, which induces malnutrition of fetus. Th is can be a trigger of development of thrifty phenotype inducing adult diseases such as diabetes mellitus. However, few studies investigate the link between socioeconomic status (SES) during early life (i.e., at the time of fetus or infant/toddler) and pregnancy or child outcomes. Th us, this symposium will try to reveal the association between SES in early life (during fetus or infant/toddler) and pregnancy or child outcomes.

Dr. Jwa will report the association between maternal educational level and blood pressure during pregnancy and pregnancy induced hypertension using hospital-based birth cohort study in Tokyo. Dr. Suzuki will tell us the link between maternal smoking status, as a proxy of

maternal SES, and childhood obesity using population-based birth cohort study in Yamanashi. Dr. Kurokawa will show the association between family income and IQ using community based birth cohort study in Miyagai. Finally, Dr. Abe will report the association between SES and child health disparity (e.g., self-rated health, asthma, etc.) up to six years of age using large panel data from Ministry of Health, Labor and Welfare.

KEYWORDS: Life course epidemiology; Birth cohort study; Socioeconomic status; Pregnancy outcomes; Child outcomes

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Associati on between Fetal Environment and Childhood GrowthKohta Suzuki

Center for Birth Cohort Studies, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Japan

B arker, who established the fetal origins of adult disease hypothesis, has stated that a cause for con-

cern is that the rising rates of childhood obesity will fuel chronic disease epidemics, including those of coronary heart disease, increased blood pressure, and adult-onset type 2 diabetes. Th e fi ndings of some studies on fetal pro-gramming of chronic diseases, including obesity-related diseases, are consistent with the Barker hypothesis, which states that fetal adaptations to intrauterine undernour-ishment may have permanent and specifi c short- and long-term eff ects on the development of various organ systems, including the cardiovascular and metabolic sys-tems. Some studies from the United Kingdom, Finland, and India have suggested that there might be a relation-ship between the specifi c path of growth, consisting of slow growth in fetal life and rapidly increasing body mass index (BMI) as an infant, and the development of type 2 diabetes or coronary heart disease. Originally, they compared these data between low and high socioeco-nomic areas. Th erefore, when considering the etiologies of such diseases, it is necessary to examine the associa-tion between fetal or perinatal undernourishment and childhood growth.

For example, maternal smoking during pregnancy is a possible major cause of fetal undernourishment. Many studies have shown that maternal smoking during preg-nancy aff ects placental and fetal circulation, which may lead to intrauterine growth retardation, low-birth-weight infants, and small-for-gestational age infants. Moreover, smoking is generally associated with socioeconomic status. Th erefore, maternal smoking during pregnancy could be also considered as a proxy indicator for socio-economic status.

On the other hand, the term ‘life course epidemiology’ has recently become popular. Th e Barker hypothesis is probably the best-known example of a life course associa-tion. Because it states that poor fetal nutrition, indicated by small birth size, leads to fetal adaptation that pro-gramme the propensity to adult disease, it is necessary to conduct individual growth analysis that includes both individual and age as diff erent-level variables.

To clarify the association between maternal smoking and childhood growth, it might be necessary to conduct a prospective cohort study which starts from fetal period. Our research center has the data of Project Koshu (for-merly Project Enzan), a dynamic, ongoing prospective cohort study of pregnant women and their children in rural Japan, which commenced in 1988. In this presen-tation, some of the results from this project would be introduced as examples of the association between fetal environment and childhood growth. Particularly, our latest result which clarifi ed the gender diff erence of the association between maternal smoking during pregnancy and childhood growth by using multilevel analysis would be also introduced. In addition, further research ques-tions, like the association between childhood lifestyle and their afterword growth would be also discussed in this presentation.

KEYWORDS: Fetal programming; Pregnancy; Childhood growth

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The Associati on of Body Physique and Intelligence Quoti ent in Children with Family Income in Tohoku Study of Child Development

Naoyuki Kurokawa Environmental Health Sciences,

Graduate School of Medicine, Tohoku University

S ome studies have reported that there is the asso-ciation between socioeconomic status (SES), and

health outcome including body physique status in chil-dren. In addition, it is suggested that SES is related to intelligence quotient (IQ) in children. Family SES may have the eff ects on health status of their children since it is considered that the SES of their children depends on the SES of their parents. We examined the associa-tion of family income that is one of SES index, IQ, body physique status such as height, weight and body mass index (BMI) in children using data from a prospective cohort study.

Th e Tohoku Study of Child Development (TSCD) is a prospective cohort study to examine the eff ects of perinatal exposure to environmentally toxic chemicals such as persistent organic pollutants, including PCBs and methylmercury, as well as maternal diet on child health and development in the Tohoku district of Japan. Th e TSCD was approved by the Medical Ethics Committee of the Tohoku University Graduate School of Medicine, and all mothers provided signed informed consent.

From January 2001 through September 2003 we recruited healthy pregnant women with their informed consent at obstetrics wards of two urban hospitals in the Tohoku region of Japan. Our cohort study is being conducted in a large city with a population of more than one million in order to assess the eff ect of the aver-age exposure in pregnant Japanese women. We initially recruited 1500 pregnant women making antenatal visits to obstetric wards of hospitals. Eligibility criteria included a singleton pregnancy and Japanese as the mother tongue. To establish an optimal study population, only neonates born at term (36-42 weeks of gestation) without con-genital anomalies or diseases were included. In addition, only neonates with a birth weight of 2400 g or more were included in the cohort study. All women delivered by March 2004, and 599 mother-neonate pairs were

registered in the cohort study according to the eligibility criteria. We obtained information about demographics, smoking status and alcohol drinking during pregnancy from a questionnaire 4 days after delivery.

Intelligence quotient of children was measured using the Wechsler Intelligence Scale for Children – Th ird Edition (WISC-III) (Wechsler, 1991). Th is test evaluates a Full Scale IQ, Verbal IQ, and Performance IQ scores.

We observed that family income was not associated with children’s body height, weight and BMI. In addition, there was no relationship between IQ and body physique in children. Verbal IQ of high family income group was signifi cantly higher than that of low family income group. However, there were no associations between Full Scale IQ and Performance IQ and family income.

In this analysis of our cohort, we found family income was related with Verbal IQ in children, although there was no association between SES and health status such as obesity in children. Findings from some cohort studies indicate that childhood IQ is inversely associated with several health outcome in adulthood. Since the TSCD study is a longitudinal prospective cohort study, we will readdress the relationship between the health status and SES when the children become older.

KEYWORDS: Children; Socioeconomic status; Body mass index (BMI)

REFERENCE:

Wechsler D. Manual for the Wechsler Intelligence Scale for Children – Th ird Edition. Th e Psychological Corporation, San Antonio, TX, 1991.

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An Analysis of Health and Socioeconomic Status of Children in Japan: Is There Health Disparity among Children in Japan?

Aya Abe Director of Department of Empirical Research on Social Security,

National Institute of Population and Social Security Research

E ven though there have been numerous studies which indicate that health disparity among children

exists in developed countries, there has been notably few studies which investigated if the same is true in Japan. Th is study is one of the fi rst attempts to look at the health disparity among Japanese children accord-ing to socioeconomic status (SES) of household. Th e analysis mainly uses the 21st Century Baby Panel Survey and the Comprehensive Survey of Living Survey, both by the Ministry of Health, Labour and Welfare (MHLW). Th e former is a large scale government panel dataset on children born in 2000 and covers up to age six, and the latter is a cross-section data across all ages.

Th e paper reveals three main fi ndings. Firstly, the results show that there are evidences of health dispar-ity according to the SES of children in Japan, at least for preschool age children. Th is is confi rmed in some health indicators such as subjective health well-being,

hospitalization and asthma. Secondly, even though the health disparity among children increases with age in the US and Canada, the data in Japan does not conform to this result. It seems to increase up to age six using the panel data, but shows rather decreasing trend for ages above six using the cross-sectional data. Th irdly, using the panel data, the paper could not fi nd an evidence indicating that the eff ect of a past health shock diff ers across SES, a fi nding diff erent from that of analysis using the US data.

KEYWORDS: Health disparity; Poverty; Children; Socioeco-nomic status (SES)

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Impact of Educati onal Level on Blood Pressure Change during Pregnancy and Pregnancy Induced Hypertension: Hospital-Based Japanese Birth Cohort Study

Seung Chik Jwa, Takeo Fujiwara Department of Social Medicine, National Research Institute for

Child Health and Development, Japan

B ACKGROUND: Pregnancy induced hypertension (PIH) aff ects 3–10% of all pregnancies and is

associated with high levels of maternal, fetal, and neo-natal morbidity and mortality (Schroeder et al., 2002). Furthermore, the long termprognosis of women with a history of PIH includes increased risks of cerebrovas-cular disease, ischemic heart disease, and renal disease (Arnadottir et al., 2005). Th us, investigation for risk factors of PIH is essential for early detection and subse-quent treatment. Low educational level has been recently known as a risk factor of the occurrence of PIH (Silva et al., 2008). Th ey revealed the absence of midpregnancy blood pressure (BP) fall in low educational group is one of the pathways for increasing occurrence of PIH. In this study, our aim is to elucidate the relationship between educational level and BP changes from early to midpregnancy for Japanese pregnant women by using hospital-based Japanese birth cohort study.METHOD: We reviewed BP values before 16 weeks and at 20 weeks of gestation and presence of PIH after 22 weeks of gestation. Nine hundred and twenty three pregnant women with BP estimations recorded before 16 weeks and at 20 weeks of gestation participated in this study. Maternal educational level was categorized into three groups: high (university or higher), mid (somecollege) and low (<high school, high school, or vocational school).

RESULT: Low educational group had signifi cantly higher BP levels in both systolic (−2.37 mmHg, 95% C.I. −4.19 to −0.54 [high educational group]; −2.43 mmHg, 95% C.I. −4.54 to −0.33[middle educational group]) and diastolic (−0.78 mmHg, 95% C.I. −2.05 to 0.49 [high educational group]; −0.67 mmHg, 95% C.I. −2.13 to 0.80[middle educational group]) in early pregnancy in comparison with the higher educational groups; however, the same associations were not found after adjustment for BMI. All of three educational groups had midpreg-nancy BP falls both in diastolic and systolic, and the BP falls were not statistically diff erentiated by educational group. Th ere were no association between educational groups and PIH.CONCLUSION: In Japanese women, low educational group showed higher BP during pregnancy than mid or high educational group. However, educational level was not associated with BP fall and PIH. BP during pregnancy might be controlled in Japanese maternal care regardless of educational groups.

KEYWORDS: Pregnancy induced hypertension; Preeclampsia; Blood pressure; Educational level; Socioeconomic status

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Symposium 6Biological and Behavioral Mechanisms Underlying Associati on between Socioeconomic Status and Health

Chair: Hideki OhiraDepartment of Psychology, Nagoya University, Japan

6–1 Functional Association of Brain and Body in Rational and Emotional Decision Making: Implications for Understanding Association between Socio-Economic Status and Heath H. Ohira

6–2 Behavioral and Neurobiological Mechanisms Linking Low Socio-Economic Status with Diseases Y. Gidron

Lower socio-economic status (SES) measured by income, education, subjective evaluation of social

class, and so on, has been consistently associated with increased rates of morbidity and mortality. However, the mechanisms through which SES gets translated into biological risks of mental and physical diseases have been not fully understood. Recently, chronic stress has received widespread attention as a potential mediating mechanism by which SES can aff ect health and disease. Specifi cally, individuals with lower SES might be more exposed to stressful life events and have fewer social resources buff ering impacts of the stressful events. Such enduring exposure to stressors might cause alterations of biological structures and functions both in brain and peripheral tissues. Interventions to improve disadvanta-geous health states of individuals with lower SES should be developed and introduced on the basis of empirical evidence about such mechanisms. In this symposium, empirical studies about biological and behavioral mecha-nisms underlying association between SES and health will be introduced and their implications for application

to realistic fi elds will be discussed. Hideki Ohira will show fi ndings of combined-neuroimaging studies to elucidate functional association of brain and body in decision making. Furthermore, modulations of the brain-body association accompanying decision making by SES will be examined and meaning of such eff ects of SES in our real life will be discussed. Yori Gidron, after indicating several possible mechanisms linking SES and health, will show the role of the vagus nerve in multiple pathways leading to chronic diseases and its relation with SES. Furthermore, he will argue possibility that interventions to increase vagal activity using relaxation methods can reduce disease risks associated with low SES. On the basis of the talks by two speakers, perspectives of advances of basic research and applied interventions in future will be discussed.

KEYWORDS: Mechanisms of SES; Brain; Vagus nerve; Behav-ior; Intervention

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6–1

Functi onal Associati on of Brain and Body in Rati onal and Emoti onal Decision Making: Implicati ons for Understanding Associati on between Socio-Economic Status and Heath

Hideki Ohira Department of Psychology, Nagoya University, Japan

T hough traditional microeconomics has sup-posed that human decisions are based on logical

and exact computation of cost-benefi t balances or effi ca-cies, studies in behavioral economics have shown that humans sometimes make seemingly irrational decisions driven by emotions. In our everyday situations, factors related to decisions are complex and which alternative will be the most benefi cial is uncertain. In such cases, we sometimes make decisions not based on logical deliberation but based on emotional preferences and intuitions. Some theorists argued that one important source of such emotional drives aff ecting decision making is bodily responses which are represented in brain regions (Damasio, 1994; Craig, 2009). Th e core idea here is that socio-economic status (SES) can explain some portions of individual diff erences of variations of decision making in the dimension of rational and irrational/emotional poles, and further can aff ect our behaviors potentially related to our health and diseases. In this talk, empirical evidence for functional association of the brain and body accompanying decision making and potential roles of SES in it will be shown as follows. (1) Heart rate orienting responses and concentration of infl ammatory cytokine (IL-6) can predict acceptance or rejection to an unfair off er in an economical negotiation game, the Ultimatum Game. Activation of the anterior insula cortex mediates

this phenomenon. As SES aff ects both cardiovascular activity and systemic infl ammation, SES can modulate decision making and economical behaviors via media-tion of such neuro-physiological mechanisms. (2) Th e front-striatum neural network including the anterior cingulate cortex, orbitofrontal cortex, insula, and ventral and dorsal striatum plays key roles in decision making in an uncertain situation which is experimentally simulated in a reversal learning task. Such brain regions further fl exibly modulate peripheral cardiovascular activities on the basis of evaluation of contingencies between options and outcomes. Chronic job stress (high job demand and low job control), which is an important aspect of SES, aff ects the functional association of the brain and body in reversal learning. Specifi cally, individuals with high chronic job stress showed reduced brain activities and blunted patterns of cardiovascular responses. Such altered brain and body functions might be linked with mental and physical risks. Suggestions of these fi ndings in a psychosocial perspective of prevention of diseases and promotion of health will be discussed.

KEYWORDS: Decision making; Brain; Body

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6–2

Behavioral and Neurobiological Mechanisms Linking Low Socio-Economic Status with Diseases

Yori Gidron Faculty of Medicine and Pharmacy, Free University of Brussels, Belgium

S ocio-economic status (SES) represents a major risk factor of morbidity and mortality. SES is related

to income, education and residence. SES predicts risk of disease risk-factors such as hypertension, chronic dis-eases such as cardiovascular disease (CVD) and cancer, and all-cause and disease-specifi c mortality. Models in behavior medicine explaining such associations typically focus on behavioral and biological mechanisms. Th is presentation will focus on biological mechanisms, yet links them to behavior too. Low SES is related to infl am-matory markers and endothelial activation, and to lower vagal nerve activity (heart-rate variability – HRV), partly explaining the link between low SES and diseases. SES also moderates relations between other factors and health outcomes – In acutely hospitalized elderly Israelis, age was positively related to dysphoria and inversely related to lymphocyte levels, but only in less educated people.

Finally, data will be presented showing the role of the vagus nerve in multiple pathways leading to chronic dis-eases and its relation with SES. Increasing vagal activity can be done using various relaxation methods at no costs, and thus, could potentially constitute a feasible way to reduce the increased disease risks associated with low SES. Future intervention trials must examine eff ects of vagal activation in low-SES people.

KEYWORDS: Behavioral medicine; Vagal nerve activity; Heart-rate variability

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Symposium 7Cross-Cultural Methodology of Research on Social Determinants of Health

Chair: Akizumi Tsutsumi, MDOccupational Health Training Center,

University of Occupational and Environmental Health, Japan

7–1 Measuring Socioeconomic Position in Japanese Epidemiological Studies K. Honjo

7–2 Occupational Class Categorizations as a Socioeconomic Status Index May Have Diff erent Meaning between Japanese Men and Women A. Tsutsumi

7–3 Genetic Predisposition and Dietary Habits in Japan as a Cross-Cultural Modifi er of Health Outcomes K. Miyaki

7–4 Health and Trust on the Asia Pacifi c Values Survey (APVS) K. Yamaoka & R. Yoshino

Discussion: Which Socioeconomic Status Indicators Are Good for Taiwan? T-L Chiang

I n this symposium, we will discuss the cross-cultural (international) diff erences of socioeconomic status

(SES) indices and SES-health outcome relationships. We may be able to propose an international collabora-tive research using this opportunity. Our distinguished speakers will address the several important methodologi-cal issues on social determinants health from their own studies.

Dr. Kaori Honjo will summarize the SES indicators and review how each indicator can relate to health out-comes referring to the studies conducted in Western countries, then she will address future challenges of refi ning measures for socioeconomic position in epide-miological research in Japan.

Using the database of Japanese community-dwelling workers, Professor Akizumi Tsutsumi will display the results to indicate that occupational class categorizations as an SES index may have diff erent meaning between Japanese men and women, and concludes that there is room for refi ning the occupational classifi cation.

Dr. Koichi Miyaki will address the very new area in this research fi eld: gene. He will introduce some genetic predispositions specifi c to the Japanese population in rela-tion to dietary habits and diet-related health outcomes,

and will show clear gradient of folate intake (calculated by a food frequent questionnaire) across socioeconomic positions—educational attainment and family income.

Professor Kazue Yamaoka and Professor Ryozo Yoshino will present the associations between sense of trust—an important dimension of social capital—and three measures of health and well-being across Asia and Pacifi c countries, to answer the relevant study question: is trust associated with health and well-being in Asia and Pacifi c countries and areas?

Finally, we will have a few comments from Professor Tung-liang Chiang. In addition to the presentations of the previous four speakers, Professor Chiang will pro-vide some international and/or Asian perspectives on SES index by referring to his own research “Which SES indicators are good for Taiwan?”

We would like to discuss what we should do to get further insight on this relevant theme including possible international collaborative research.

KEYWORDS: Epidemiology; Gender; Genetic predispositions; Socioeconomic position; Trust

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7–1

Measuring Socioeconomic Positi on in Japanese Epidemiological Studies

Kaori HonjoOsaka University Global Collaboration Center

M easuring socioeconomic position, which indicate one’s structural location within society,

has been one of the major and diffi cult challenges in health inequality research. Traditionally, majority of research have used education level, occupation, income, and wealth as measures for socioeconomic position in epidemiological research.

In Japan, researchers closely examined social inequali-ties in health and a number of epidemiological studies on the association between socioeconomic position and health have been produced during the last decade. As many of them employed education level, occupation, and income as measurements for socioeconomic position, one begins to wonder how those indicators could relate to health in a way to create gradients.

In Weberian sociology, education level, occupation, and income were regarded as key factors to predict indi-vidual’s “life chances.” Especially, educational attainment is thought to provide key information about probability of individual future success. Education attainment can

determine types of occupations that one can obtain; people with a higher degree are more likely to obtain a prestigious occupation. People with a prestigious occu-pation are likely to earn higher income than those with obtaining lower education. Th us, types of occupations are likely to predict the amount of economical returns to people, as a form of income that closely relates indi-vidual economical power to obtain material resources. In this aspect, occupation can be a middle factor between education level and income.

In this presentation, I will address how each socio-economic indicator can relate to health and its strengths and limitations within epidemiological research. Th en, I will address future challenges refi ning measures for socio-economic position in epidemiological research in Japan.

KEYWORDS: Socioeconomic position; Measurement; Japan

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7–2

Occupati onal Class Categorizati ons as a Socioeconomic Status Index May Have Diff erent Meaning between Japanese Men and Women

Akizumi Tsutsumi, MDOccupational Health Training Center,


L iterature indicates that workers in less privileged occupations are more vulnerable to occupational

stress, which provides one of the mechanisms of social determinants of health. Th e aims of the present study were to analyze the association between incident stroke, occupational class and stress and to examine whether the association is found in both men and women in a prospective study of Japanese male and female workers.

A total of 3,190 male and 3,363 female Japanese community-dwelling workers aged 65 or under with no history of cardiovascular disease were followed. Occupational stress was evaluated using a demand-con-trol questionnaire. Th e impact on stroke was examined in stratifi ed analyses by the two categories of occupa-tion (white-collar and blue-collar) and two categories of position (manager and non-manager), separately for men and women. Participants’ occupations at baseline were classifi ed according to the National Statistics guide-lines (Ministry of Internal Aff airs and Communications, 1998). Th e following occupations were included: profes-sional or technician; clerk; sales worker; service worker; farming, forestry, or fi sheries worker; security worker; transportation or communications worker; construc-tion worker; craft worker or laborer and unclassifi ed. Regarding occupation, the fi rst four job categories (from professional/technician to service worker) were classed as white-collar jobs; the remainder were classed as blue-collar jobs. If participants reported themselves to be a manager, they were classed as white-collar, regardless of their chosen job category. Positions were classed as either manager or non-manager. Subjects were categorized as managers if they reported themselves to be self-employers or managers at their companies. Th e managerial posi-tions included relatively large numbers of employers or administrative personnel.

We identifi ed 147 incident strokes (91 in men and 56 in women) during the 11-year follow-up period. We found a signifi cantly higher risk of incident stroke in men with high job strain (combination of high job demand and low job control) among blue-collar workers and those in non-managerial jobs, but not among white-collar workers or those in managerial positions. Th e opposite trends were observed in women, i.e., signifi cant elevated risks among white-collar and managerial workers, but not among blue-collar workers or those in non-managerial positions.

As service/sales occupations resemble low occupa-tional class with instability, low pay and high job demand in many contexts, we conducted an explanatory analysis in an alternative occupational category in which service/sales workers were classed as blue-collar occupations (low occupational class). Th e initially observed risk of job strain among female white-collar workers was reduced and became insignifi cant in the explanatory analysis, and the risk in male blue-collar workers became more prominent.

Our study of Japanese workers provided supportive evidence for vulnerability to occupational stress among lower occupational class workers in males but not in females. Obviously, there is room for refi ning the occu-pational classifi cation.

KEYWORDS: Gender; Occupations; Psychological stress; Socio-economic factors

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7–3

Geneti c Predispositi on and Dietary Habits in Japan as a Cross-Cultural Modifi er of Health Outcomes

Koichi Miyaki, MD, PhDDivision of Clinical Epidemiology, Department of Clinical Research and Informatics,

National Center for Global Health and Medicine, Japan

T he association of socioeconomic status (SES) with health outcomes attracts public attention worldwide.

When we discuss the health levels of countries which have undergone modernization such as Japan and other Asian nations, it is essential to take the impact of lifestyle westernization into account. From the earliest times, dif-ferent culture has diff erent eating pattern. But the wave of westernization come all over the world, and Japanese were also infl uenced. A longitudinal epidemiological study demonstrated that consumption of animal products in Japan increased from 1960s to 1990s, refl ecting dietary westernization, and this change was accompanied by the elevation of serum total cholesterol level. Despite the cholesterol elevation in Japanese, the age-adjusted death rate from ischemic heart diseases (IHD) has not risen. Moreover, Japan has one of the lowest death rates from IHD among developed countries. Th is discrepancy can be attributable to genetic predispositions specifi c to the Japanese population.

Th e International HapMap Consortium has prepared a database of approximately 1.6 million SNP, covering the entire genomic region, of 1,184 individuals from 11 diff erent populations throughout the world, enabling visual assessment of common features and diff erences among races. Our recent study in Japanese subjects sug-gested a signifi cant glycohemoglobin (HbA1c) infl uence under the interaction of CDKAL1 gene and caloric intake. Regarding this gene’s polymorphism, comparison of the frequency of this allele among diff erent races indicates that the frequencies of the risk allele in Asian races are three times higher than those in Caucasians. Th is fi nd-ing suggests that even when the biological mechanism underlying a disease-associated gene polymorphism is consistent among races, the frequency of the polymor-phism can vary greatly among races, possibly resulting in diff erences in health status achieved under identical healthcare systems and socioeconomic situations.

Th ere are not only quantitative but also qualitative diff erences. It is widely recognized that type 2 diabetes

mellitus in Japanese people are characterized by the lack of accompanying severe obesity. Th e pathophysiologi-cal diff erences underlying this characteristics remain unknown, but recently it was shown that C566T poly-morphism of KCNJ15 expressed on pancreatic beta cells is associated with diabetes mellitus in non-obese Japanese people. According to the Hapmap 3 databese, this poly-morphism is not seen at all in Caucasians. Th is fi nding indicates that the impact of the pathologic condition of

“obesity” on diabetes mellitus shows certain qualitative diff erences among diff erent races.

Recently, evidences indicating that the inequalities of socio-economical factors infl uence the health outcomes are being accumulated also in Japan. For example, folate has been implicated to have protective eff ects in athero-sclerosis, depression, cognitive function and so on and we hypothesized it as the mediator of the association above. Our group examined the association of SES with dietary folate intake level in 2,266 Japanese workers. After adjusting age and sex, both the years of education and equivalent household income signifi cantly aff ect the suffi cient folate intake. 36.4% subjects did not attain the Japanese recommended dietary allowances (RDA) level of folate. In the United States, the Food and Drug Administration mandated the folate fortifi cation of grain products by January 1998, and RDA level is higher than that of Japan. We do not have fortifi cation policy and nutritional intervention has a room to relieve the SES eff ect on health outcomes in Japan. Th is is the typical example of diff erence in health policy. When we think cross-culturally, we need to pay attentions to genetic and cultural background factors as a modifi er of health outcomes.

KEYWORDS: Health outcome; Economic development; Dietary habit; Genetic polymorphism; Cross-cultural modifi er

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7–4

Health and Trust on the Asia Pacifi c Values Survey (APVS)Kazue Yamaoka1, Ryozo Yoshino2

1Teikyo University, Graduate School of Public Health, Tokyo, Japan2Th e Institute of Statistical Mathematics, Tokyo, Japan

I t has been increasingly acknowledged that trust as one of social capital factors is an important deter-

minant of health and overall well-being. Cross-country studies including countries from Europe, North America, and Asia found some indices of social capital to be posi-tively associated with health. To investigate the relations of social and cultural factors to health, Yamaoka (2008) has analyzed population-based survey result from the East Asia Values Survey (EAVS) conducted by Yoshino and his colleagues during 2002–2004. Th e present study aims to advance the research and examine the eff ects of trust and related factors on individual health based on the results of newly developed survey projects. We analyzed the results of the fi rst and the second Asia Pacifi c Values Surveys (APVS), conducted by Yoshino and his colleagues (2004–2009, 2010–), in this study. Th e research question was: “Is trust associated with health and well-being in Asia and Pacifi c countries and areas?”

Th e target population was adults residing in each country. Th e questionnaire was a semi-structured ques-tionnaire that was specifi cally developed for the study. In all questionnaires, linguistic cross-cultural comparability was examined through the translation and back-transla-tion method between Japanese and each foreign language. Because one of the most important objectives of our

survey was to investigate the applicability of statistically rigorous methods of random sampling, we tried very hard to use probabilistic random sampling whenever possible. Th e sample selection process diff ered corresponding to the circumstances in each country. Th e details of the surveys were reported in each survey report (http://www.ism.ac.jp/~yoshino/index.htm).

Sense of trust – a dimension of cognitive social cap-ital – is measured by two items related to trust such as “interpersonal trust” and “norms of reciprocity.” Organizational membership, a dimension of structural social capital, has been cited as a factor that infl uences health (Kawachi & Kennedy, 1997), and in this study it was measured as a dichotomous variable.

Th ree measures of health and well-being, namely: the number of self-reported somatic symptoms; degree of subjective health satisfaction; and of life satisfaction, were examined in the present study. Th e results of the analysis will be shown in the presentation.

KEYWORDS: Subjective health; Trust; Cross-cultural survey; Asia Pacifi c Values Survey (APVS); Social capital

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Symposium 8Social Determinants of Health: Interventi on and Policy

Chair: Naoki Kondo, MD, PhDDepartment of Health Sciences, Interdisciplinary Graduate School of

Medicine and Engineering, University of Yamanashi

8–1 Can Systems Approaches Help Us Understand the Impact of Interventions in Social Epidemiology? A. V. Diez-Roux

8–2 Health Impacts Assessment: A Tool Linking Policy and Social Determinants of Health Y. Fujino

8–3 WHO’s Urban HEART – Th e Urban Health Equity Assessment and Response Tool M. Kano

I n recent years, there are moves trying to shift from the research on social determinants of health (SDH)

to implement action on SDH. Empirical evidence on SDH is complex by its nature, i.e., that it is stuck on the complex web of causality which involves not only individual-level factors but also many, mutually asso-ciating, higher-level factors at the global, macro-social, and intermediate (or meso) levels. Moreover, actions on SDH involve many “players,” who are the people in the community, health care providers, policy makers, enterprises, and many others. Policy makers in public health are required to harmonize those players’ interests, which can be very challenging in some cases.

In this symposium, we invite three leading research-ers who have devoted their eff orts to develop systems for the better understanding of the complex SDH cau-salities and the tools assisting policy makers to develop health policies based on the evidence of SDH. Th e fi rst speaker, Professor Ana Diez-Roux from the University of Michigan, will discuss about achievement and chal-lenges of the new “systems approaches,” a simulation technique recently introduced to the fi eld of SDH study, which has attracted many researchers in this fi eld because of its high potentiality for better and more pragmatic

understandings of the complex causal pathways on SDH. Th e second speaker, Dr. Yoshihisa Fujino of the University of Occupational and Environmental Health will provide a brief introduction of the Health Impact Assessment (HIA), a rapidly spreading framework of the assessment of the impacts of policy interventions on population health. His speech will cover the importance of better understanding of SDH for HIA and how the knowledge on SDH can be used in a HIA process, as well as the recent trends in HIA activities in the world. Our fi nal speaker is Dr. Megumi Kano of the WHO Kobe Centre, who has taken a central role in developing Urban HEART, a World Health Organization’s tool for Health Equity Assessment that has been developed to guide decision makers of urban cities assessing the health equity in their cities and making proper evidence-based policies. In the discussion with all participants after these three talks, we will wrap-up this session addressing future possibilities and challenges of the actions on SDH.

KEYWORDS: Policy; Intervention; Systems approaches; Health Impact Assessment; World Health Organization

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8–1

Can Systems Approaches Help Us Understand the Impact of Interventi ons in Social Epidemiology?

Ana V. Diez-Roux, MD, PhD, MPH Center for Social Epidemiology and Population Health,

University of Michigan

T here has been growing interest in the applica-tion of systems thinking and systems tools to the

understanding of the causes of health inequalities and to the evaluation on the impact of interventions. Th is presentation will review the fundamentals of systems approaches, discuss how they diff er from observational and experimental studies, and highlight their potential utility in social epidemiology. Examples of their use will be provided. Th e presentation will conclude with a review of the challenges inherent in the use of systems tools.

KEYWORDS: Inequalities; Systems; Health disparities

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8–2

Health Impacts Assessment: A Tool Linking Policy and Social Determinants of Health

Yoshihisa Fujino, MD, MPH, PhD Department of Preventive Medicine and Community Health,


H ousing, education, transport, food, city plan-ning, namely, social determinants, all have great

impacts on health of individual and community. Th ese issues naturally belong to non-health sector policies. However, there is no social mechanism in which health impact of policies are considered prospectively in Japan, and health impact of non-health sector polices are often overlooked in a policy-making process. Health impact assessment (HIA) is defi ned as “a combination of pro-cedures, methods, and tools by which a policy, program, or project may be judged as to its potential eff ects on the health of a population, and the distribution of those eff ects within the population” (WHO, 1999). Th e aims of this presentation are to give a brief introduction of HIA, and discuss following issues with participants:

• Th e conceptual roots of HIA: environmental impact assessment, social determinants, and health inequality

• Role of social determinants in HIA• “Health assessment” on the basis of socio-environ-

mental model• Emphasis on health inequity: Health Equity Impact

Assessment• A practical tool to support Health in All Policies

KEYWORDS: Health Impact Assessment (HIA); Socio-envi-ronmental model of health; Health in All Policies; Healthy Public Policy

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8–3

WHO’s Urban HEART – The Urban Health Equity Assessment and Response Tool

Megumi Kano, DrPHWorld Health Organization Centre for Health Development

(WHO Kobe Centre)

B ACKGROUND: In 2006–07, the WHO Centre for Health Development (WKC) served as the hub for

the Knowledge Network on Urban Settings, which was one of the nine knowledge networks supporting the work of the WHO Commission on Social Determinants of Health. Th e fi ndings from this network elucidated the complex web of determinants of urban health and the actions needed to address them. Since then, WKC has been intensifying its eff orts to equip urban policy makers with the evidence and tools necessary to improve health equity. In order to facilitate appropriate policy actions especially at the local government level, WKC subse-quently developed the Urban Health Equity Assessment and Response Tool (Urban HEART).OBJECTIVE: Urban HEART is a new tool available from WHO which guides decision-makers through a pro-cess to identify health inequities in their city (or cities) by assessing indicators on health outcomes and health determinants, and then developing actions based on the evidence generated.METHOD: Th e tool was developed through a joint eff ort led by the WHO Kobe Centre in collaboration with regional offi ces of WHO, and city and national offi cials from across the world. Th e expertise of an Ad Hoc Advisory Group helped strengthen the scientifi c validity and practical utility of the tool. Inputs from the teams that pilot-tested the tool were essential in the

development of Urban HEART. In total, 17 munici-palities in 10 countries (Brazil, Indonesia, Iran, Kenya, Malaysia, Mexico, Mongolia, Philippines, Sri Lanka, Viet Nam) participated in the pilot test.RESULTS: Urban HEART was published in 2010 and is currently available in English, French and Spanish. A companion User Manual which provides step-by-step instructions on how to implement Urban HEART is also available. Standardized training workshops have been conducted to facilitate the uptake of Urban HEART, globally. Some cities/countries are institutionalizing the use of Urban HEART. Th e pilot study results and grow-ing interest in Urban HEART are promising signs of its wider application and its potential for making health equity assessment and response a routine practice for city governments.CONCLUSIONS: A new tool is available from WHO which responds to the needs of local and national policy makers who want to systematically use broad-based evi-dence to identify health inequities and prioritize actions for tackling them. Further research is necessary to evalu-ate and improve the eff ectiveness of the tool.

KEYWORDS: WHO; Urban health; Health equity; Equity assessment; Health determinants

63

POSTERSESSIONS

Poster Session A10:15–10:45, August 6 (Sat)Elevator Hall (14th Floor)

A–1 Income and Health among Japanese Elderly Using a Panel Data Y. Fujino et al.

A–2 Organizational Justice and Psychological Distress among Permanent and Non-permanent Employees in Japan: A Prospective Cohort Study A. Inoue et al.

A–3 One-Year Test-Retest Reliability of Diagnosis of Major Depression Using a Web-Based Version of the WHO Composite International Diagnostic Interview (CIDI) in a Working Population H. Shimoda et al.

A–4 Diff erence in Use of Emergency Department Services among Subscribers to Two Health Insurance Plans in Japan: A Hospital-Based Study H. Inada et al.

A–5 Eff ect of Social and Economic Status on the Association between Intimate Partner Violence and Healthcare Utilization: Secondary Analysis of the Japanese Study of Stratifi cation, Health, Income, and Neighborhood N. Kawakami et al.

A–6 Factors Associated with Non-utilization of Health Checkups and Physician/Dentist Consultations: Access to Preventive and Curative Services in Japan Y. Kobayashi et al.

A–7 Patterns of Degrading Self-Rated Health and Its Factors: Using Group-Based Trajectory Models T. Nakata

Poster Session B10:00–10:30, August 7 (Sun)Elevator Hall (14th Floor)

B–1 Income Equality in Japanese Corporations and Employee Health T. Kouno et al.

B–2 Income Inequality, Social Capital and Self-Rated Health and Dental Status in Older Japanese J. Aida et al.

B–3 Exploring Hikikomori – A Mixed-Methods Qualitative Research R. K. F. Yong et al.

B–4 Association of Objective and Subjective Social Status with Psychological Distress among Japanese Workers: Explanations from Internal and External Resources K. Kubota et al.

B–5 Alternative Splice Variants of SMG-1 as a Potential Marker for Brief Naturalistic Stressors in Peripheral Leukocytes Y. Kuwano et al.

B–6 High-Th roughput Screening of Immunomodulators Identifi es VEGF as a Potential Biomarker for Trait Anxiety and Depressive Mood in Healthy Japanese University Students M. Honda et al.

B–7 Health Eff ect of Job Mobility Y. Shiotani

B–8 Mediation of the Association between Social Class and Health through Psychological Resources in the US and Japan C. Kan et al.

POSTERS

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A–1

Income and Health among Japanese Elderly Using a Panel DataYoshihisa Fujino1, Ryuichi Tanaka2, Shinya Matsuda1

1Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health2National Graduate Institute for Policy Studies, Japan

OBJECTIVE: Th is study aimed to examine the eff ect of income on health among Japanese elderly using a panel data.METHODS: A total of 3,000 subjects aged 60 years or older were randomly recruited in Y City, Japan, in 2002, of whom 2,773 provided complete information for anal-ysis. A trained local welfare commissioner visited the subjects annually from 2002 to 2007. Mobility status was measured according to the Typology of the Aged with Illustrations, a validated instrument for the measurement of elderly function. Income level was classifi ed according to taxation base for long-term care insurance premiums. First-diff erence method was used to examine the eff ect of income level on mobility concerning individual eff ects. In addition, instrumental variable (IV) method, which assuming sequential moment restriction, was used to consider endogeneity.

Structural ModelHit=βt+β1Iit-1+β2Hit−1+Xitβ3+ε

1it

Iit=αt+α1Hit+α2Iit−1+Zitα3+ε2

itε1

it=α1i+u

1it

ε2it=α

2i+u

2it

H_it: Health measureI_it: Income measureX_it, Z_it: Strictly exogenous control variables

RESULTS:

Dynamic Panel Model of Eff ect on Mobility Status.

Coef. SE p 95% CI

Mobility_LD 0.075 0.025 0.003 0.026 0.124

Income_LD −0.005 0.034 0.878 −0.072 0.061

Living arrangement_D1 0.463 0.031 0.000 0.402 0.524

CONCLUSION: Previous year’s health and current living arrangement measure aff ects the current health, but income has no statistically signifi cant eff ect on health.

KEYWORDS: Income; Cohort; Panel data; Instrumental vari-able

A–2

Organizati onal Justi ce and Psychological Distress among Permanent and Non-permanent Employees in Japan: A Prospecti ve Cohort StudyAkiomi Inoue1, Norito Kawakami2, Kanami Tsuno2,3, Kimiko Tomioka4

1Department of Mental Health, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health2Department of Mental Health, Graduate School of Medicine, Th e University of Tokyo3Japan Society for the Promotion of Science4Department of Community Health and Epidemiology, Nara Medical University

OBJECTIVE: Organizational justice has recently been introduced as a new concept as psychosocial determi-nants of employee health and an increase in precarious employment is a challenging issue in occupational health. However, no epidemiological study investigated the association of organizational justice with mental health among employees while taking into account employ-ment contract. Th e purpose of the present study was to investigate the prospective association of organizational justice (procedural justice and interactional justice) with psychological distress by employment contract among Japanese employees.METHODS: A total of 373 males and 644 females from fi ve branches of a manufacturing company in Japan were surveyed. At baseline (August 2009), self-administered questionnaires, including the Organizational Justice Questionnaire (OJQ), the K6 scale (psychological distress scale), the Eysenck Personality Questionnaire-Revised (EPQ-R), and other covariates, were used. After one-year follow-up (August 2010), the K6 scale was used again to assess psychological distress. Multiple logis-tic regression analyses were conducted by gender and employment contract.RESULTS: After adjusting for demographic characteristics, psychological distress, and neuroticism at baseline, low procedural justice was signifi cantly associated with a higher risk of psychological distress at follow-up among non-permanent female employees while no signifi cant association of procedural justice or interactional justice with psychological distress at follow-up was observed among permanent male or female employees. Th e results of non-permanent male employees could not be calcu-lated because of small sample size.CONCLUSION: Low procedural justice may be an important predictor of psychological distress among non-permanent female employees.

KEYWORDS: Procedural justice; Interactional justice; Mental health; Precarious employment; Longitudinal study

POSTER

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A–3

One-Year Test-Retest Reliability of Diagnosis of Major Depression Using a Web-Based Version of the WHO Composite Internati onal Diagnosti c Interview (CIDI) in a Working Populati onHaruki Shimoda1, Akiomi Inoue2, Norito Kawakami1, Kanami Tsuno1,3

1Department of Mental Health, Graduate School of Medicine, Th e University of Tokyo2Department of Mental Health, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health3Japan Society for the Promotion of Science

OBJECTIVE: Th e purpose of this study was to investigate the one-year test-retest reliability and its demographic correlates of the lifetime diagnosis of major depressive disorder assessed by a self-administered web-based ver-sion of the WHO-Composite International Diagnostic Interview (CIDI) depression section in a working population.METHODS: A total of 1,060 out of all employees (N=1,279) in Japan responded to two web-based surveys using the depression section of the WHO-CIDI in 2009 and 2010, with an one-year interval. Th e concordance between lifetime diagnoses of major depressive disorder at two occasions was calculated as percent agreement (%), Gwet’s AC1, and Yule’s Q, and these indicators were compared among groups classifi ed by sex, age, education, and marital status.RESULTS: For the total sample, percent agreement was 94%, AC1 was 0.93, and Yule’s Q was 0.82. AC1 and Yule’s Q for those less educated were lower. AC1 and Yule’s Q for those less educated were lower. Among those who were not diagnosed in 2009, females and younger age group were more likely to be diagnosed in 2010 (p<0.05).CONCLUSION: Th e one-year test retest reliability of the web-based version of CIDI depression section was high in percent agreement, AC1 and Yule’s Q. Among subgroups, the agreement indicators were lower for the less educated, suggesting that educational status aff ects recalling or reporting a lifetime episode of major depressive disor-der. Disagreement of the diagnoses at the baseline and follow-up may suggest present mental status aff ected the lifetime diagnosis of major depression.

KEYWORDS: WHO-Composite International Diagnostic Interview (WHO-CIDI); Major depression; Reliability; Psy-chiatry; Demographic characteristics

A–4

Diff erence in Use of Emergency Department Services among Subscribers to Two Health Insurance Plans in Japan: A Hospital-Based StudyHaruhiko Inada, Yasuki KobayashiDepartment of Public Health, Graduate School of Medicine, University of Tokyo

OBJECTIVE: To describe the use of the emergency department services (EDS) among subscribers to Japan’s National Health Insurance (NHI) and Employee’s Health Insurance (EHI) before and after the increase of copayment introduced in April 2008 at a large sub-urban hospital.METHODS: We collected data on patients who used the EDS before and after the increase of copayment. Patients were classifi ed by the presumed urgency status which was defi ned by two conditions: Patients who presented to the emergency department by ambulance (urgent) or other means (nonurgent); Patients who were hospital-ized after the visit (urgent) or sent home (nonurgent). We employed Poisson regression analysis to model the number of patients of each status as dependent variables, with health insurance plan, age, sex, increased copay-ment, and time of visit as independent variables, and person-hours as an off set term. Models were selected by Akaike’s information criterion.RESULTS: Use of EDS was 1.14–1.34 times more among NHI subscribers than EHI subscribers in all four statuses, with largest diff erence in patients who presented to the emergency department by ambulance. After the increase of copayment, use of EDS declined approximately by 40% among nonurgent patients and remained unchanged among urgent patients. Interaction term between health insurance plan and increased copayment was not selected.CONCLUSION: Use of EDS was higher among NHI sub-scribers than EHI subscribers. Th e eff ect of increased copayment was consistent across the insurance plans.

KEYWORDS: Emergency department; National health insur-ance; Employee’s health insurance; Copayment

POSTERS

66

A–5

Eff ect of Social and Economic Status on the Associati on between Inti mate Partner Violence and Healthcare Uti lizati on: Secondary Analysis of the Japanese Study of Strati fi cati on, Health, Income, and NeighborhoodNorito Kawakami, Maki UmedaDepartment of Mental Health, Graduate School of Medicine, Th e University of Tokyo

OBJECTIVE: Th is study investigated the cross-sectional association of the intimate partner violence (IPV) with healthcare utilization using a preliminary data set of the Japanese Study of Stratifi cation, Health, Income, and Neighborhood (J-SHINE). Th e association was tested by social economic status (SES) to examine the modify-ing eff ect of SES on healthcare utilization among those who experienced IPV.METHODS: Secondary data of 4,280 respondents to the baseline survey of the J-SHINE were analyzed. Respondents were aged 25 to 50 years’ old who lived in Kanto area, Japan, and had a partner at the time of survey. IPV was assessed by a modifi ed version of CTS2 Short Form, and defi ned as having psychological or physical perpetration or/and victimization experience from their partner in the past 12 months. Logistic regres-sion model was used to assess the association between IPV and healthcare utilization adjusting for SES (house-hold income and education). Th e association was further examined, stratifi ed by SES.RESULTS: Th e IPV group utilized health care in the past 12 months more frequently (70.0%) than in the non-IPV group (65.5%) (p=0.006). After adjusting for SES, IPV was found to be signifi cantly associated with health care utilization (OR=1.35; 95%CI=1.15–1.58). Th e associa-tion was stronger among a group with lower household income or with higher education, while the interaction term was not signifi cant (p>0.05).CONCLUSION: Experiencing IPV was found to increase utilization of health care. Household income and edu-cation seem to have diff erential modifi cation eff ects on the association.

KEYWORDS: Intimate partner violence; Health care utilization; Social and economic status; Japan

A–6

Factors Associated with Non-uti lizati on of Health Checkups and Physician/Denti st Consultati ons: Access to Preventi ve and Curati ve Services in JapanYasuki Kobayashi, Chie Kaneto, Satoshi ToyokawaDepartment of Public Health, Graduate School of Medicine, Th e University of Tokyo

OBJECTIVE: To investigate the factors associated with access to preventive and curative services in Japan.METHODS: Th is study used data from the Japanese Study of Stratifi cation, Health, Income, and Neighborhood (J-SHINE). Subjects were 25–50 years old and were randomly selected from residents of 4 cities in the Kanto region. Logistic regression models were used to examine the possible eff ects of gender, age, marital/partner status, educational level, household income (equivalent income), working status, health insurance type (National Health Insurance/Social Insurance), and residential area on non-utilization of health checkups (i.e., preventive services) or physician/dentist consultations (i.e., curative services) in the past year. Additional analyses by reason for non-utilization were also conducted.RESULTS: Non-utilization of health checkups was signifi -cantly associated with female gender, younger age, lower educational level, lower household income, out-of-work status, and enrollment in the National Health Insurance. When analyzed by reason for non-utilization, a strong association was found between cost concerns and lower household income, and between lack of opportunity (including lack of information) and younger age. Lower household income and younger age were also signifi cantly associated with non-utilization of physician/dentist con-sultations. Cost concerns and lack of time were primary reasons for not seeing a physician/dentist among people with lower household income.CONCLUSION: Certain demographic and socioeconomic characteristics, especially age and household income, may aff ect access to preventive and curative services in Japan.

KEYWORDS: Access to healthcare; Socioeconomic character-istics; Demographic characteristics; Japan

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67

A–7

Patt erns of Degrading Self-Rated Health and Its Factors: Using Group-Based Trajectory ModelsTomoo NakataHokusei Gakuen University

OBJECTIVE: Th e aim of this study is to examine the “Longer life but worsening health” hypothesis, which is constructed about deteriorating health, using the group-based trajectory analysis. While there are some approaches to validate the health trajectories, this model has some advantages, such as non-continuous variables can be handled.METHODS: Th is study employed the National Survey of the Japanese Elderly, from wave I (1987) to wave IV (1996) , which was conducted by Michigan University and Tokyo Metropolitan Institute of Gerontology. Th e independent variable was a series of dummy variable of self-rated health (SRH) and independent variable was age. Education and gender were used as time-stable covariates and occupational and marital statuses were used time-varying covariates.RESULTS: From the goodness of fi t test using Bayesian information criterion (BIC), dividing into three groups was adequate in this analysis. Adding exogenous variables in this model, these facts were revealed of this analysis were as follow: 1) Th e fi rst group are occupied by women, the others are males; 2) Th e members of the third group have higher education; 3) Both marital and occupational statuses are also eff ects on health of some groups.CONCLUSION: Th ese results show that, females tend to enjoy good health, but their health declines dramatically, males’ SRH is defi ned by their education, the less-edu-cated people are in poor health predictably. Th ese seem to consistent with the “compression of morbidity” theory concerning social stratifi cation and gender.

KEYWORDS: “Longer life but worsening health” hypothesis; Social stratifi cation; Process of deteriorating health; Life events

POSTERS

68

B–1

Income Equality in Japanese Corporati ons and Employee HealthToshiaki Kouno, Yukiko Saito-UmenoEconomic Research Center, Fujitsu Research Institute

OBJECTIVE: To assess the relationship between the health of employees and intra-company wage inequality.METHODS: We obtained monthly reports on Health Insurance Associations from the Ministry of Health, Labour, and Welfare in accordance with the Law Concerning Access to Information held by Administrative Organs. Because Health Insurance Associations are established with respect to each major company or trade organization, our dataset is a national survey which covers the majority of Japanese employees working in major Japanese companies and industries. We investigated the relationship between the health index (mortality rate and rate of persons receiving injury and sickness allowance) and average salary, average age, intra-company wage inequality, and other determinants of health in a cross sectional study and a panel data study.RESULTS: Income inequality was signifi cantly correlated with mortality rate and rate of persons receiving injury and sickness allowance after controlling for confound-ing factors, including average age, average income, and ratio of women.CONCLUSION: Th ese data suggest that intra-fi rm wage inequality aff ects the health of employees in major Japanese companies and industries.

KEYWORDS: Income equality; Health Insurance Association; health; Japan

B–2

Income Inequality, Social Capital and Self-Rated Health and Dental Status in Older JapaneseJun Aida1, Katsunori Kondo2, Naoki Kondo3, Richard G. Watt4, Aubrey Sheiham4, Georgios Tsakos4

1Department of International and Community Oral Health, Tohoku University Graduate School of Dentistry, Sendai, Japan2Center for Well-being and Society, Nihon Fukushi University, Nagoya, Japan3Department of Health Sciences, Interdisciplinary Graduate School of Medicine and Engineering, University of the Yamanashi, Chuo-shi, Japan4Department of Epidemiology and Public Health, University College London, London, UK

OBJECTIVE: Th ere are relatively few multilevel studies on the relation between income inequality, social capital and health outcomes. Th e aim of this study was to examine whether the associations between income inequality and two disparate health outcomes, self-rated health and dental status, were attenuated by individual and com-munity social capital.METHODS: Self-administered questionnaires were mailed to subjects in the Aichi Gerontological Evaluation Study (AGES) Project in 2003. Responses were obtained from 5,715 subjects and 3,451 were fi nally included into the analysis. Gini coeffi cient was used as measure of income inequality. Trust and volunteering were used as cognitive and structural individual-level social capital measures. Rates of subjects reporting mistrust and non-volunteering in each local district were used as cognitive and struc-tural community-level social capital variables. Sex, age, marital status, education, individual- and community-level equivalent income and smoking status were used as covariates. Dichotomized responses of self-rated health and number of remaining teeth were used as outcomes in the multilevel logistic regression.RESULTS: Income inequality was signifi cantly associated with poor dental status (OR=1.86) and marginally signif-icantly associated with poor self-rated health (OR=1.39). Community-level structural social capital attenuated the covariate adjusted odds ratio of income inequality for self-rated health by 16% whereas the association between income inequality and dental status was not substantially changed by any social capital variables.CONCLUSION: Social capital partially accounted for the association between income inequality and self-rated health, but did not aff ect the strong association of income inequality and dental status.

KEYWORDS: Income inequality; Social capital; Self-rated health; Dental status; Multilevel analysis

POSTER

S

69

B–3

Exploring Hikikomori – A Mixed-Methods Qualitati ve ResearchRoseline Kim Fong Yong1, Richard Fielding2, Norito Kawakami11Th e University of Tokyo2Th e University of Hong Kong

OBJECTIVE: In Japanese, hikikomori are people who voluntarily withdraw into social isolation for over six months. Etiology and epidemiology are poorly under-stood, and evidence for interventions is lacking. Th e purpose of this study is to describe onset and mainte-nance of hikikomori.METHODS: Direct recruitment, snowballing and par-ticipant observation in on-line chat rooms were used to recruit participants and obtain data, which was then subject to grounded theory analysis.RESULTS: Of 168 participants several were unconnected with Japan, the oldest being 60 years old. Th ree major themes emerged of hikikomori as passive coping, trust and existence. Each theme comprised one or more cat-egories, which in turn evidenced a number of diff erent elements. Defi nitive characteristics of hikikomori were obtained from respondents through virtual participant observation. Th e emergent theoretical framework and the list are mutually supportive in the results obtained from this study, which suggested emotional pain exists in hikikomori in relation to human relationships. Th e results of the present study suggest that hikikomori is characterized by more diff use features, including dif-fi culties in coping with people or tasks, diffi culties with trust, unhappiness about life and poor concept of time. Th ere was no evidence of violent or aggressive behaviours.CONCLUSION: We conclude that hikikomori is not unique to Japanese youth, but more widespread and diverse anomic coping style for dealing with social dis-aff ection seen cross-culturally.

KEYWORDS: Hikikomori; Social withdrawal; Social isolation; Social disaff ection; Anomic coping style

B–4

Associati on of Objecti ve and Subjecti ve Social Status with Psychological Distress among Japanese Workers: Explanati ons from Internal and External ResourcesKazumi Kubota, Akihito Shimazu, Norito KawakamiDepartment of Mental Health, Graduate School of Medicine, Th e University of Tokyo

OBJECTIVE: Poor psychological health is more common among people of low socioeconomic status (SES). However, how SES has an impact on psychological health is unknown. Th is study investigated whether the asso-ciation between SES and psychological health can be explained by external and internal resources.METHODS: A web-based cross-sectional survey was con-ducted in October 2010 among registered monitors of a survey company in Japan. Th e questionnaire included subjective social status (SSS), family income, psycho-logical distress, internal resources (self esteem and self effi cacy), job demands, external resources (job control and worksite support) and demographics. A total of 13,564 monitors were randomly invited to the survey. Th e fi rst 2,520 respondents were included in this study, and completed data from 2,239 respondents were then analyzed (1,145 males and 1,090 females). Analysis of covariance (ANCOVA) was conducted, with demo-graphics, job demands, external and internal resources as covariates.RESULTS: Low SSS group had signifi cantly higher psy-chological distress compared to middle and high SSS groups after adjusting for demographic characteristics, and external and internal resources (F=3.23, p<0.05). Although low family income group had also signifi cantly higher psychological distress compared to middle and high family income groups after adjusting for demo-graphic characteristics (F=10.65, p<0.001), the association was not signifi cant after adjusting for external and inter-nal resources (F=0.49, p=0.985).CONCLUSION: SSS was associated with psychological distress independent of external and internal resources, whereas family income would be associated with it prob-ably mediated by external and internal resources.

KEYWORDS: Subjective social status (SSS); Socioeconom-ics status (SES); Psychological distress; Internal resources; External resources

POSTERS

70

B–5

Alternati ve Splice Variants of SMG-1 as a Potenti al Marker for Brief Naturalisti c Stressors in Peripheral LeukocytesYuki Kuwano, Ken Kurokawa, Sakurako Katsuura, Naoko Yamagishi, Yuzuru Satake, Keisuke Kajita, Yoko Akaike, Manami Honda, Kensei Nishida, Kiyoshi Masuda, Toshihito Tanahashi, Kazuhito RokutanDepartment of Stress Science, Institute of Health Biosciences, Th e University of Tokushima Graduate School, Tokushima, Japan

OBJECTIVE: Alternative splicing is a process by which exons are either included or excluded from a single pre-mRNA. Th is process expands the coding capacity of the genome and also regulates the gene expression program in response to surrounding environment. In this study, we investigate a brief naturalistic stressor-dependent alternative splicing events in peripheral leukocytes and identify novel stressor-associated alternative splicing variants.METHODS: We recruited 28 medical students who took a computer-based testing (CBT) as brief naturalistic stress. Venous blood was taken from each subject 7 weeks before, one day before, immediately after, and one week after the examination. We chose 5 male students having top 5-ranked STAI state anxiety and transcript diversity was analyzed using Human Exon 1.0 ST array. Salivary cortisol level was also measured.RESULTS: We selected alternative splicing events dif-ferentially observed between immediately after versus either 7 weeks before, one day before, or one week after the examination. We found 27 genes as the candidates that produced acute stress-responsive variants. Th e brief naturalistic stressor preferentially induced skip-ping rather than inclusion of the pre-mRNAs: 21 out of 27 pre-mRNAs underwent skipping. According to the InterProScan, SMG-1, known as a regulator of non-sense-mediated mRNA decay, showed skipping exon 63 encoding FATC domain that is essential for SMG-1 kinase activity.CONCLUSION: Th ese results suggest that alternative splic-ing, particularly exon skipping, is one of the complex responses to stressful events. Th ese spliced variants identi-fi ed in this study might be useful markers for assessment of psychosocial stress responses.

KEYWORDS: Gene; Microarray; Splicing; University students; Brief naturalistic stress

B–6

High-Throughput Screening of Immunomodulators Identi fi es VEGF as a Potenti al Biomarker for Trait Anxiety and Depressive Mood in Healthy Japanese University StudentsManami Honda, Sakurako Katsuura, Yuki Kuwano, Naoko Yamagishi, Ken Kurokawa, Yuzuru Satake, Keisuke Kajita, Yoko Akaike, Kensei Nishida, Kiyoshi Masuda, Toshihito Tanahashi, Kazuhito RokutanDepartment of Stress Science, Institute of Health Biosciences, Th e University of Tokushima Graduate School, Tokushima, Japan

OBJECTIVE: Anxiety and depressive mood is sometime associated with dysregulation of the immune system. Th e aim of this study was to identify neuro-immune mediators related to anxiety and depressive mood in healthy young adults.METHODS: We recruited 209 healthy students (125 men and 84 women, aged 20.7±2.7 years) of our medi-cal school. Anxiety and depressive mood were assessed by the Spielberger state trait anxiety inventory (STAI) and the Zung-self rating depression scale (Zung-SDS), respectively. Salivary cortisol and chromogranin A (CgA) were measured by EIA and 50 diff erent mediators, such as cytokines and growth factors, in sera were measured by a multiplex-suspension array system (Bio-Plex). Signifi cance levels set at p<0.05.RESULTS: Among the 50 mediators, 44 mediators were measurable, and each mediator showed substantial indi-vidual variations. First, we selected candidate cytokines by analyzing Pearson correlation coeffi cient between mediators and STAI-state, STAI-trait, or SDS scores. Th en these cytokines were subjected to multiple regres-sion analysis adjusted for gender, BMI, salivary cortisol, CgA, and other infl ammatory cytokines (IL-1β, IL-6, TNF-α, and MIF). Vascular endothelial growth factor (VEGF) was independently and negatively associated with trait anxiety (p<0.05) and depressive mood (p<0.01). In contrast, IL-1β was independently and positively associated with depressive mood (p<0.05). Interaction between gender and VEGF or IL-1β was not observed.CONCLUSION: Our high-throughput screening identi-fi ed VEGF as a potential biomarker for trait anxiety and depressive mood in healthy young adults.

KEYWORDS: Cytokines; University students; Anxiety and depressive mood; VEGF

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B–7

Health Eff ect of Job MobilityYoshiya ShiotaniAffi liated Member of the Center for the Study of Social Stratifi cation and Inequality at Tohoku University (Faculty of Arts and Letters)

OBJECTIVE: Th e present study examines the eff ect of job mobility on self-rated health. Th ey say that labor market fl uidization is ongoing and people tend to have more job mobility experience compared to past period. Th e present study focuses on below two points: (1) Which types of job mobility do decrease individual health? (2) Does the eff ect of job mobility exist after considering present social resource?METHODS: Th e study analyzes the 2005 SSM (Social Stratifi cation and Social Mobility) survey data. Th e series of SSM survey has been conducted once every ten years since 1955 and it is most important data set for Japanese social stratifi cation research. Respondents of the 2005 survey are Japanese men and women aged 20–69 (N=5,742, RR=44.1%). Th e data set includes self-rated health and individual overall job history that was measured retrospectively. Th ere is rich information about each job position such as contents of work, fi rm size, and employment status (e.g., regular or non-regular work) etc. Comparing condition of last job and that of present one, the study defi nes some types of job mobility. Th e relationship between types of job mobility and pres-ent self-rated health is examined controlling for present amount of social resources such as income, education and social support.RESULTS: Analysis is in progress. Th e result will be shown at the symposium.CONCLUSION: Interpretation and conclusions will be shown based on the result.

KEYWORDS: Job mobility; Self-rated health; Japan

B–8

Mediati on of the Associati on between Social Class and Health through Psychological Resources in the US and JapanChiemi Kan1, Norito Kawakami1, MIDJA collaborators1Department of Mental Health, Graduate School of Medicine, Th e University of Tokyo

OBJECTIVE: Recently, researchers have proposed that psychological resources (PSs) might be a factor explaining the association between social class, such as socioeco-nomic status (SES) and subjective social class (SSS), and health. Th e contributions of PSs to SES-health associa-tion may vary by country, as well as gender. Th is study aimed to investigate mediating eff ects of selected PSs for the association of social class with health in the US and Japan, separately for men and women.METHODS: Participants were adults (30–84 years) from a random sample from community residences in the US (the MIDUS survey, N=1,805) and that in Tokyo, Japanese (the MIDJA survey, N=1,027). Measurements were obtained on educational level and SSS, PSs (sense of control, self-esteem, optimism/pessimism, and neuroti-cism), and health status (self-rated health and number of chronic conditions). Mediation eff ects of these PSs were tested by the mediation analysis, using a SPSS macro.RESULTS: Total mediation eff ects through four PSs were signifi cant for most equations except for the education-chronic conditions association among Japanese women. Neuroticism signifi cantly mediated social class associa-tion with the two health outcomes most consistently in the US and Japan. Sense of control and self-esteem signifi cantly mediated most of social class association with self-rated health in the US and Japan. Optimism/pessimism signifi cantly mediated some of the association, but only among women in the US and Japan.CONCLUSION: Th e results suggested that neuroticism, sense of control, and self-esteem are mediators of the link between social class and health both in the US and Japan. However, there also seemed to be gender- and health outcome-specifi c mediation eff ects of these PSs, which need to be investigated further.

KEYWORDS: Social class; Psychological resources; Health; Country; Gender

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